Haryana

Karnal

CC/212/2021

Dinesh Bhati - Complainant(s)

Versus

Cholamandlam MS General Insurance Company Limited - Opp.Party(s)

Ved Pal

10 Apr 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 212 of 2021

                                                        Date of instt.12.04.2021

                                                        Date of Decision:10.04.2024

 

Dinesh Bharti son of Shri Hari Chand Bharti, resident of house no.462, Bharti Villa, near Bharti Dairy, Budda Khera Tehsil and District Karnal, aged about 55 years. Aadhar card no.7723 1854 1133.

 

                                                                        …….Complainant.

                                              Versus

 

Cholamandlam MS General Insurance Company Ltd. having its branch office at City Centre, Sector-12, opposite mini secretariat, Karnal through its Branch Manager.

 

                                                                 …..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Dr.  Suman Singh…..Member

 

 Argued by: Shri Ravi Sharma, counsel for the complainant.

                    Shri Naveen Khetarpal, counsel for the OP.

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant is having a Group Health Insurance policy bearing no.2876/00025954/000007/000/00, valid from 27.09.2019 to 26.09.2020, for an amount of Rs.7,50,000/-. The same has been renewed from the OP from 27.09.2020 to 26.0.2021. Said renewed policy is having risk cover of an amount of Rs.10,00,000/-. On 13.07.2020, complainant started some breathing problem and he was taken to the Aashirwad Advanced Heart Lung and critical care centre, Karnal where his ECHO Cardiography was conducted and the doctor opined that he is having Aortic Valve disease and advised the complainant for Dobutamine ECHO for Aortic valve disease. On 29.08.2020, complainant got conducted Dobutamine stress Echocardiography from Paras Hospital, Panchkula and the doctor opined that the complainant need heart operation but the family members of the complainant have refused to get the operation of the complainant as they want to get opinion from some other hospital. Thereafter, complainant was shifted to the Medanta the Medicity, Gurgaon on 29.09.2020 where many tests were conducted and Dr. Anil Bhan advised for the heart operation of the complainant and accordingly on 01.10.2020 his operation was conducted and he was discharged from the hospital on 08.10.2020. The complainant has spent an amount of Rs.7,21,365/- on his treatment. After discharge from the hospital, complainant submitted the bills with the OP and lodged claim of the abovesaid amount and the OP completed certain formalities from the complainant and assured that the said amount will be disbursed to him very soon but the same was not disbursed by the OP and lingered the matter on one pretext or the other. On 05.11.2020, vide letter OP demanded some documents and same were duly supplied by the complainant. Thereafter, complainant received a letter dated 14.12.2020, vide which the claim of complainant has been repudiated on the ground that signs and symptoms of the present ailment AOE were existing since one year which is prior to the inception of policy, hence present ailment is considered as pre-existing disease and the claim is not admissible as per General Exclusion clause 3.2. The said plea taken by the OP is totally illegally, null and void because prior to 13.07.2020, the complainant was not having any kind of problem. Even the Doctor of Medanta Hospital gave in writing that the aforesaid problem is recently diagnosed and was not an old disease. On receipt of said letter from the OP, complainant approached the OP and requested for making payment of the insured amount but OP did not pay the same. Prior to getting policy from the OP, complainant was having health policy from the year 2016 to 2019 from the National Insurance Company and never took such type of claim from that company which proves that the complainant was not having any pre-existing disease. The abovesaid act and conduct of the OP is illegal, null and void and deficiency in service and unfair trade practice due to which complainant has been suffering from great mental pain, agony and harassment. Hence complainant filed the present complaint.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that complainant had taken a health insurance policy no.2876/00025954/000007/000/00, valid from 27.09.2020 to 26.09.2021, for an amount of Rs.10,00,000/- from OP. On 13.07.2020, complainant felt some breathing problem and got admitted to the hospital. He was further advised for Dobutamine ECHO for Aortic value disease. The same was conducted on 29.08.2020 from Paras hospital, where he was suggested for heart operation but the complainant refused to do the same. He further consulted with Medanta hospital on 29.09.2020 where the heart operation was done. He was discharged from the hospital on 08.10.2020. He spent Rs.721365/- towards the treatment. On perusal of documents submitted by the complainant, it was observed that the signs and symptoms of the present ailment AOE were existing since one year, which is prior to the inception of policy. Hence, present ailment is considered as pre-existing disease and the claim is not admissible as per General Exclusion clause 3.2 which reads as No indemnity is available or payable for claims directly or indirectly cause by, arising out of or connected to any pre-existing any pre-existing condition(s) as defined in the policy. Until 24 months of continuous coverage have elapsed, since inception of the first policy with the insurer. So, being not maintainable, claim of the complainant was repudiated by the OP, vide repudiation letter dated 14.12.2020. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy for the period from 27.09.2019 to 26.09.2020 Ex.C1, copy of insurance policy for the period from 27.09.2020 to 26.09.2021 Ex.C2, copy of ECHO Cardiography report Ex.C3, copy of Dobutanine Stress Echocardiography from Paras Hospital investigation report dated 29.08.2020 Ex.C4, copy of discharge summary and bill of treatment of complainant of Medanta Hospital Ex.C5, copy of letter/query report dated 02.10.2020 Ex.C6 to OP by Medanta Hospital Doctor  Shri Anil Bhan, copy of health claim query letter dated 05.11.2020 Ex.C7, copy of claim repudiation letter dated 14.12.2020 Ex.C8, copies of mediclaim policies of complainant and his family from National Insurance Company from 16.10.2016 to 15.10.2019 Ex.C9 to Ex.C11 and closed the evidence on 08.02.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Sujeet Kumar Sahu Ex.RW1/A, copy of repudiation letter dated 14.12.2020 Ex.R1, copy of insurance policy alongwith terms and conditions Ex.R2 and closed the evidence on 06.07.2023 by suffering separate statement.

6.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant purchased a health insurance policy from the OP. Prior to purchasing policy from OP, the complainant was having health policy from the year 2016 to 2019 from the National Insurance Policy and thereafter ported the said policy to the OP company. On 13.07.2020, complainant started some breathing problem and he was taken to the Aashirwad Advanced Heart Lung and critical care centre, Karnal and thereafter taken to Paras Hospital, Panchkula and the doctor opined that the complainant need heart surgery. On 29.09.2020, complainant was shifted to the Medanta the Medicity, Gurgaon  where  on 01.10.2020 his heart surgery was conducted and he was discharged from the hospital on 08.10.2020. The complainant has spent an amount of Rs.7,21,365/- on his treatment. After discharge from the hospital, complainant lodged the claim with the OP for reimbursement of the said amount and completed all the formalities but the claim amount was not disbursed by the OP and repudiated the same, vide letter dated 14.12.2020 on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version has vehemently argued that the signs and symptoms of the present ailment AOE were existing since one year, which is prior to the inception of policy. Hence, present ailment is considered as pre-existing disease and the claim is inadmissible as per General Exclusion clause 3.2. So, the claim of complainant has rightly been repudiated by the OP, vide repudiation letter dated 14.12.2020 on the ground of pre-existing disease and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, the complainant had purchased the policy in question from the OP. It is also admitted that during the subsistence of the insurance policy, complainant was hospitalized in various hospitals. 

11.           The claim of the complainant has been repudiated the by the OP, vide letter Ex.C8/Ex.R1 dated 14.12.2020 on the ground which is reproduced as under:-

“On scrutiny of the claims documents submitted, we observe that the claim is not admissible for the following reasons:

On perusal of the documents, it is observed that the signs and symptoms of the present ailment AOE were existing since one year, which is prior to the inception of policy (27 September, 2019). Hence, present ailment is considered as pre-existing disease and the claim is inadmissible as per General Exclusion clause 3.2 which reads as No indemnity is available or payable for claims directly or indirectly cause by, arising out of or connected to any pre-existing any pre-existing condition(s) as defined in the policy. Until 24 consecutive months of coverage for the insured person have elapsed, since inception of the first policy with the insurer.”

 

12.           The claim of the complainant has been repudiated by the OP on the ground of pre-existing disease.

13.            The onus to prove its version was relied upon the OP but OP has miserably failed to prove the same by leading any cogent and convincing evidence. There is nothing on file to prove that complainant was having any disease prior to inception of the insurance policy. Complainant has alleged that he was having health policy from the year 2016 to 2019 from the National Insurance Company, which are Ex.C9 to Ex.C11 and thereafter he got ported the policy with the OP company. The said pleas have not been denied by the OP. The portability defined by the IRDA vide its circular Reference No. IRDA/HLT/MISC/CIR/209/ 09/2011) is as under:-

Portability:  Portability means the right accorded to an individual health insurance policyholder (including family cover) to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policyholder chooses to switch from one insurer to another insurer or from one plan to another plan of the same insurer, provided the previous policy has been maintained without any break.                 

14.           There is no break in the medical insurance policy issued by the National Insurance Company, prior to portal of the same in the OP company. The complainant further relied upon the clause 4.10 © of Portability, which is reproduced as under:-

Pre-Existing disease will be covered in the policy if you were insured continuously and without interruption for at least 4 years under another Indian insurer’s individual health/ family health insurance policy for the reimbursement of medical costs for inpatient treatment in a hospital.

 15.          In the present case, the insured patient admitted in the hospital first time for the abovesaid disease on 13.07.2020. Meaning, thereby, waiting period of 24 months is not applicable in the present case. Hence, the plea taken by the OP has no force.

 16.          We further fortified with the observation of Hon’ble National Commission in case titled as Mrs. Rubi Chandra Dutta Versus M/s United India Insurance Co. Ltd., (2011) 3 scale 654, decided on 16.12.2016 wherein it is held that “It was 2 years before switching over the policy with the OPs. Therefore, once portability scheme was accepted by OPs then they had no right to decline the claim upto the amount of sum assured of previous insurance policy in case it was within the terms and conditions of the policy. The policy with New India Assurance Company was continuing since 2001 and counsel for OPS was unable to pin point how the claim to the extent of Rs.1,30,000/- allowed by the District Forum was not payable under the policy. Clause 1 of the policy speaks that under portability right accorded to an individual health insurance policy holder to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policy holder chooses to switch from the one insurer to another insurer or from one plan to another plan. Under that scheme whatever has been gained by the insured under the policy insured by the previous insured will be gained by the insured under the portability scheme. Therefore, we do not agree with the plea raised by the OPs. Even otherwise, the policy was continuing one since 2001.”               

17.           Furthermore, complainant has placed on file letter/query report Ex.C6 dated 02.10.2020 issued by Doctor Anil Bhan of Medanta Hospital wherein it has been specifically mentioned that patient is not diabetic and has been recently diagnosed to be hypertensive-first consultation paper as provided by patient and his family is dated 13.07.2020. Thus, in view of the above, the claim of complainant was repudiated by the OP only on the basis of presumption and assumption. Thus, the repudiation letter is totally arbitrarily, unjustified, biased, based on the presumptions and assumptions.  

18.            Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

 19.          Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, the act of the OP while repudiating the claim of the complainant amounts to deficiency in service and unfair trade practice.

20.           The complainant has spent Rs.7,21,365/- on his treatment, it has been proved from the copy of bill Ex.C5. Moreover, said bill amount neither denied nor rebutted by the OP.  Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

21.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.7,21,365/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 14.12.2020 till its realization. We further direct the OP to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses. This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:10.04.2024                                                                     

                                                               

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 (Vineet Kaushik)       (Dr. Suman Singh)

                          Member                          Member