Before  the District Consumer Dispute Redressal Commission [Central], 5th Floor                                         ISBT Building, Kashmere Gate, Delhi

                               Complaint Case No.-163/06.07.2017

Gurpreet Kaur wife of Shri Chiranjeev Singh

B3-304 Uniworld City , Sector-30, Gurgaon

Haryana-122001                                                                     ...Complainant

                                      Versus

United India Insurance Co. Ltd., through

Anil Kumar Kukreti, Branch Manager,

Branch Office- Jhandewalan (040401),

213-215 Namdhari Chambers,

Desh Bandhu Gupta Road

Karal Bagh, New Delhi-110005                                              ...Opposite Party

                                                                   Order Reserved on:     17.01.2023

                                                                   Date of Order:             09.03.2023

Coram: Shri Inder Jeet Singh, President

              Shri Vyas Muni Rai,    Member

              Ms. Shahina, Member -Female

Inder Jeet Singh

                                             ORDER

1.1. (Introduction to case of parties) :  It is a complaint of deficiency of services by the complainant that she was denied her valid medical bills and reimbursement despite it was within the parameter of policy, apart from denying cashless facilities, her claim was repudiated by invoking pre-existing disease exclusion clause of 4.1, which was not  applicable, rather there is specific certification by the doctors that disease was discovered during treatment. There was no history of pre-existing disease in the previous medical test record.

1.2: However, on the other-side OP states the claim was rightly declined because of pre-existing disease and it falls within the exclusion clause of 4.1. of policy contract, there was no deficiency of service.

1.3: It is not out of context to mention that the complaint is being prosecuted by the complainant personally through her husband, the documents were filed with the complaint and at the stage of evidence, however, they are titled as 'evidence' but their serial numbers were changed in evidence, therefore, exhibit number mentioned in the affidavit of evidence (referred as Evidence) will be referred so that they are compatible to each other. Secondly, care is also taken by compiling together material facts from scattered facts.

2.1 (Case of complainant ) :  Insured/Chiranjeev Singh took Family Medicare 2014 Policy no.0404012816P108844184 for him and for other family members, including the complainant from OP starting from October 5, 2015 and later it was valid/renewed  from 05.10.2016 to 04.10. 2017 (referred as Evidence-4) [The complainant had wrongly mentioned period 05.10.2015 to 04.10.2017 in the complainant, but on objection of OP, it was stated to be an accidental error and to be read as 05.10.2016 to 04.10. 2017]. There was sudden abdomen pain to the complainant, she was brought to hospital for examination and treatment. The complaint given detail chronologically, it is as under:-

(i)  On 07.03. 2017, complainant encountered sudden episode of abdomen pain was taken to Emergency department of Fortis Memorial Research Institute, Gurgaon (Fortis).

(ii) She  was discharged from Fortis in about one hour of  treatment after the pain and symptoms were relieved. The doctors suspected Acute Pancreatitis and recommended a review in Gastroenterology OPD.

(iii). On March 09.0.3 2017, complainant visited a Consultant in Gastroenterology and explained the episode of March 07, 2017 along with some previous infrequent occurrence of abdomen pain over last few years. In addition to some medication, the Consultant recommended some blood tests and CT Enterography.

(iv). On 10.03.2017, CT Enterography was conducted which came out with suggestive findings with possibility of Neuroendocrine Tumour / GIST and recommended Endoscopy for further evaluation (referred as Evidence-6) .

(v) On 14.03. 2017, Endoscopy was conducted which identified the presence of Gastric GIST (Tumor).

.(vi) On March 16, 2017, the Consultant referred the case further to Gastrointestinal Endo Surgeon to take next decision regarding the treatment of GIST (referred as Evidence-7).

(vii)  On 17.03.2017, the Gastrointestinal Surgeon recommended Laparoscopy surgery for removal of Gastric GIST and 24,03.2017 was scheduled for the same (referred as Evidence-8).

(viii) As part of the preparation for surgery, OP was informed through Fortis
TPA as part of normal process for cashless claim. However OP denied cashless facility claim on the basis of Clause 4.1 (any pre-existing condition of 48  months of continuous coverage of such insured person have elapsed with the inception of

first Policy with the Company).

(ix).  On 20.03.2017, a clarification by Fortis Surgeon was submitted to  OP by clarifying that although the patient has been facing infrequent pains for few years as shared with FORTIS Consultant, however the detection of Gastric GIST is incidental finding during conduct of CT Enterography and Endoscopy. Consultant recommended that GIST be removed, before it turns cancerous. However, it has no relation with the history of infrequent abdomen pain experienced by  the complainant (referred as Evidence-1).

(x) As per the understanding shared by Consultant in Fortis, the cause of in frequent abdomen pains still remains undetected and she was advised to consult again in event of occurrence of the pain so that further attempts can be made to diagnose to diagnose the actual cause.

(xi)  Even on repeated contacts over phone with Insurance Agent and also directly to representatives of OP over next few days, the Company refused to reconsider the denial for cashless claim.

(xii)  Since the surgery had to be conducted anyway, Fortis TPA and Insurance Agent recommended that complainant can pursue the reimbursement with OP after the surgery is conducted and patient would be discharged. Since the surgery was schedule  for 24.03.2017 and complainant was discharged.

2.2. Then on 04.04.2017 reimbursement of bill was requested and submitted to OP's  Agent along with all necessary medical reports and bills in original and bills  were of Rs. 2,77,215/-incurred in consultation, hospitalization, diagnostics, surgery and medicines (referred as Evidence-9).  However, after few weeks OP denied the claim and  informed its decision over phone from insurance agent. It was requested on 25.05.2017 (referred as Evidence-10) to reconsider the denial decision by considering the report of endoscopy conducted in the year 2013 that no such GIST was existing (Evidence-7) prior to the date of subject policy. However, on 23.06.2017 a letter  (referred as Evidence-11) was received from OP denying her claim  on the basis of Clause 4.1.

2.3 OP is not justified in denying the cashless claim by wrongly citing clause 4.1 of existing condition, until 48 months of continuous coverage of such insured person have elapsed, whereas the treatment and hospitalization of complainant for GIST was discovered during the course of diagnosis for detecting cause of abdomen pain, it was not known from the inception of Medicare Policy in October 2015, or existing earlier.
Thus, clause 4.1 cannot be invoked anyway. The  complainant has not suppressed any ailment or condition at the time of inception of the policy.
The decision of OP does not show the faith and the spirit with which,
complainant had bought the Medicare policy from OP
at the time of inception of the policy. The complainant fortifies her complaint with the  copies of following record:-

(a) Family Medicare Policy Card valid till October 04, 2017 (Evidence-4).

(b) Fortis Discharge Summary dated 07.03.17 for emergency treatment of abdomen pain.

(c) Clarification/certificate dated  20.3.2017 by Fortis Surgeon that Gastric GIST is a "New" finding and has no relation with the history of abdomen pain in patient (Evidence-5).

(d) FORTIS Discharge Summary dated  28.3.2017 post laparoscopic surgery of Gastric  GIST (Evidence-2).

(e)  Expense Summary of 04.04.2017 of consultation, hospitalisation, diagnostics, of complainant (Evidence-9).

(f) Request dated 25.5.2017 to OP to reconsider its denial decision (Evidence-10)

(g) Previous Endoscopy report dated 06.05.2013 indicating negative diagnosis for any GIST (Evidence-1)

(j) Letter dated May 25, 2017 from OP denying cashless claim (Evidence-11).

2.4: The detailed transaction and documentary evidence proves that the Gastric GIST Laparoscopic Surgery done to complainant on 24.3.2017 was result of new findings by doctors and it does not fall under pre-existing conditions of clause 4.1 of the Medi-care policy to deny her valid claim. The complainant is entitled for immediate reimbursement of valid medi-claim of Rs.2,77,215/- besides minimal compensation of Rs.80,000/- on account of delay in payment, apart from other multiple expenses & costs. 

3.1 (Case of OP):   The OP opposes the complaint that it  is false & frivolous complaint. The complainant came without clean hands, therefore, the same is liable to be dismissed with heavy costs. The disease of the complainant is not covered under the terms and conditions of the policy and there is violation of clause 4.1 of the policy (terms of policy are Annexure-A), the  Gastric GIST Laparoscopic surgery conducted on 24.3.2017 was not a result of new finding, therefore, the claim of the complainant has been repudiated by the OP and closed the file as 'no claim'.  OP's TPA scrutinized the claim and opined that diseases of the complainant is pre-existing, the claim of the complainant has rightly held as 'no claim'. OP also denies that the complainant had first bought medi-care policy from OP starting 05.10.2015 or it valid from 05.10.15 to 04.10.2017, since the Medical policy is issued only for the period of one year. While vehemently denying other allegations of complaint, OP pleads that the policy issued was subject to terms and conditions of the policy but complainant's treatment falls in exclusion clause 4.1 of the policy. The  OP not only denies other allegations of complaint but also the claim of amount of treatment & compensation, since clause 4.1. is applicable being exclusion clause or if the cause of pain was unknown, the clause would not be applicable. The complaint deserves dismissal.

4.   The complainant denies the allegations and plea of OP stated in reply, except that there is accidental error in mentioning the period of policy.  The complainant reaffirm the complaint correct.

5.  Complainant's husband Shri Chiranjeev Singh/insured, filed affidavit of evidence coupled with documents supported to the complaint. The complaint is also accompanying with identity card of complainant. On the other side OP's Shri Jagdish Narang, Deputy Manager, filed detailed affidavit of evidence with terms and conditions of policy, on the lines of reply to the complaint.

6.   Both the parties filed their respective written arguments. Moreover, Insured/Chiranjeev Singh also made oral submission for the complainant and Shri Prashant Prakash Advocate for the OP.

7.1 : (Findings) :  The contentions of both the sides are considered and assessed. As apparent, there is no dispute of issue of Medi-care policy to insured/ Chiranjeev Singh against premium, tenure of policy, examination, treatment  and surgery of complainant in the hospital, details and payment of bills, repudiate of  claim by OP, complainant's request for reconsideration of repudiation decision but its denial. However, there is serious rival claim on point of pre-existing disease as well as applicability of exclusion clause no.4.1.  It needs to be explored. In order to appreciate the rival plea, the exclusion clause is re-produced:-

Exclusion Clause-4.1:  Any pre-existing condition(s) as defined in the policy, until 48 months of continuous coverage of such insured person have elapsed, since inception of his/her first policy as mentioned in the schedule attached to the policy.

7.2 : The complaint has filed medical record of her examination in Fortis hospital of 7.3.2017, that she had sudden abdomen paid and after about an hour she was treated there and discharged on the same day since pain was relieved-symptoms were relieved, she was recommended review in OPD. 

7.3 :  Thereafter, what events took place has been described in detail in paragraph no. 2.1 above, with documentary evidence inclusive of advise of surgery, which was performed on 24.03.2017, the complainant was diagnosed of 'GIST stomach'. [GIST  is abbreviation of Gastro-intestinal Stromal Tumor. GIST is a type of cancer that begins in the digestive system]. One of the document is discharge summary of 28.03.2017. It depicts complaint of pain in abdomen on and off three months. There is also mentioning of past history, which record as 'nothing significant'.

          The second relevant document is certificate of 20.3.2017 (Evidence-1) issued by the same  treating hospital, that the complainant is diagnosed  with GIST in stomach, the complaint of pain is not related with the findings of  CT scan, the GIST in stomach was an accidental findings and needs removal,  the history of pain has nothing to do with GIST.

          The third document is previous endoscopy report of 6.5.2013 (Evidence-3), which  do not suggest diagnosis of GIST.

          These aspects do not suggest and infer that the complainant was knowing that she was suffering from GIST prior to taking of medi-care policy, rather it was accidental findings and then she was advised its removal. In case policy is taken, but insured is diagnosed of a disease, whether it would be considered for exclusion as per clause 4.1, it is being construed so by the Insurer. The exclusion clause 4.1. of pre-existing disease is already reproduced above, however, it is not to be read in isolation since 'pre-existing disease' is  also defined in clause no. 3.28, which reads as "any condition or ailment or injury or relation condition(s) for which you had sign or symptom and/or diagnosed and/or received medial advise/treatment within 48 months prior to first policy issued by the insurer."  The literal meaning of clause 4.1 r/w clause 3.28 is clear in itself that there is no proof that the complainant was diagnosed or knowing of GIST or had any advise/treatment for GIST 48 month prior to Medicare policy.  The complainant was diagnosed of GIST as mentioned in discharge summary of 28.3.2017 (Evidence-2) and certificate (Evidence-1). Thus, the complainant has proved her case against OP and OP could not establish applicability of exclusion clause 4.1 to repudiate the valid claim of the complainant.

7.4 :   The complainant has also proved bills paid as enumerated in summary of expenses (Evidence -9), she is entitled for settlement of that claim amount of Rs.2,77,215/- from the Insured/OP.

7.5:  The complainant had to part with money for payment of bills for want of extending the cashless facilities by OP, therefore, the complainant is entitled for interest @6%pa against OP from the date of complaint till realisation of amount by the complainant.  

7.6 : Since the complainant was denied her valid claim and complainant was put to additional trauma for seeking the claim, therefore, compensation of Rs.25,000/- is quantified in favour of complainant and against the OP. The costs of litigation is quantified as Rs.5,000/-.

8,  Accordingly, the complaint is allowed in favour of complainant and against the OP to pay a sum of Rs.2,77,215/- along-with simple interest of 6% p.a. from date of filing of complainant till realisation of amount, apart from damages of Rs.25,000/- & costs of Rs.5000/- payable within 30 days from the date of receipt of this order. 

9. Copy of this Order be sent/provided forthwith to the parties free of cost as per Regulations.

10:  Announced on this 09th day of  March, 2023 [फागुन  18, साका 1944].   It is relevant to record that great difficulties are being faced for long for want of stenographer & PA in the functioning of Commission as a single stenographer Gr-III is provided.

[Vyas Muni Rai]                        [ Shahina]                            [Inder Jeet Singh]

           Member                            Member (Female)                              President