Chandigarh

DF-I

CC/572/2023

S. SUNINDER VEER SINGH Surinder Sarao - Complainant(s)

Versus

M/S CARE HEALTH INSURANCE LIMITED COMPANY - Opp.Party(s)

HARSH NAGRA

04 Nov 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/572/2023
Date of Institution	:	13/12/2023
Date of Decision	:	4/11/2024

 

S. Suninder Veer Singh @ Surinder Saro S/o Late Lakhbir Singh Resident of Flat no 1003/04 Block G1, Maya Garden City Zirakpur SAS Nagar Mohali Punjab.

.Complainant

Versus

1. M/S Care Health Insurance Limited Company Regd. Office SCO 56-57, 2nd Floor, Sector 9-D, Chandigarh through its Branch Manager.

2. M/S Care Health Insurance Limited Company Regd. Office 5th Floor, 19 Chawala House, Nehru Place, New Delhi Through its Managing Director.

Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

                                                                               

ARGUED BY	:	Sh. Harsh Nagra, Advocate for complainant
	:	Sh. Raj K. Narang, Advocate for OPs

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by the complainant under Section 35 of the Consumer Protection Act 2019 against the opposite parties (hereinafter referred to as the OPs). The brief facts of the case are as under:-
   1. It transpires from the averments as projected in the consumer complaint that in December 2022  the complainant was looking for a health insurance policy in the market and he came across the policy of the OPs and the  OP No.1 told the complainant that their policy is best in the market and by believing their words  the complainant  purchased medical policy namely Care Advantage (hereinafter referred to be subject policy) from the OPs  on 20.12.2022 on paying premium amount of Rs.22,105/- with sum insured to the tune of Rs.25.00 lakh valid till 19.12.2023. The policy is annexed as Annexure C-1.  At the time of buying the subject policy, the complainant informed the OP that he was not suffering from any disease and fit and fine. However,  on 01.02.2023 when the complainant has a pain in the stomach and in order to get himself treated, visited the local doctor at Doctor Square multi-speciality Hospital. VIP road, Zirakpur, many medical tests were done on him and the report of all the test were shocking as his total leucocytes Count were more than the normal range. The test report and the doctor prescription is annexed as Annexure C-2(colly). Upon reviewing the haemogram report of the complainant on 02.02.2023, the doctor asked him to get CECT of whole abdomen tested and the test report came on 03.02.2023. The said test report is annexed as Annexure
      C-3. On 06.02.2023, the complainant visited the said doctor again and he referred the complainant to a senior specialist doctor in sector 19 Chandigarh where PET scan of complainant was conducted on 7.2.2023. The prescription and the report of PET scan is annexed as Annexure C-4 & C-5. After getting the result of PET Scan report, the complainant came to know about that he was suffering from cancer and it needed to be operated upon immediately. Thereafter the complainant asked the  customer CARE of OPs if it is covered under the same policy and  he was informed that  he is covered under the policy  and he can get treatment in the best of the hospitals. Believing the words of the OPs’ representative, the complainant went to Fortis hospital Mohali (hereinafter referred to be treating hospital) to get himself treated and he was admitted in the said hospital and underwent the treatment with regard to his illness. At the time of admission in the said hospital, the complainant’s family member showed their insurance policy to them and they submitted their claim in TPA department of the said hospital for approval. However, the family of the complainant was shocked to see that vide pre-authorization letter Annexure C-6 dated 10.02.2023 the OPs denied the claim on various grounds which are un- ethical and arbitrarily. Thereafter the complainant tried his level best to get the approval for the insurance claim but the OPs refused to grant him any claim regarding his ongoing treatment in the hospital. In this regard a reply Annexure C-7 was sent from the treating doctor to the OPs regarding the said treatment. However, again the OPs vide repudiation letter Annexure C-8 dated 17.02.2023 rejected the claim on the unethical grounds. It is alleged that the complainant has spent a huge amount for his treatment and bills issued by the treating hospital are annexed as Annexure C-9 (colly). In this manner, the aforesaid act amounts to deficiency in service and unfair trade practice on the part of OPs. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
   2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action and concealment of fact. However it is admitted that the subject policy Annexure OP-1 was issued to the complainant covering the complainant and his daughter for a sum insured upto Rs.25.00 lakh and the same was valid w.e.f. 20.12.2023 to 19.12.2023. It is further alleged that cashless request of the complainant was cancelled vide Annexure OP-4 on the ground of non-disclosure of material facts of pre-existing disease at the time of obtaining the policy. It is further alleged that in fact the insured and Dr.  Sanjeev tried to manipulate the actual history of the patient since as per ICP of the treating hospital,  the patient is K/C/o caricinoma colon  ascending and Caecum without the duration mention and as the complainant has not disclosed about the said pre-existing disease at the time of obtaining the policy, it is clear violation of  Clasue 6.1 of the terms and conditions of the subject policy and the claim of the complainant was repudiated and the policy was rightly cancelled. On merits, the facts as stated in the preliminary objections have been re-iterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
   3. Despite grant of numerous opportunities, no rejoinder was filed by the complainant to rebut the stand of the OP.
2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully. including the written arguments on record.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant  has purchased the subject health policy from the OPs which was valid w.e.f. 20.12.2022 to 19.12.2023 covering the complainant and his daughter Harleen Kaur with coverage of Rs.25.00 lakh as is also evident from Annexure C-1 and during the currency of the policy, the complainant got treatment from various hospitals and finally got his surgery  done from the treating hospital i.e. Fortis Hospital, Mohali  where he remained admitted w.e.f. 14.2.2023 till 23.2.2023 as is evident from discharge Annexure OP-6 and the cashless request of the complainant was denied by the OPs vide Annexure C-6 dated 10.2.2023 and finally the claim of the complainant was repudiated by the OPs vide repudiation letter Annexure C-8 dated 17.2.2023, 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 for the relief as prayed for as is the case of the complainant or if the complaint of the complainant being false and frivolous liable to be dismissed as is the defence of the OPs.
   2. In the back drop of the foregoing admitted and disputed facts on record, it is clear that the entire case of the parties is revolving around  the subject policy, terms and conditions thereof repudiation letters and medical record of the complainant, which are required to be scanned carefully to determine the real controversy between the parties.
   3. Perusal of Annexure C-1 clearly indicates that the subject policy was issued by the OPs to the complainant and his daughter Harleen Kaur with coverage of 25.00 lakh  on receiving premium amount of Rs.22,105/- and the same was valid w.e.f.  20.12.2022 to 19.12.2023. Annexure C-2  is the test report dated 1.2.2023 which clearly indicates that the Doctor Square Hospital had referred the patient to conduct CECT abdomen. Annexure C-3  is the report of CECT  issued by Expert Imaging. Annexure C-4  is the prescription slip issued by Kare Partners multi specialty hospital who referred the patient to a senior doctor and PET scan. Annexure C-5 is the report of PET scan which shows some complication relating to malignant pathology. The  relevant portion of the said report is reproduced as under:-

“Impression: Scan findings in this case reveals:

• Ill-defined intensely hypermetabolic eccentric circumferential mural thickening seen arising from the ascending colon and hepatic flexure with exophytic component and infiltrating the adjoining segment VI of liver, as described - suggestive of locally advanced primary malignant pathology.
• Hypermetabolic precaval and regional nodes - suggestive of lymphatic metastases.”
  4. Thus, it is clear from PET scan report that the insured  patient was diagnosed with locally advanced primary malignant pathology. Admittedly thereafter the complainant was taken to  the treating hospital i.e. Fortis Hospital  where he was treated and remained admitted w.e.f. 14.2.2023 to 23.2.2023 as is evident from Annexure OP-6 and was diagnosed adenocarcinoma ascending colon etc.  the relevant portion discharge summary is reproduced as under:-

“Diagnosis

ADENOCARCINOMA ASCENDING COLON AND HEPATIC FLEXURE AND INFILTRATION INTO RIGHT KIDNEY AND LIVER (SEGMENT VI) AND DUODENUM (D2-D3 JUNCTION)

SURGERY: EXPLORATORY LAPAROTOMY +EXTENDED RIGHT HEMICOLECTOMY +LIVER RESECTION (SEGMENT VI)+ ILEOCOLIC ANASTOMOSIS AND RIGHT RADICAL NEPHRECTOMY+TUMOUR BEARING SEGMENT OF DUODENUM RESECTED DONE ON 15/02/23

x x x x x x x x

x x x x x x x

Past History/Comorbidities

NOTHING SIGNIFICANT

Physical Examination

On admission, Conscious, oriented. No pallor. No icterus. No clubbing. No lymphadenopathy. No pedal edema, BP-120/80 mmHg. Temp- Afebrile, Pulse rate 98/min, RR-22min, SpO2 97% on room air, Chest- Bilateral air entry equal, CNS- NAD. P/A - soft,non distended Bowel sounds present, mass in right hypochondrium and right lumbar region, non tender.

Course In The Hospital Patient presented to FHM with above mentioned complaints. All relevant investigations were done. After consent, clearance and PAC, patient was taken up for EXPLORATORY LAPARATOMY EXTENDED RIGHT HEMICOLECTOMY +LIVER RESECTION (SEGMENT VI)+ ANASTOMOSIS ILEOCOLIC AND RIGHT RADICAL NEPHRECTOMY TUMOUR BEARING SEGMENT OF DUODENUM RESECTION DONE ON 15/02/23

OPERATIVE NOTES- Large tumor arising from colon-ascending colon & hepatic flexure infilterating posteriorly into right kidney, superiorly into liver segment VI gall bladder anteriorly at the junction of D2-D3( duodenum), massive tumor with dense desmoplastic reaction. Rest of small bowel and intraabdominal organs grossly healthy.

OPERATIVE STEPS: Under GA, in supine position, parts painted and draped. Midline lapurotomy incision made. Abdomen opened in layers. Incision extended towards right side transversely. Operative findings noted. Right colon mobilized by cattall- braasch maneuver. Right branch of middle colic artery located, clipped and cut. Medial to lateral approach taken. lleocolic, right colic artery ligated and cut. Extended right hemicolectomy performed after mobilizing right colon and carefully separated colon and tumor from right ureter. stapled closure of transverse colon done using NTLC-75 mm. Terminal ileum transected 15 cm from ileocolic junction using NTLC 75 MM. Tumor fixed posteriorly to kidney. Right nephrectomy done by Dr A.S Bawa and team. Tumor infilterated into liver segment VI. Liver resection done segment VI using CUSA and Ligasure and hemostasis done at resected liver bed. Longitudinal Stapled closure of duodenum after resection of tumour bearing segment.Cholecystectomy done. Ileocolic anastomosis done -side to side using”

5. Thus, one thing is clear on record that the complainant had taken treatment for the aforesaid ailment during the currency of the subject policy. Perusal of Annexure C-6 clearly indicates that the OPs have denied cashless facility to the complainant on the ground of concealment of material facts with regard to the health of the  insured. Annexure C-9 (colly)  are the reports and bills. Annexure OP-3 is the daily doctor’s progress report which indicates that the complainant was having only past history of hyper tension, DM, CAD  and Hypothyroidism and has not undergone  any surgery prior to obtaining the policy.
6. The learned counsel for the complainant submitted that as it stands proved on record that the complainant was not having any pre-existing disease prior to obtaining the subject policy rather have good health at the time of obtaining the subject policy and as such the OPs have wrongly denied the cashless request and thereafter repudiated the claim of the complainant and the complainant is entitled for the relief.
7. On the other hand the counsel for the OPs submitted that as it stands proved on record that the complainant was suffering from pre-existing disease  i.e.    adenocarcinoma ascending colon  which fact was not disclosed by him at the time of obtaining the subject policy and as such the claim of the complainant was rightly repudiated and the complaint is liable to be dismissed.
8. There is no force in the submissions of the learned counsel for the OPs as it stands proved on record from the medical record having been relied upon by both the parties and issued by the treating hospital that except hypertension, DM, CAD  and Hypothyroidism, the complainant had no other pre-existing ailment nor he had undergone any surgery prior to obtaining the subject policy, which is further corroborated from  Annexure OP-3 produced on record by the OPs as well as from Annexure OP-6  the discharge summary wherein under the heading of Past history/comorbidities nothing significant has been mentioned, making it clear that the complainant was not suffering from any pre-existing disease which had any nexus with the  ailment for which the complainant had undergone surgery in the treating hospital  during the currency of the policy.
9. The defence of the OPs that even during investigation it was found that the insured patient was found to be suffering from K/C/o caricinoma colon  ascending and Caecum without the duration mentioned by Dr. Sanjeev, which shows that Dr. Sanjeev and insured actually tried to manipulate the actual history of the insured patient. However, when the medical officer of the treating hospital has referred in his report Annexure C-7 alongwith other medical record having been relied upon by the parties that the insured patient  was not having any pre-existing disease which has any direct nexus or connection with the present ailment for which the treatment was taken by the complainant from the treating hospital especially when the said fact is unrebutted by the OPs in order to prove that the complainant was having pre-existing disease prior to obtaining the subject policy and the same was having nexus with the ailment for which the complainant has taken treatment from the treating hospital, it is safe to hold that the complainant was not suffering from the ailment for which he has taken treatment from the treating hospital prior to obtaining the subject policy and the OPs have failed to prove that  hyper tension, DM, CAD  and Hypothyroidism have any nexus with the current ailment  for  which the complainant has filed the instant claim.
10. The 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 as under:-

       “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.”

 

11. 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.”

12. 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."

13. 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.”

 

14. 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 had taken treatment from the treating hospital.  Hence, it is unsafe to hold that the OPs were justified in rejecting/denying the claim of the complainant and the present consumer complaint deserves to succeed.  .

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 the claim amount of ₹18,36,983/- to the complainant alongwith interest @ 9% per annum (simple) from  the date of repudiation of claim till onwards
   2. to pay ₹30,000/- to the complainant as compensation for causing mental agony and harassment;
   3. to pay ₹10,000/- to the complainant/s as costs of litigation.
5. This order be complied with by the OPs jointly and severally within a period of 45 days from the date of receipt of certified copy thereof, failing which the amount(s) mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
6. Pending miscellaneous application(s), if any, also stands disposed off.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 4/11/2024			[Pawanjit Singh] President
mp
			[Surjeet Kaur] Member