Chandigarh

DF-I

CC/235/2023

MOHAN LAL Sharma - Complainant(s)

Versus

CARE HEALTH INSURANCE COMPANY LTD - Opp.Party(s)

WAZIR SINGH

13 Dec 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/235/2023
Date of Institution	:	03/05/2023
Date of Decision	:	13/12/2023

Mohan Lal Sharma son of Sh. Sampuran Dass r/o H.No.99, Rajendra Park, Mahesh Nagar, Ambala (HR)

… Complainant

V E R S U S

1. Care Health Insurance Company Ltd., Branch Office # SCO No.56-57-58, 2^nd Floor, Sector 9-D, Chandigarh, through its Branch Manager.
2. Care Health Insurance Ltd., #604-607, 6^th Floor, Tower-C, Uniteck Cyber Park, Sector-39, Gurugram (HR) through its authorised officer/person.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                               

ARGUED BY	:	None for complainant
	:	Ms. Niharika Goel, Advocate for OP-1
	:	OP-2 ex-parte.

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Mohan Lal Sharma, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that, in the month of May 2023, complainant alongwith his wife Smt. Meera Rani Sharma, had purchased a mediclaim policy namely “Care – Comprehensive Health Insurance Policy” (hereinafter referred to as “subject policy”) and cover type Floater, which was valid w.e.f. 27.3.2021 to 26.3.2023 (Annexure C-1) for two years on payment of premium of ₹70,126/-.  On 22.9.2022, the complainant suddenly suffered health problem with illness of right MCA Infarct, Left ICA Stenosis <50% for which he was taken to Indus International Hospital, Derabassi for immediate treatment and on 24.9.2022 he was discharged and at that time he had spent an amount of ₹60,000/- for his treatment.  Further payment of ₹36,000/- was incurred towards treatment of complainant during that period.  Copies of discharge summary, medical bills and IPD bill are Annexure C-2 & C-3. On 15.3.2023, complainant again felt chest pain, anxiety and sweating due to which he was taken to Civil Hospital, Ambala in emergent situation and due to his critical condition, he thereafter was taken to Adesh Medical College and Hospital, Kurukshetra for his treatment where he was admitted to ICCU for evaluation and management. As the complainant was diagnosed with double vessel disease, he was advised for PCI stent to LCX/Stage PCi to LAD and he was brought to Fortis Hospital, Mohali by his relative for treatment.  On 17.3.2023, CAG was done and it was revealed TVD;PTCA+Stents to LCX-OM and RCA was done and accordingly two stents were implanted and the complainant was discharged on 19.3.2023. The complainant incurred an amount of ₹4,70,000/- on his treatment and copies of OPD card, discharge summaries and inpatient summary bill are Annexure C-4 to C-7. The complainant had submitted all the bills of his treatment to the OPs, but, surprisingly the genuine claim of the complainant was repudiated vide letters (Annexure C-8 and C-9) on the ground that the complainant has concealed the factum of pre-existing ailment of diabetes and due to non-disclosure of material facts.  In this manner, the aforesaid acts of the OPs amount to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OP-1 resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, cause of action, concealment and non-disclosure of material facts.  However, it is admitted that the subject policy was issued to the complainant covering the complainant and his spouse for sum insured of ₹5.00 lacs subject to policy terms and conditions. It is further alleged that the patient was provisionally diagnosed with acute CVA, Left side weakness, TIA?, MCA Infarct, but, the claim was denied vide letter dated 27.9.2022 being withdrawn by the complainant.  It is further alleged that cashless request for reimbursement of subsequent claim was also denied and finally the reimbursement claim was also denied on the ground of non-disclosure of material facts/pre-existing ailments at the time of filling the proposal form by the complainant. Since the complainant was history of diabetes at the time of filling the proposal form and the said fact was not disclosed by him, the claim was rightly repudiated. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. OP-2 did not turn up before this Commission, despite proper service, hence it was proceeded against ex-parte vide order dated 9.10.2023.
4. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, contesting parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for OP-1 and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had purchased the subject policy for himself and his wife from the OPs which was valid w.e.f. 27.3.2021 to 26.3.2023 on payment of premium of ₹70,126/- covering the risk for the sum of ₹5.00 lacs and the complainant had taken treatment for first ailment i.e. with respect to the illness of right MCA Infarct, Left ICA Stenosis  from the Indus International Hospital on 22.9.2022 from where he was discharged on 24.9.2022 and second time had taken treatment from the Fortis Hospital where he remained admitted on 17.3.2023 and was discharged on 19.3.2023 and was treated for heart ailment and the claim of the complainant was repudiated by the OPs on the ground of non-disclosure of pre-existing disease i.e. diabetes, the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in repudiating the claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs have rightly repudiated the claim of the complainant and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, medical record, repudiation letter and the proposal form and the same are required to be scanned carefully in order to determine the real controversy between the parties.
   3. Perusal of the subject policy (Annexure 1) indicates that the same was valid w.e.f. 27.3.2021 to 26.3.2023 in the complainant and his wife were insured. Annexure 16 is the proposal form in which the complainant has been shown to have no pre-existing disease.
   4. Annexure C-9 is the repudiation letter which clearly indicates that the claim of the complainant was repudiated on the ground of non-disclosure of diabetes and material facts/pre-existing ailments and the relevant portion of the same reads as under :-

       “We have reviewed the claim filed by you pertaining to Health Insurance Policy (30865783) and hereby inform you that the claim is not payable as per policy terms and conditions listed below :-

• NONDISCLOSURE OF DIABETES AT THE TIME OF POLICY INCEPTION
• NON DISCLOSURE OF MATERIAL FACTS/PRE-EXISTING AILMENTS AT TIME OF PROPOSAL.”

 

5. Provisional discharge summary of Indus International Hospital (Annexure C-2) indicates that the complainant was admitted on 22.9.2022 and discharged on 24.9.2022 and he was treated and diagnosed as under:-

“PRIMARY DIAGNOSIS

        RIGHT MCA INFARCT

LEFT ICA STENOSIS <50%

COMORBIDITY

        TYPE 2 DIABETES MELLITUS (20 YEARS) – OHAS

DISCHARGE DIAGNOSIS

        RIGHT MCA INFARCT

        LEFT ICA STENOSIS <50%

        TYPE 2 DIABETES MELLITUS

CHIEF COMPLAINTS

        C/O LEFT SIDED WEAKNESS

        DIZZINESS

        HEADACHE

        VERTIGO

HISTORY OF PRESENT ILLNESS

        PATIENT CAME TO HOSPITAL FOR FURTHER MANAGEMENT K/C/O DIABETES MELLITUS.”

 

6. Annexure C-6 is the discharge summary of Fortis Hospital which shows that the complainant was admitted on 16.3.2023 and was discharged on 19.3.2023 and was treated and diagnosed as under :-

        “Diagnosis

1. ACS

2. TVD ON CAG (17/3/23]

3. PTCA WITH STENT TO LCX-OM AND RCA DONE [17/3/23]

4. ADHF-IMPROVED

5. MODERATE LV DYSFUCTION ~30%

6. DM TYPE-2

7. OLD CVA [6 MONTH BACK]

DM TYPE-2

Presenting Complaints

Patient presented with complaints of breathlessness with ghabrahat with chest discomfort since 2 to 3 days. Patient admitted to FHM for further evaluation and management.

Past History/Comorbidities

1. DM TYPE-2

2. OLD CVA [6 MONTH BACK]

Physical Examination

On admission, Conscious, oriented. No pallor, no icterus, no clubbing, no lymphadenopathy, no pedal edema, BP-140/80 mmHg, Temp- Afebrile, Pulse rate 102/min, RR- 22/min, SpO2 98% on room air, B/L Clear Chest on examination. CNS- NAD, Abdomen- Soft, Non-tender, non-distended, bowel sounds present.

Course In The Hospital

Patient admitted with above mentioned complaints and was investigated thoroughly. CAG done on 17/03/23 that revealed TVD; PTCA+STENTS TO LCX-OM AND RCA was done in the same sitting. 2-D ECHO was done report s/o LVEF ~35% with RWMA present. There were no post procedure complications. Patient subsequent stay in the hospital was uneventful and now patient is being discharged on optimum medical management with advice to follow up in OPD.”

7. Thus, one thing is clear from the documentary evidence adduced by the parties that, in fact, the complainant was firstly treated for illness of right MCA Infarct, Left ICA Stenosis whereas second time he was treated for heart ailment where two stents were implanted by the Fortis Hospital, as is also evident from the discharge summary (Annexure C-6) and the claim of the complainant has only been repudiated by the OPs on the ground that he has not disclosed about diabetes at the time of policy and has concealed material facts/pre-existing ailments at the time of proposal.
8. However, there is no merit in the aforesaid ground of repudiation of the claim by the OPs, as it has come on record that even the previous ailment, for which the complainant had taken treatment from the Indus International Hospital i.e. right MCA Infarct, Left ICA Stenosis, has no connection with the subsequent ailment for which the complainant has taken treatment from the Fortis Hospital.  Moreover, in the repudiation letter, OPs have only given reference of diabetes.
9. It has been held by the Hon’ble State Commission, Delhi, in the case titled S.S. Jaspal Vs. National Insurance Co. Ltd. & Ors., IV (2022) CPJ 26 (Del.) that common lifestyle disease like diabetes and hypertension, cannot be treated as pre existing diseases and cannot be a ground of repudiation of claim by Insurance companies. The relevant portion of the order is reproduced as under :-

 “Consumer Protection Act, 1986 - Sections 2(1)(g), 14(1)(d), 15 - Insurance (Mediclaim) -Angioplasty and Stenting - Suppression of pre-existing disease alleged - Repudiation of claim Deficiency in service - District Forum dismissed Complaint - Hence Appeal - Complainant experienced pain in chest and remained admitted in Hospital from 24.6.2004 to 30.6.2004, where he had undergone Angioplasty and Stenting, by incurring Rs.3,20,126 on treatment - Previous medical history is based upon information provided by family of patient - Respondents failed to show any evidence regarding pre-existing disease suffered by insured at time of getting policy - Common lifestyle disease like diabetes and hypertension, cannot be treated as pre existing diseases and cannot be a ground of repudiation of claim by Insurance companies - Respondents failed to show any evidence that any medical tests or examination was done, before issuing said policy in question - Respondents are directed to pay a sum of Rs.3,20,126 (Cost of Medical Expenses) to Appellant along with interest @ 6% p.a.”

10. Similarly, the Hon’ble National Commission in the case titled Sunil Kumar Sharma v. Tata AIG Life Insurance Company and Ors., Revision Petition No.3557 of 2013 decided on 1.3.2021, while dealing with the issue of pre-existing disease, has held as under:-

“14.   Moreover the claim had been repudiated only on the ground that the insured was suffering from diabetes for a long time. So far as life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No.656 of 2007, decided on 17.09.2007 held as under:

"Insurance – Mediclaim -Reimbursement-Present Petition filed for appropriate directions to respondent to reimburse
expenses incurred by him for his medical treatment, in accordance with policy of insurance - Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hyper tension - Petitioner was advised to undergo ECG, which he did - Insurer accepted proposal and issued cover note. It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors. That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without hypertension. It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless. Policy would be reduced to a contract with no content, in event of happening of contingency. Therefore Clause 4.1 of policy cannot be allowed to override insurer's primary liability. Main purpose rule would have to be pressed into service. Insurer renewed policy after petitioner underwent CABG procedure. Therefore refusal by insurer to process and reimburse petitioner's claim is arbitrary and unreasonable. As a state agency, it has to set standards of model behaviour; its attitude here has displayed a contrary tendency. Therefore direction issued to respondent to process petitioner's claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."

11. Further, the Hon’ble National Commission in the case titled as Neelam Chopra Vs. Life Insurance Corporation of India & Ors., IV (2018) CPJ 321 (NC) while dealing with the question of suppression/ non-disclosure of material facts has held as under :-

     12. In the present case, clearly the cause of death is cardio respiratory arrest and this disease was not existing when the proposal form was filled. Clearly, there is no suppression of material information in respect of this disease, which is the main cause of death. The other disease of LL Hansen, which was prevailing for five weeks on the date of admission on 1.8.2003 was also not existing when the proposal was filed by the DLA. The fact of DLA having been treated in the year 2002 for LL Hansen is not supported from any direct evidence though PGI Chandigarh in its certificate has mentioned that disease was treated in 2002. Moreover, this disease does not have any correlation with the cause of death in the present case. Hon’ble Supreme Court in Sulbha Prakash Motegaonkar and Ors. v. Life Insurance Corporation of India, Civil Appeal No.8245 of 2015, decided on 5.10.2015 (SC) has held the following:

        “We have heard learned Counsel for the parties.

                It is not the case of the Insurance Company that the ailment that the deceased was suffering from was a life threatening disease which could or did cause the death of the insured. In fact, the clear case is that the deceased died due to ischaemic heart disease and also because of myocardial infarction. The concealment of lumbar spondylitis with PID with sciatica persuaded the respondent not to grant the insurance claim.

                We are of the opinion that National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischaemic heart disease and myocardial infarction had nothing to do with this lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified.”

12. In view of the foregoing discussion and the ratio of law laid down above, it is clear that the OPs/insurer have not been able to connect the previous diseases/ailments with the present diseases/ailments, for which the insured patient had taken treatment from the treating hospital.  Hence, it is unsafe to hold that the OPs/insurer were justified in repudiating/rejecting the claim of the complainant and the present consumer complaint deserves to succeed. 
13. Now coming to the quantum of relief, since the complainant has proved the bill (Annexure C-3) amounting to ₹26,752 + 2,469 + ₹500 = ₹29,721/- and bill (Annexure C-7) amounting to ₹4,34,512/-, it is safe to hold that OPs/insurer are liable to pay the said amounts i.e. ₹29,721 + ₹4,34,512 = ₹4,64,233/- to the complainant alongwith interest and compensation etc. for the harassment suffered by him.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹4,64,233/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 5.4.2023 onwards.
2. to pay an amount of ₹20,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 13/12/2023 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member
			Sd/- [Suresh Kumar Sardana] Member