Thread: STAR Health Insurance

Paramjit Singh aged 40 years son of Sh. Shingara Singh, resident of H.no.214-A, Rishi Nagar, Ludhiana.



…..Complainant.

Versus



Star Health & Allied Insurance Co. Ltd., through its Branch Manager, 2770/1, 1st Floor, Chandan Tower, Pakhowal Road, Gurdev Nagar, Ludhiana.

.........Opposite party.


O R D E R



1- Case of the complainant, in this complaint u/s 12 of the Consumer Protection Act, 1986, is that on being approached by representative of the opposite party, he got health policy, by paying premium of Rs.4100/- and got health insurance coverage of Rs.3 lacs. Unfortunately on 5.10.2007, met with an accident within the area of Mandi Gobindgarh and qua accident, DDR no.43 dated 5.10.2007 was lodged in P.S. Mandi Gobindgarh. From accident site, was taken to CMC & Hospital, Ludhiana, in an ambulance, by his friend. On examination, right arm was found fractured and for treatment, remained admitted in that hospital. Intimation of admission in the hospital, was given to the opposite party upon which, one Mr. Amit Jhamb, Assistant Area Manager recorded statement of the complainant and obtained necessary information from him. Documents as sought were made available to him. Expenses of treatement were born by the complainant from out of his pocket.


Though, he was entitled for cashless treatment. But at the time of discharge from the hospital, none had come from the opposite party, to make payment to the hospital. Thereafter again, due to persisting same arm problem, got hospitalized at Ludhiana hospital, Ferozepur Road, Ludhiana, qua which intimation was given to the opposite party, but none came to the hospital. He spent Rs.50,000/- on treatment which opposite party is liable to pay him under the policy alongwith Rs.1 lac for causing harassment and Rs.1 lac as costs.

2- Opposite party in their reply, have admitted taking insurance policy by the complainant, but claimed that he failed to produce requisite papers. Without investigation of such papers, they are not in a position to sanction claim of the complainant. His claim was never repudiated and complaint, as such, is pre-mature. They have controverted allegations of the complainant. The complainant, under terms and terms of the policy, was required to submit documents, as desired. He failed to make available hospital record, discharge slip, police report, invoices, medical reports, bills, investigation reports. Unless and until those documents are made available, claim can not be settled. Hence, there is no deficiency in service on their part.

3- To prove their respective claims, both parties adduced evidence in the shape of affidavits and documents.

4- We have heard the learned counsel for parties and have gone through the entire record placed on the file thoroughly.

5- It is admitted that Medi Classic Individual Policy (Ex.C2 and Ex.R2) stands obtained by the complainant, effective from 20.7.2007 to 19.7.2008. But we have no material on the record that under this policy, any claim was lodged by the complainant with the opposite party. Though, complainant has filed copy of DDR dated 5.10.2007 Ex.C1 qua the accident, vouchers and receipts Ex.C3 to Ex.C20 regarding purchase of medicines. But there is no proof that he under the policy, ever lodged claim with the opposite party.

6- The only material which is available is that complainant had filled Pre-Authorization Request Form Ex.R4 and thereupon, opposite party vide communication Ex.R5 dated 22.2.2008, required from Ludhiana Medicity, Ludhiana, to submit proof of accident, previous admission discharge summary or previous treatment details. Similarly, communication Ex.R6 dated 21.2.2008 was sent to the same medical institute, Ludhiana Medicity, Ludhiana. But there is nothing before us that those letters were complied by the hospital authorities.

7- In these circumstances, we have no hesitation, but to allow the complaint and pass following directions:-

Complainant may lodge claim qua the amount spent on his treatment, alongwith medical certificates/reports, invoices qua purchase of medicines and payment made to the hospital etc. and the opposite party, on lodging such claim by the complainant, shall decide it within 60 days and then make payment of the amount found due under the insurance policy Ex.C2 (Ex.R2) to the complainant. In peculiar circumstances, we pass no order as to compensation or costs. Copy of order be supplied to the parties free of costs. File be consigned to record room.

Mrs. Lalitha N.Shetty,

W/o Mr.BNarayan Shetty,

Aged 60 yrs,

Residing at No.586, 2nd Main Road,

2nd Block, Rajajinagar, Bangalore.



…. Complainant

V/s



01. Star Health and Allied

Insurance Company Limited,

No.1, New Tank Road,

Valluvarkottam High Road,

Nungambakkam, Chennai-34.



02. Star Health and Allied Insurance

Company Limited, M.G.Road,

Bangalore – 560 001.

…. Opposite Parties



-: ORDER:-



This complaint is for a direction to the Opposite Parties to pay Rs.1,13,352/- towards reimbursement of the medical expenses with interest at 18% Per Annum from the date of the bill and to pay damages of Rs.2,00,000/- for the mental agony suffered by the complainant.

2. The case of the complainant is as under:-

The complainant had obtained a Star Senior Citizens Red Carpet Insurance Policy from the Opposite Party for the period from 12/09/2008 to 11/09/2009. During the first week of November 2008 the complainant developed abdominal pain, vomiting and fever. She under-went certain tests and was admitted to Panesia Hospital on 08/11/2008. Before admission to the hospital, she was asked to undergo Ultra Sound Scanning. Pursuant to Ulter Sound scanning, a cancerous growth was detected by the Doctors and she was operated upon on 09/11/2008 and was discharged from the hospital on 19/11/2008. She incurred expenses of Rs.1,13,352/- for surgery and treatment. After discharge from the hospital, she lodged claim with the Opposite Party for reimbursement of the medical expenses. On receipt of the claim, the Opposite Party sought for certain clarifications regarding the details of treatment and breakup for treatment and the same was furnished.


Finally by the letter dated 19/02/2009, the Opposite Party repudiated the claim on the ground that the Ultra Sound Scanning report dated 05/11/2008 reveals Intra and Extra hepatic biliary ductal dilatation due to obstruction at the distal end of the common bile duct stricture and hence the incubation period of the disease is prior to the commencement of the policy namely 12/09/2008. Upon enquiry, she was informed that the claim was under the exclusion terms of the policy. The claim of the Opposite Party that the disease or condition of the complainant was pre existing before the issuance of the policy is unfounded as the same was not at-all within the knowledge of the complainant.


Only after she under-went Ultra Sound Scanning, her health condition was detected. Therefore, the contention of the Opposite Party that the disease was pre existing is a blatant withdrawal and negation from the contractual obligation. The act of the Opposite Party in refusing to reimburse the medical expenses to the complainant is an apparent violation of the insurance policy besides deficiency in service. The Opposite Party caused unwarranted stress and mental agony to the complainant who is a Senior Citizen, besides severe financial set back. Hence, the complaint.



3. In the version, the contention of the Opposite Parties is as under:-

The allegations in the complaint do not constitute deficiency in service on the part of the Opposite Parties. During the course of business, the Opposite Party had issued a medi-claim policy in favour of the complainant for the period from 12/09/2008 to 11/09/2009. The liability if any under the policy is subject to terms, conditions and exceptions. During the validity of the policy, the complainant informed about the hospitalization and treatment undergone and made claim for reimbursement of certain medical expenses and hospitalization charges said to have been incurred for taking treatment for carcinoma 2nd part of Duodenum + head of pancreas at Panacea Hospital, Bangalore.


As per the medical records the complainant was admitted to the hospital from 08/11/2008 to 19/11/2008 for whipples procedure for pancreatico duodenectomy-carcinoma 2nd part of duodenum which has spread to pancreas. The medical records were verified by the Officiers of the Opposite Party as well as by Dr.S.Krishna Shankar, medical officer. The said scan shows “infiltration of ampulla with gross dilatation of CBD. Tumor adherency to pancreatic duct. Obstructive dilation extra and intra hepatic biliary radicles. Enlarged celiac lymph nodes. The Biopsy report shows “Intestine shows acute on chronic inflammation. Serosa shows chronic inflammation and apart from this there are areas of necrosis hemorrhage, calcification and infiltration of the head on pancreas.


There is a well differentiated tumor in the second part of the duodenum, which has spread to the pancreas. Gall bladder shows chronic hemorrhagic cholecystitis. On verification of the reports, the said Doctor has come to the conclusion that it is therefore evidence with such a finding of chronic pathology in the abdomen in the biopsy and CT Scan, the patient would certainly have got symptoms in the past 12 months for which requisite treatment would have been given. The insured is a Doctor who has taken the insurance policy in favour of his parents and as such the abdominal pain would not have gone unnoticed which as reports reveals disease existed prior to the policy of insurance. Therefore the ailment for which the complainant was treated existed much prior to the insurance cover.


The claim made by the complainant was referred to the panel Doctors to ascertain the correctness of the claim made by the complainant. On receipt of the opinion of the Doctors and while processing the file, it was noticed that the disease for which the complainant was treated existed even prior to taking the policy and therefore it was pre existing. Therefore, the Opposite Party came to the conclusion that the claim made by the complainant falls outside the purview of the policy under exclusion Clause-1 with regard to the pre existing condition and as such the claim was repudiated. The repudiation after thoroughly following the terms, conditions and exceptions of the policy cannot be said to be Unfair or Unjust and as such the complaint is not maintainable. On these grounds, the Opposite Parties have prayed for dismissal of the complaint.

4. In support of the respective contentions both the parties have filed affidavits. The Opposite Parties have also filed the affidavit of Dr. Krishna Shankar who claims to be working as a Senior Medical Officer with the Opposite Party and claims to have verified the medical records submitted by the complainant and gave opinion that the disease was pre existing. The complainant had tendered interrogatories to Dr.Krishna Shankar, the witness for the Opposite Parties. But those interrogatories were not answered by the witness. The learned counsel for the Opposite Parties has filed written arguments. We have heard the arguments of the learned counsel for the complainant.



5. The points for consideration are:-

1. Whether in the facts and circumstances of the case, the repudiation of the claim of the complainant by the Opposite Parties justified?



2. Whether the complainant entitled to the relief prayed for in the complaint?

6. Our findings are:-

Point No(1) : In the Negative

Point No(2) : As per final order,

for the following:-

-:REASONS:-

7. There is no denial of the fact that the Opposite Party had issued a Medi-claim policy favouring the complainant for the period from 12/09/2008 to 11/09/2009. The fact that the complainant was hospitalized from 08/11/2008 to 19/11/2008 in Panesia Hospital and she uner-went surgery is also undisputed. Thus, the hospitalization of the complainant was within about two months from the date of commencement of the policy. As per the discharge summary, the copy of which is produced by the complainant, the complainant had approached Panesia Hospital with the history of abdominal pain, vomiting and fever since 2- 3 days as on 05/11/2008 and on investigation including Ultra Sound Scanning she was diagnosed as having Bilateral crepts, Rhonchi, tenderness in RHC and Epigastrium and she was diagnosed to have carcinoma 2nd par tof duodenum + head of pancreas and she was subjected to surgery under whipple’s procedure on 09/11/2008 and was discharged on 19/11/2008. On the basis of the medical records, the Opposite Party wants to contend that the complainant was suffering from the said diseases much prior to the inception of the insurance policy and therefore it was pre- existing and as such the claim is exclusion under exclusive Clause of the insurance policy.


In the affidavit filed in support of the claim, the complainant has stated that she suffered abdominal pain, vomiting and fever on 03/11/2008 met the Doctor on 05/11/2008 and as per the advise, she under-went Ultra Sound Scanning and only on receipt of the report of Ultra Sound Scanning, her health condition was detected. Therefore, it is the contention of the complainant that prior to 03/11/2008 she had no knowledge about the disease with which she was suffering from. According to the Opposite Party, the verification of the medical report makes it clear that the patient would certainly have got symptoms in the past 12 months for which requisite treatment would have been given. To the same effect is the affidavit of Dr.Krishna Shankar.


This makes it clear that only on assumption the Opposite Party wants to contend that the patient would certainly have got symptoms in the past 12 months for which requisite treatment would have been given. Only on the basis of assumption and presumption a claim under the policy cannot be repudiated. Except the affidavit of Dr.Krishna Shankar, no other material is produced by the Opposite Party to show that even prior to the inception of the policy, the complainant had taken treatment for the disease, in respect of which she under-went surgery. In the absence of material, the repudiation of the claim on assumption cannot be said to be justifiable. In the decision reported in 2008 CTJ 699 in the case of NATIONAL INSURANCE CO. LTD., V. SHRAWAN BHATI, the Hon’ble National Commission has held that “repudiation of insurance claims on assumptions is not sustainable in law”.


From the material on record, it can be said that the complainant had no knowledge or symptoms of the disease prior to 03/11/2008 which is subsequent to the inception of the policy. If the complainant had no knowledge of the disease even it cannot be said that the existence of the disease was suppressed by the complainant while making proposal for insurance policy. In the decision reported in 2008 CTJ 347 in the case of NATIONAL INSURANCE COMPANY LTD., V. RAJ NARAIN, the Hon’ble National Commission has held that most of the people are totally unaware of the symptoms of the disease that they are suffering from and therefore an Insurance Company cannot be allowed to take advantage of the exclusion clause of pre existing disease of his Medi-calim policy to repudiate the claim preferred by an insured.


In view of the decision of the Hon’ble National Commission and in the absence of material to show that the complainant had taken treatment for the disease much prior to the inception of the policy, the mere assumption on the part of the insurance company and its Doctors cannot be made the basis to repudiate the claim on the ground that the disease was pre existing before the inception of the policy. As stated earlier, Dr.Krishna Shankar who had filed affidavit in support of the defense of the Opposite Party has failed to answer the interrogatories tendered by the complainant. Therefore, even his affidavit filed in lieu of evidence in examination in chief cannot be considered. If the affidavit of the said witness is excluded from consideration, there remains no material to support the contention of the Opposite Party that the disease for which the complainant had taken treatment was pre existing.


For these reasons, we hold that the Opposite Party was not justified in repudiating the claim made by the complainant and as such the complainant is entitled for reimbursement of the medical expenses incurred for treatment as per terms of the policy. However, we find that the complainant has claims Rs.1,13,352/- towards medical expenses whereas the insurance policy is taken for a sum of Rs.1,00,000/-. Therefore, the complainant is entitled to claim reimbursement of the medical expenses only to the extent of Rs.1,00,000/- and not Rs.1,13,352/- as claimed. The complainant is also not entitled to claim damages or compensation as the same is outside the purview of the contract of insurance. In the result, we pass the following:-



-:ORDER:-



1. The complaint is ALLOWED IN PART.

2. The Opposite Party is directed to pay Rs.1,00,000/- (Rupees One Lakh only) to the complainant towards reimbursement of the medi-claim expenses together with interest at 6% Per Annum from 19/02/2009 – the date of repudiation till the date of payment and shall also pay costs of Rs.2,000/-.

3. Compliance of this order shall be made within eight weeks from the date of communication.

4. Send a copy of this order to both parties free of costs

Paramjit Singh aged 40 years son of Sh. Shingara Singh, resident of H.no.214-A, Rishi Nagar, Ludhiana.



…..Complainant.

Versus



Star Health & Allied Insurance Co. Ltd., through its Branch Manager, 2770/1, 1st Floor, Chandan Tower, Pakhowal Road, Gurdev Nagar, Ludhiana.

….Opposite party.










O R D E R









1- Case of the complainant, in this complaint u/s 12 of the Consumer Protection Act, 1986, is that on being approached by representative of the opposite party, he got health policy, by paying premium of Rs.4100/- and got health insurance coverage of Rs.3 lacs. Unfortunately on 5.10.2007, met with an accident within the area of Mandi Gobindgarh and qua accident, DDR no.43 dated 5.10.2007 was lodged in P.S. Mandi Gobindgarh. From accident site, was taken to CMC & Hospital, Ludhiana, in an ambulance, by his friend. On examination, right arm was found fractured and for treatment, remained admitted in that hospital. Intimation of admission in the hospital, was given to the opposite party upon which, one Mr. Amit Jhamb, Assistant Area Manager recorded statement of the complainant and obtained necessary information from him. Documents as sought were made available to him. Expenses of treatement were born by the complainant from out of his pocket.


Though, he was entitled for cashless treatment. But at the time of discharge from the hospital, none had come from the opposite party, to make payment to the hospital. Thereafter again, due to persisting same arm problem, got hospitalized at Ludhiana hospital, Ferozepur Road, Ludhiana, qua which intimation was given to the opposite party, but none came to the hospital. He spent Rs.50,000/- on treatment which opposite party is liable to pay him under the policy alongwith Rs.1 lac for causing harassment and Rs.1 lac as costs.

2- Opposite party in their reply, have admitted taking insurance policy by the complainant, but claimed that he failed to produce requisite papers. Without investigation of such papers, they are not in a position to sanction claim of the complainant. His claim was never repudiated and complaint, as such, is pre-mature. They have controverted allegations of the complainant. The complainant, under terms and terms of the policy, was required to submit documents, as desired. He failed to make available hospital record, discharge slip, police report, invoices, medical reports, bills, investigation reports. Unless and until those documents are made available, claim can not be settled. Hence, there is no deficiency in service on their part.

3- To prove their respective claims, both parties adduced evidence in the shape of affidavits and documents.

4- We have heard the learned counsel for parties and have gone through the entire record placed on the file thoroughly.

5- It is admitted that Medi Classic Individual Policy (Ex.C2 and Ex.R2) stands obtained by the complainant, effective from 20.7.2007 to 19.7.2008. But we have no material on the record that under this policy, any claim was lodged by the complainant with the opposite party. Though, complainant has filed copy of DDR dated 5.10.2007 Ex.C1 qua the accident, vouchers and receipts Ex.C3 to Ex.C20 regarding purchase of medicines. But there is no proof that he under the policy, ever lodged claim with the opposite party.

I would like to know if Star Health paid the bills of Gayathri Hospital raised on account of treatment to Sri Chennappa to the Complainant?

Quite nice and informative post..
Well please share some more details related to this.I appreciate your job for sharing such needed information here.Please keep sharing in future..

May I know whether they paid the bills? Whether an Execution Petition started? or was there an appeal whether the appeal is pending or allowed or dismissed? Will somebody appraise us of the status of this complaint now? Thanks for your help