Punjab

Ludhiana

CC/20/18

Ram Gopal - Complainant(s)

Versus

Adiya Birla Health Insurance Co..Ltd - Opp.Party(s)

A.N.Juneja Adv.

19 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:18 dated 16.01.2020.                                                 Date of decision: 19.10.2023.

 

Ram Gopal aged 47 years son of Shri Shri Jot Ram, resident of House No.455/10/A, New Kidwai Nagar, Ludhiana.                                                                                                                                       ..…Complainant

                                                Versus

1. Aditya Birla Health Insurance Company ltd., Regd. Office: One India Bulls Centre, Tower 1, 9^th Floor, Jupiter Mill Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai-400013, through its Director/M.D.
2.  Aditya Birla Health Insurance Company Ltd., S.C.O. 16-17, 7^th Floor, Fortune Chambers, Feroze Gandhi Market, Ludhiana, through its Manager.                                                                                                                                                                      …..Opposite parties 

Complaint Under section 12 and 14 of the Consumer Protection Act, 1986.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Rahul Juneja, Advocate.

For OPs                          :         Sh. Ajay Chawla, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant availed a family floater insurance policy No.P/211218/01/2018/005127 of Star Health & Allied Insurance Company Ltd. The complainant further stated that representative of the opposite parties approached him to port his earlier family floater mediclaim insurance policy and assured for waiver of 48 months waiting period as well as for timely settlement of the claim and payment in case of hospitalization for a period of more than 24 hours. It was further assured that all the pre-existing diseases of the complainant and family will be covered under the policy since there is a clause under the policy about the waiting period of 36 months in case of pre-existing disease whereas the period of 48 months waiting period will be waived off for the complainant. As such, the complainant ported his earlier insurance policy from Star Health & Allied Insurance Co. Ltd. and availed service of opposite parties vide insurance policyNo.11-18-0045864 by paying premium of Rs.15,489/- for a sum assured of Rs.5,00,000/-having validity from 27.11.2018 to 28.11.2019. The requisite medical tests of the complainant were got conducted before porting the policy. The complainant further stated that during subsistence of the insurance policy he suffered from severe chest pain on 22.07.2019 and was taken to D.M.C. & Hospital, Ludhiana in emergency where he remained admitted from2 2.07.2019 to27.07.2019 and was diagnosed for “Type 2 Diabetes Mellitus and CAD-Acute TNF Inferior Wall MI, EF-36%.”  The complainant was discharged on 27.07.2019 and he spent Rs.1,70,004.43 on his treatment besides expenses for medicines. The complainant lodged claim with opposite parties for reimbursement of said amount but his claim was repudiated by the opposite parties vide letter dated 07.09.2019, on the reason reproduced as under:-

“As per documents submitted Non-Disclosure of Diabetes/Hypertension is noted from the start of policy with Aditya Birla Health Insurance hence denied. As per documents submitted misrepresentation in the documents/admission is noted.”

According to the complainant, the repudiation of his claim is totally illegal and it amounts to deficiency in service and unfair trade practice. As the complainant ported his policy from Star Health & Allied Insurance Company Ltd. and at the time of portability, the benefit of waiver of 48 months of waiting period was given to the complainant as such, the ailment/diagnose of the complainant was fully covered within waiver of period of 48 months and he is fully entitled for the claim amount. The complainant claimed to have suffered mental pain, agony, harassment etc. due to deficiency in services and unfair trade practice on the part of the opposite parties for which he is entitled to compensation. In the end, the complainant prayed for issuing directions to the opposite parties to make the payment of claim amount of Rs.1,70,004.43 along with compensation of Rs.2,00,000/- and litigation expenses of Rs.21,000/-.

2.                Upon notice, the opposite parties filed joint written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability of the complaint; lack of jurisdiction etc. Under the column facts of the case, the opposite parties stated that the complainant applied for portability of his existing insurance policy bearing No.P/211218/01/.2018/005127 with Star Health & Allied Insurance Company Ltd. into Aditya Birla Health Insurance Company Ltd. and upon receipt of duly signed port form dated 10.12.2018, the previous policy was ported and Family Floater Policy No.11-18-0045864-00 was issued in name of Ram Gopal with Active Health – Platinum Enhanced plan w.e.f. 10.12.2018 to 09.12.2019. The complainant also filled the proposal form. However the complainant concealed the material fact regarding his past medical condition. The opposite parties further stated that on 23.07.2019, they received pre-authorization claim of the complainant from Dayanand Medical College and Hospital for reimbursement of Rs.2,00,000/- which was registe4rd and they raised query to the complainant for submission of additional documents/information. The complainant was suffering from diabetes with coronary artery disease prior to taking of the policy which was not disclosed by the complainant at the time of taking the policy and as such, his claim was denied vide denial letter dated 07.09.2019.  The opposite parties denied any deficiency service on their part.

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections and facts of the case. The opposite parties have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1, Ex. C2 is the copy of discharge summary, Ex. C3 is the copy of investigation report, Ex. C4, Ex. C5 is the copy of claim denial letter dated 07.09.2019, Ex. C6 is the copy of Aadhar card of the complainant, Ex. C7 to Ex. C11 are the copies of bills/receipts, Ex. C12, Ex. C13 is the copy of ECG report, Ex. C14, Ex. C15 is the copy of echocardiography report,  Ex. C16 is the copy of segmental wall motion assessment, Ex. C17, Ex. C18 is the copy of coronary angiography report, Ex. C19, Ex. C20, Ex. C23 is the copy of angiography report-diagramatic, Ex. C21, Ex. C22 is the copy of primary coronary angioplasty report, Ex. C24 is the copy of microbiology result report, Ex. C25 is the copy of blood bank result report, Ex. C26 to Ex. C29 is the copy of insurance policy, Ex. C30 is the copy of premium receipt and closed the evidence.

4.                On the other hand, counsel for the opposite parties tendered documents Ex. OP1 is the power of attorney,  Ex. OP2 is the copy of welcome letter Ex. OP3 is the insurance policy,  Ex. OP4 is the copy of  claim denial letter dated 07.09.2019, Ex. OP5 is the copy of customer information sheet/proposalform. The opposite parties failed to conclude their evidence despite grant of sufficient opportunities including imposition of costs and grant of last chance and as such, their evidence was closed by order vide order dated 20.07.2023.

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 documents produced on record by both the parties.

6.                The complainant is the regular subscriber to health insurance policies since 27.11.2014 from Star Health and Allied Insurance co. Ltd., and this fact can be perused from the policy Ex. C26 to Ex. C29 = Ex. OP3. The complainant ported his family floater health insurance policy  with the opposite parties vide policy Ex. C26 to Ex. C29 = Ex. OP3 w.e.f. 10.12.2018 to09.12.2019. During the subsistence of coverage of said policy, complainant remained hospitalized from 22.07.2019 to 27.07.2019 at Dayanand Medical College & Hospital, Ludhiana where he was diagnosed of diabetes mellitus and CAD-Acute Inferior Wall MI and Coronary Angiography was performed as per discharge summary Ex. C1. An amount of Rs.1,74.254.43 Ex. C and Ex. C8 were incurred on his treatment. The claim of the complainant was denied vide letter Ex. C4 on the following grounds:-

“On scrutiny of the documents it has been observed that the claim is not admissible as per the below mention clause.

Reason: As per documents submitted Non-Disclosure of Diabetes Hypertension is noted before the start of policy with Aditya Birla Health Insurance hence denied. As per documents submitted mispresentation in the documents/ admission is noted.

Section A. PREAMBLE: This Policy has been issued on the basis of the Disclosure to Information Norm, including the information provided by You in respect of the Insured Persons in the Proposal Form and any other details submitted in relation to the Proposal Form. This Policy is a contract of insurance between You and Us which is subject to the receipt of premium in full and the terms, conditions and exclusions of this Policy. 18. Disclosure to Information Norm means the Policy shall be void and all premium paid hereon shall be forfeited to the Company, in the event of fraud, misrepresentation, mis-description or non-disclosure of any material fact... Fraudulent Claims If any claim is found to be fraudulent, or if any false declaration is made, or if any fraudulent devices are used by You or the Insured Person or anyone acting on their behalf to obtain any benefit under this Policy then this Policy shall be void and all claims being processed shall be forfeited for all Insured Persons. All sums paid under this Policy shall be repaid to Us by You on behalf of all Insured Persons who shall be jointly liable for such repayment.vi. Permanent Exclusions: 11. Conditions for which treatment could have been done on an outpatient basis any Hospitalization.”

7.                The main basis of repudiation of the claim by the opposite parties is that complainant concealed the factum of his having suffering from diabetes mellitus and CAD-Coronary Artery Disease. It is the specific case of the complainant that before porting of policy to the opposite parties, requisite medical tests were conducted. The opposite parties did not produce any previous medical record of the complainant, report or affidavit of any investigator on record to substantiate its claim. Perusal of discharge summary Ex. C1 and Ex. C2 shows that the complainant visited Dayanand Medical College & Hospital, Hero DMC Unit Institute for the first time on 22.07.2019 with chief complaints of chest pain few hours prior to admission. A conjoint reading of medical certificate and record produced by the complainant clearly shows that he was not having pre-existing disease of diabetes mellitus and CAD-Coronary Artery Disease. Even seeing from another aspect, the complainant had been availing policies since 2014 and the history of diabetes mellitus and Coronary Artery Disease came into force during subsistence of coverage under the policy itself.

8.                Further reference can be made to Religare Health Insurance Company Ltd. Vs Subhash Chander Aggarwal in 2017(3) CLT 140 whereby it has been held by Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh the hypertension is a common disease and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack and repudiation on account of pre-existing disease was not justified.

9.                The counsel for the opposite parties has referred to the proposal form Ex. OP5 dated 19.11.2018 under the head of medical/lifestyle related information, the complainants have denied having heart attack, heart disease (ischemic/coronary), heart valve disease or any heart disease or procedure/surgery like angioplasty/PTCA or bypass surgery (CABG), High Cholesterol or High Triglycerides, Peripheral Vascular Disease etc. However, the complainant had been availing insurance policies since the year 2014 and he got the ported his earlier insurance policies from Star Health & Allied Insurance Co. Ltd with the opposite parties. In this regard reference can be made to the Insurance Regulatory and Development Authority of India Notification dated 12.07.2016 which clearly defines ‘Portability’ means the right accorded to an individual health insurance policyholder (including family cover), to transfer the credit gained for pre-existing conditions and time bound exclusions, from one insurer to another or from one plan to another plan of the same insurer.

10.              In a case titled as Manmohan Nanda Vs United India Assurance Co. Ltd. and others 2022(I) CPJ 20 (SC) wherein the Hon’ble Supreme Court of India has held as under:-

“(6)   The appellant’s argument that there is no hard and fast rule that every person with DM-II will necessarily have a cardiac disease merely because it is a risk factor holds water. A person who does not suffer from DM-II can also suffer from a cardiac ailment. He had disclosed his DM-II status for which he was under treatment. The ECG report and other tests also indicated normal parameters. Further, statins were a preventive prescription to prevent development of cardiac issues as DM-II is a risk factor, not because he had a cardiac ailment or hyperlipidaemia. Further, the examining physician was informed of the same before the policy was taken. Accordingly, there was no suppression of any material fact by the appellant to the insurer.

(7)     It was for the insurer to gauge related complications based on the information provided. The insurance company did not think that the medical and health condition of the appellant was such which did not warrant issuance of a medical policy. The insurance company therefore did not decline the proposal of the assured as a prudent insurer.”

11.                        In the light of above said facts and circumstances, the opposite parties were not justified in denying the claim of the complainant and as such, there is deficiency in service on the part of the opposite parties. In the given facts and circumstances of the case, if the opposite parties are directed to settle and reimburse the claim with respect to hospitalization of the complainant at Hero DMC Heart Institute, Ludhiana from 22.07.2019 to 27.07.2019 in terms of policy terms and conditions along with interest @8% per annum on the settled amount from the date of filing of complaint till its actual payment. The opposite parties are also burdened with composite costs of Rs.10,000/-.

12.              As a result of above discussion, the complaint is partly allowed with direction to the opposite parties to settle and reimburse the claim with respect to hospitalization of the complainant at Hero DMC Heart Institute, Ludhiana from 22.07.2019 to 27.07.2019 in terms of policy terms and conditions along with interest @8% per annum on the settled amount from the date of filing of complaint till its actual payment within 30 days from the date of receipt of copy of order. The opposite parties shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainants within 30 days from the date of receipt of copy of order.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

13.              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:19.10.2023.

Gobind Ram.