Punjab

Ludhiana

CC/19/246

Jagjit Kaur - Complainant(s)

Versus

Universal Sompo General Insurance Company Limited - Opp.Party(s)

M.S.Sethi Adv.

24 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 246 dated 23.05.2019.                                                                 Date of decision: 24.01.2023.

 

Jagjit Kaur w/o. Amarjit Singh, r/o. 418, Uganda Building Benjamin Road, CMC Chowk, Ludhiana.                                                                                                                                                                                          .…Complainant

                                                Versus

1. Universal Sompo General Insurance Co. Ltd., registered office at Unit 401, 4^th Floor, Sangam Complex, 127, Andheri Kurla Road, Andheri (East), Mumbai-400059 through authorized signatory.
2. Universal Sompo General Insurance Co. Ltd., SCO-11, 5^th Floor, Feroze Gandhi Market, Ludhiana through authorized signatory.                                                                                                                 …..Opposite parties 

                   Complaint under Section 12 of Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. M.S. Sethi, Advocate.

For OPs                          :         Sh. Rajeev Abhi, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that the complainant first time hired the services of the opposite parties for insuring for health care insurance for self and husband for the period 07.07.2010 to 06.07.2011(Ex. C1) on completion of formalities and also allotted customer ID 101328401392& hereafter said policy Health Care Plus was renewed every year (Ex. C2 to Ex. C8) and lastly it was got renewed for the period 18.07.2018 to 17.07.2019. The complainant paid Rs.15,019/- as premium vide policy No.2817/50785315/08/000 for sum insured of Rs.5,00,000/-. During the policy period of 18.07.2018 to 17.07.2019, the complainant was got admitted in CMC Hospital from 14.02.2019 to 20.02.2019 with compliant of fever and cough for 3 days and breathlessness for 1 day. However, cashless facility was denied by the opposite parties vide letter dated 16.02.2019 addressed to CMC Hospital, Ludhiana on the ground that the patient is a known case of bronchial asthma since 10 years and this fact is not disclosed in proposal form. However, the opposite parties made clear that the denial of authorization request shall not be construed to mean that she cannot claim for reimbursement under the terms and conditions of the policy. Thereafter the complainant paid the hospital bill and medicine expenses amounting to Rs.41,325/- (Rs.35,825 + Rs.5,500/-) and again submitted the claim for reimbursement with opposite parties. The opposite parties vide letter dated 09.04.2019 demanded certain documents from the complainant but later on repudiated the claim vide letter dated 21.04.2019 on the ground which is reproduced as under:-

“As per records reviewed, the insured is already a known case of asthma since 15-20 years as mentioned in indoor records. The insured provided relevant consultation of year 2015, 2016 but no earlier complete records including x-ray/other investigation reports submitted to us since first confirmed with Asthma. The insured did not disclose detailed past medical history in the proposal form on policy inception date. Hence claim stands repudiated as per policy guidelines.

In this regard, we regret to inform you that the claim is not admissible as per following policy clause:

Disclosure of information norm means the policy shall bed void and all premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure of any material fact.”

The complainant stated that the contents of the repudiation letter are wrong and not based on reality and formulated by opposite party just to denying the liabilities payable under the policy. The opposite parties have not disclosed the said policy clause and neither it was made part of the policy nor ever communicated to the complainant. In the policy from 00.00 of 18.07.2018 to midnight 17.07.2019 period, it is duly disclosed that policy subject to the following special conditions as NA for the disputed period as such, the opposite parties have no right for taking defence of said policy clause. However, it is also disclosed in the said policy (Ex. C9) which is reproduced as under:-

          “Clauses/Endorsement attached to the policy:

Continue health insurance cover in India from any of the insurers without break (Date) 18.07.2013 period of insurance without any break; 5 years.”

The opposite parties have wrongly and intentionally repudiated the claim as except this, no other terms/conditions/clause was attached separately with the policy. The complainant further stated that the opposite parties without relying upon the documents and without taking opinion of the treating doctor succeeded in repudiating the claim just on the basis of history disclosed in the hospital record which was duly clarified by her son vide its letter Ex. C20.  Moreover, the opposite parties are silent on the justification dated 14.02.2019 submitted by the treating doctor Gautam Aggarwal of SPS Hospital, Ludhiana and they are silent on the issue which shows their malafide intention to reject the claim on flimsy grounds. The complainant submitted that she has not lodged any claim from the inception of the policy since 7/2010 to 2014 bearing customer ID No.101328401392 (Ex. C1 to Ex. C5) which proves that only after diagnosing by Dr. Gautam Aggarwal, she first time acknowledged having asthma and question for  non-supply of earlier records including x-ray/other investigation reports does not arise as the treating doctor duly disclosed in the certificate dated 24.02.2019 that said disease as known case of COPD for the last 3-4 years. However, the opposite parties in letter dated 16.02.2019 (Ex. C16) disclosed the said period of k/c/o asthma since 10 years but in the other letter dated 21.04.2019 (Ex. C18) described such period since 15-20 years whereas the documents shows that the ailment is since 2015 which is after inception of first policy in 07.07.2010 (Ex. C1) hence the repudiation of the claim is not based on reasonable grounds rather it is based on presumption and myth.
The opposite parties falsely and wrongly had taken the shelter of proposal form after the gap of period of 9 years since inception of policy Ex. C1. The complainant has submitted that she has never preferred any claim during this period. However, she has paid huge premium of Rs.1,09,220/- whereas she has claimed only Rs.41,325/-. As such, the opposite parties have falsely given assurance of paying claim but despite of collecting huge premium they denied claim on false and illegal grounds with the motive to get the insurance policy itself become useless which amounts to unfair trade practice and deficiency in service on the part of the opposite parties. In the end, a prayer has been made to quash the repudiation letter dated 21.04.2019 and also to pay the claim amount of  Rs.41,325/- besides paying  75,000/- as compensation and Rs.15,000/- as litigation costs.

2.                Upon notice, the opposite parties appeared and filed joint written statement. In the preliminary objections, the opposite parties assailed the complaint on the ground of maintainability, concealment of material facts etc. The complaint is barred under Section 26 of the Consumer Protection Act. The opposite parties alleged that the complainant had obtained the insurance policy i.e. IOB Health Care Plus Policy from them valid from 18.07.2018 to 17.07.2019 bearing policy No.2817/50785315/08/000 for herself and her husband Amarjit Singh for a total sum insured of Rs.5,00,000/-. The opposite parties further alleged that the insurance policy is a contract in itself and the parties are bound by the terms and conditions of the policy. Nothing can be added or subtracted out of it as per law laid down by the Hon’ble Supreme Court of India. It is one of the conditions in the policy under the head, ‘Disclosure of information norms means the policy shall bed void and all premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure of any material facts.’ Insurance policy is issued on the principles uberrimae fides. Utmost good faith is a cardinal principle of insurance. This means that all the parties to an insurance contract must deal in good faith, making a full declaration of all material facts in the insurance proposal. Material facts are those that would influence an underwriter as to whether he should or should not accept the risk. If a party fails to adhere to the principles of utmost good faith, the outcome of the claim may be affected. The insurance policy is issued on the basis of the proposal form. The opposite parties further alleged that the complainant has lodged the claim for reimbursement of the medical expenses incurred on her treatment with CMC Hospital, Ludhiana w.e.f. 14.02.2019 to 20.02.2019 with diagnosis of Bronchial asthma – acute infective exacerbation; severe pulmonary hypertension (RVSP 75 mm Hg); chronic kidney disease stage 3? Etiology. As per discharge summary a 68 years old patient k/c/o bronchial asthma presented with fever and cough was admitted in the hospital with the aforesaid diagnosis. As per discharge summary she was found to have CKD stage 3 with an EGFR of 55. CMC Hospital, Ludhiana on behalf of the complainant had sent the authorization request for her cashless treatment dated 16.02.2019 and on receipt of the documents submitted by the hospital, the cashless authorization was declined vide cashless denial letter dated 16.02.2019 duly communicated to the said hospital for the reasons reproduced as under:-

“Patient is k/c/o Bronchial asthma since 10 years, this fact is not disclosed while taking the policy. Hence the cashless facility is denied.”

The opposite parties further alleged that it was made clear in the said letter that the denial of authorization for cashless access does not apply denial of treatment and does not in any way prevent the insured from seeking necessary medical attention or hospitalization. It is further made clear that the denial of preauthorization request shall not be construed to mean that the complainant cannot claim for reimbursement under the terms and conditions of the policy. After discharge from the hospital, the complainant has lodged the claim with opposite parties and had submitted certain documents along with the claim. The complainant was called upon vide deficiency letter dated 09.04.2019 followed with the reminder dated 20.04.2019 to provide the documents for process of the claim which are reproduced as under:-

• Consultation record dated 26.02.2019
• Past 3-4 years treatment records with all consultation papers, investigation reports, medicine consumed with bills in support of declaration given of asthma duration since last 3-4 years only.
• Copy of indoor records from the hospital.
• All original investigation reports vide charges mentioned in the final bill.

The opposite parties further alleged that the complainant has submitted only relevant consultation of year 2015 and 2016 but no earlier complete records including x-ray/other investigation reports were submitted to them since first confirmed with asthma till date and as such has withheld the material documents required for processing of claim in spite of the written demands raised by opposite parties vide deficiency letter dated 09.04.2019 and reminder dated 20.04.2019. The opposite parties further alleged that M/s. JD Health Care Services, Corporate Office at 843, Sector 11, Garden Colony, Kharar, District Mohali was appointed to investigate the reimbursement insurance claim of the complainant who had submitted his reimbursement insurance claim verification report dated 18.04.2019 with the opposite parties clearly recommending for repudiation of the claim on account of non-disclosure and PED (pre-existing disease) of Bronchial asthma under the head Recommendations reproduced as under:-

“Since the patient is known case of Bronchial Asthma for last 15-20 years and suffering from HTN for last 1-2 years as evident from ICP, hence claim may be repudiated for non-disclosure and PED of Bronchial Asthma."

The said investigator has also submitted his observations about the reimbursement insurance claim of the complainant under the head other observations which are also reproduced as under:-

          As per insured:

• Patient was having the complaints of Mid Fever and Breathlessness along with weakness and is taking treatment from Dr. Gautam Aggarwal at SPS Hospital for breathlessness for last 3-4 years and is taking Rotacap.
• Patient is not suffering from any other chronic illness.

As per ICP

• Patient presented to CMCH on 14.2.2019 with the complaints of breathing difficulty with cough for last 7 days.
• Patient is having past history of heart disease and asthma and is on treatment for same.
• Patient is known case of bronchial asthma for last 15-20 years and is on medication for same and also a known case of hypertension for last 1-2 years and chronic kidney disease Stage 3.
• ECHO report dated 15.2.2019 suggestive of mild MR and patient is OBESE with a weight of 90 kg with a height of 5’3”.

                   As per the outpatient record of CMC Hospital, Ludhiana, Unit No.C-7878810 name Jagjit Kaur, the complainant is:

          K/c/o bronchial asthma – on medication x 15-16 years.

Further as per inpatient case notes Form No.26 of CMC Hospital, Ludhiana dated 14.02.2019, 68 years old k/c/o bronchial asthma (15-20 years) on MDI and oral bronchodilators and as per Nursing Process Form No.429 of CMC Hospital, Ludhiana a 68 years old lady came to OPD as follow up case of bronchial asthma x 15 years. The opposite parties alleged that after the report of report of M/s. JD Health Care Services dated 18.04.2019 along with enclosures and as per medical record submitted by the complainant and also obtained by the opposite parties during processing of the claim and after scrutinizing the documents placed in the claim fie in terms of the insurance policy and after due application of mind by the officials of the opposite parties, the claim of the complainant was repudiated vide claim repudiation letter dated 21.04.2019 on the ground that the claim is not admissible as per the policy clause reproduced as under:-

“Disclosure of information norms means the policy shall bed void and all premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure of any material facts.”

As the complainant was a k/c/o asthma for 15-20 years as mentioned in the indoor records and that the complainant has not provided compete records of x-ray and other investigation reports since first confirmed with asthma and since the insured did not disclose the detailed past medical history at the time of taking policy on policy inception date. The claim of the complainant has been rightly repudiated as no claim and the grounds of repudiation are legal, valid and enforceable and are in accordance with the terms and conditions of the policy. The opposite parties denied deficiency in service and negligence on their part. The opposite parties further alleged that the complainant has not disclosed at the time of taking policy but disclosed the disease at the time of 8^th renewal to add “Bronchial Asthma” when she was hospitalized.

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections and have denied that there is any deficiency of service. The opposite party further alleged that not lodging any claim in the previous policy has no relevancy with the caim in question. Dr. Gautam Aggarwal is not the treating doctor and the claim is lodged in respect to the treatment with CMC Hospital and the consultant incharge is Dr. Mary John, Professor and other consultants are Dr. Charis Baby and Dr. Tabitha. The said doctors/consultants are MD, Professor, Assistant Professor and Senior Residents. It is these three doctors who have treated the complainant. The complainant was never treated by Dr. Gautam Aggarwal anc the certified dated 24.09.2019 issued by said doctor is without any serial number and is not supported by any corroborated document of treatment and same has got no evidential value. The complainant is not entitled to any claim and in the end, prayed for dismissal of the complaint.

3.                In support of her claim, the complainant tendered her affidavit Ex. CA1 in which she reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 to Ex. C9 are the copies of policy schedule renewed from time to time, Ex. C10 is the copy of discharge summary, Ex. C11 to Ex. C15 are the copies of bill, Ex. C16 is the copy of cashless denial letter dated 16.02.2019, Ex. C17 is the copy of deficiency letter dated 09.04.2019,  Ex. C18 is the copy of claim repudiation letter dated 21.04.2019, Ex. C19 is the copy of certificate dated 24.02.2019 issued by Dr. Gautam Aggarwal, of SPS Hospital, Ex. C20 is the letter written by Gurmeet Singh to the opposite parties and closed the evidence.

4.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Sh. Piyush Shanker, Officer of the opposite parties and affidavit Ex. RB of Dr. Gurpreet Singh of M/s. JD Health Care Services along with documents Ex. R1 is the copy of policy schedule cum tax invoice w.e.f. 18.07.2019 to 17.07.2019, Ex. R2 is the policy terms and conditions, Ex. R3 is the copy of reimbursement insurance claim verification report dated 18.04.2019, Ex. R4 is the copy of health insurance claim form, Ex. R5 is the copy of discharge summary, Ex. R6 and Ex. R8 are the copies of echocardiography report, Ex. R7 is the copy of patient record, Ex. R9 is the is the copy of nursing process, Ex. R9A is the copy of outpatient record dated 26.02.2019, Ex. R10 is the copy of deficiency letter dated 20.04.2019, Ex. R11 is the copy of deficiency letter dated 09.04.2019, Ex. R12 is the copy of claim repudiation letter dated 21.04.2019, Ex. R13 is the copy of cashless request form, Ex. R14 is the copy of I card of the complainant, Ex. R15 is the copy of aadhar card of the complainant, Ex. R16 is the copy of cashless denial letter dated 16.02.2019, Ex. R17 is the  reimbursement insurance claim verification report dated 18.04.2019 and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties. We have also gone through the written arguments submitted by the complainant.

6.                Admittedly, the complainant was availing insurance cover from the opposite parties since 2010. Admission in the written statement and the documents Ex. C1 to Ex. C9 prove this fact. In the present case, the policy inception date is 07.07.2010 as per Ex. C1 and the cashless facility has been denied on the ground of non-disclosure of asthma since 10 years ago. Further in the repudiation letter dated 21.04.2019 (Ex. R12) whereby history of asthma has been alleged 15 to 20 years. The opposite parties were required to take into consideration the medical certificate dated 24.02.2019 issued by Dr. Gautam Aggarwal (Ex. C19) wherein it has been specifically written that Jagjit Kaur is a known case of COPD (Chronic Obstructive Pulmonary Disease) for the last 3-4 years. Meaning thereby this disease occurred during the renewal period of original policy. Further the opposite parties were required to produce the proposal forms submitted by the complainant at the time of inception of the policy. Therefore, there was no misrepresentation, mis-description or non-discourse of any material fact on the part of the complainant. As such, the declining of pre-authorization claim or subsequent repudiation is not justified.  In view of the facts and circumstances, it would be just and appropriate if the opposite parties are directed to consider and reimburse the claim of the complainant as per policy terms and conditions along with composite cost of Rs.10,000/-.

7.                As a result of above discussion, the complaint is partly allowed with direction to the opposite parties to consider and reimburse the claim of the complainant strictly according to the terms and conditions of the policy within 30 days from the date of receipt of copy of order. The opposite parties shall further pay composite compensation of Rs.10,000/- (Rupees Ten Thousand only) to complainant within 30 days from the date of receipt of copy of the order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

8.                Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

 

Announced in Open Commission.

Dated:24.01.2023.

Gobind Ram.

 

 

 

 

 

 

 

 

 

Jagjit Kaur Vs Universal Sompo GIC                                       CC/19/246

 

Present:       Sh. M.S. Sethi, Advocate for complainant.

                   Sh. Rajeev Abhi, Advocate for OPs.

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with direction to the opposite parties to consider and reimburse the claim of the complainant strictly according to the terms and conditions of the policy within 30 days from the date of receipt of copy of order. The opposite parties shall further pay composite compensation of Rs.10,000/- (Rupees Ten Thousand only) to complainant within 30 days from the date of receipt of copy of the order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

 

Announced in Open Commission.

Dated:24.01.2023.

Gobind Ram.