Haryana

StateCommission

A/588/2017

RAJINDER SINGH - Complainant(s)

Versus

NEW INDIA ASSURANCE CO. - Opp.Party(s)

DEEPAK VERMA

23 May 2018

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No:   588 of 2017

Date of Institution: 15.05.2017

Date of Decision : 23.05.2018

 

Rajinder Singh s/o Sh. Tarlochan Singh, Resident of House No.1201, Sector 19-II, HUDA, Kaithal, District Kaithal.

                                      Appellant-Complainant

Versus

1.      The New India Assurance Company Limited Registered and Head Office-87, Mahatma Gandhi Road, Mumbai-400001.

2.      The New India Assurance Company Limited, Kaithal through its Branch Manager.

                                      Respondents-Opposite Parties

 

CORAM:             Mr. Balbir Singh, Judicial Member.

                                                                                                         

Argued by:          Shri Deepak Verma, Advocate for appellant.

                             Shri Rajneesh Malhotra, Advocate for respondents.

 

                                                   O R D E R

 

BALBIR SINGH, JUDICIAL MEMBER

 

        This complainant’s appeal is directed against the order dated December 15^th, 2016 passed by District Consumer Disputes Redressal Forum, Kaithal (for short ‘the District Forum’) whereby complaint was dismissed.

2.                Rajinder Singh-complainant (appellant herein) was provided one medical insurance policy bearing No.35360434142800000082 regarding the period from June 18^th, 2014 to June 17^th, 2015 by The New India Assurance Company Limited-Opposite Parties (for short ‘the Insurance Company’).  In fact, prior to the above mentioned period also, the complainant used to obtain yearly medical insurance policy from the opposite parties for a period of ten years. As per terms and conditions of the insurance policy, the Insurance Company is liable to pay all the expenses incurred for illness of the insured-Rajinder Singh during the existence of the insurance policy and he is entitled to get treatment from multispecialty hospital of his choice also. On April 17^th, 2015 the complainant suffered pain in his chest and he was taken to Shah Hospital, Kaithal from where he was referred to Fortis Hospital, Mohali where he remained admitted for his treatment from 27.04.2015 up to 05.05.2015.  During his treatment in the above mentioned hospital, blockage in arteries was detected. During his stay in Fortis Hospital, the complainant spent and paid an amount of Rs.7,13,209/- for his treatment.  The insurance company was informed in this regard on 27.04.2015. An amount of Rs.28,732/- was spent for treatment when the complainant got treatment from Shah Hospital, Kaithal. Out of the total amount, the opposite parties only approved payment of Rs.2,70,000/- as expenses for his treatment and refused to make payment of the remaining amount.

3.                The complainant filed compliant under Section 12 of the Consumer Protection Act, 1986 with a prayer to direct the opposite parties to pay the balance amount of Rs.4,41,940/- with interest and to pay an amount of Rs.50,000/- on account of un-necessary harassment and mental agony.

4.                The opposite parties in their written version have taken plea that the complaint is not maintainable in the present form; that the complainant has no locus standi to file the present complaint and that the District Forum has no jurisdiction to decide this complaint. The claim of the complainant was processed by Raksha TPA Private Limited (Third Party Administrator). The team of the doctors TPA opined that the patient Rajinder Singh is a known case of hypertension and diabetes mellitus for the last three years. After going through the previous claim history it was also found that the patient had already taken claim for treatment of Community Acquired pneumonia Viral with acute Respiratory Distress Syndrome (ARDS) under the earlier insurance policy No.353604341201000000068. The complainant did not disclose the above mentioned disease in the proposal form and deliberately concealed the material facts. In this situation, the Raksha TPA Private Limited decided that as per condition No.5 of New India Family Floater, the enhanced sum issued of the current policy year will not be applicable and the sum insured available would be Rs.3,00,000/- lacs only and settled the claim for Rs.3.00 lacs less 10% TDS and made payment of an amount of Rs.2,70,000/-. It is prayed that the complaint filed by the complainant be dismissed.

5.                Parties led evidence in support of their respective claims before the District Forum.

6.                After hearing arguments, vide impugned order dated 15^th December, 2016 passed by the learned District Forum, the complaint filed by the complainant was dismissed.

7.                Aggrieved with the impugned order dated 15th December, 2016, the appellant-complainant has filed the present First Appeal No.588 of 2017 with a prayer to set aside the impugned order and to allow the complaint and grant relief to the complainant as prayed in the complaint.

8.                I have heard learned counsel for the parties and perused the case file.

9.                During the course of arguments, there was no controversy of any type that the complainant was provided one medical insurance policy bearing No.35360434142800000082 (Mark C-2) regarding the period from June 18^th, 2014 to June 17^th, 2015 by the opposite parties. It is also admitted fact that prior to the above mentioned one year period, the complainant used to obtain medical insurance policy under the same scheme for the last ten years continuously. It is also admitted fact that regarding the insurance policy provided prior to the insurance policy provided w.e.f. 18.06.2014, the total insured amount was mentioned as Rs.3.00 lacs. The insured amount was got enhanced while providing the above mentioned policy regarding the period from 18.06.2014 up to 17.06.2015.

10.              It is admitted fact that on 27.04.2015, due to complaint of pain in chest, the complainant was taken to Shah Hospital, Kaithal from where for necessary treatment, he was referred to Multispecialty Fortis Hospital, Mohali. The complainant remained admitted in Multispecialty Hospital from 27.04.2015 up to 05.05.2015. As per complainant, during this period, he made payment of Rs.28,732/-in Shah Hospital, Kaithal and thereafter made payment of Rs.7,13,209/- in Fortis Hospital, Mohali for his treatment. It is admitted that out of the total amount spent, payment of only an amount of Rs.3,00,000/-  was allowed by the opposite parties considering the total sum insured in the previous policy bearing No.353604341201000000068. Out of that amount also 10% amount was deducted as TDS and only an amount of Rs.2,70,000/- was paid to the complainant. Version of the complainant is that he is entitled to receive payment of the balance amount spent for his treatment total amounting to Rs.4,41,940/-.

11.              The insurance claim of the complainant was repudiated on the ground that the complainant concealed material facts and did not disclose regarding his pre-existing disease at the time of providing the insurance policy of the current year. In fact, while providing the insurance policy, regarding the period 18.06.2014 to 17.06.2015, the insured amount has been got enhanced from 3,00,000/- lacs to Rs.8,00,000/-. For enhancement of the insured amount, the Insurance Company is required to furnish fresh proposal form and is required to submit required information as per terms and conditions of the insurance policy. As per version of the opposite parties, the complainant at the time of getting enhanced the total insured amount, did not disclose regarding his pre-existing disease and thus violated the terms and conditions of the insurance policy. Learned counsel for the opposite parties argued that in the case summary Exhibit R-4 issued from Fortis Hospital, it is mentioned that patient was admitted at Fortis Hospital, Mohali on 12.01.2013 with history of cold (Rhinorrhoea) and Dry cough for 2-3 days followed by progressive difficulty in breathing for 2 days. The patient had no history of similar complaints in the past and had been on treatment for diabetes and hypertension for the last three years. The patient had no history of tobacco smoking or alcoholism. In the case summary it is not made clear that who told the treating doctor regarding past history of diabetes.  In case summary itself it is not mentioned that the treating doctor based past history after going through any of the document regarding treating the disease in past. The observation in Exhibit R-4 appears to be without any basis. Moreover, the treating doctor who prepared the case summary has not been examined by the opposite parties to make it clear that on what basis he made the above mentioned observations. This fact also cannot be overlooked that the complainant was being provided medical insurance policy by the opposite parties during the provisional ten years prior to the issuance of the current period insurance policy. No document has been placed on the file to prove level of the diabetes as well as hypertension. The above mentioned disease of diabetes and hypertension cannot be considered as dangerous to life in any way. On this point of controversy, a decision of the Hon’ble National Consumer Disputes Redressal Commission (for short ‘the National Commission’) in case law United India Insurance Company Limited and another versus S.K. Gandhi, 2015 (2) CLT 71, supports the version of the complainant. Like in the above mentioned case, as per facts of the case in hand also, it could not be made clear as to whether the patient himself stated that he was suffering from diabetes and hypertension for the last about three years. During the course of arguments, learned counsel for the appellant-complainant argued that merely because in the case summary observation regarding past history of the patient are made that he remained a patient of diabetes and hypertension for the last three years, findings cannot be given that actually the complainant was a patient of diabetes and hypertension  more particularly in the circumstances as neither the treating doctor has been examined nor it is mentioned in the summary report itself that the complainant himself told that he was suffering from diabetes and hypertension for the last about three years. Learned counsel for the complainant argued that merely due to observations made in the case summary Exhibit R-4, insurance claim of the complainant cannot be declined considering it a case of pre-existing disease. In support of his this contention, learned counsel for the appellant-complainant has placed his reliance upon following decisions of the Hon’ble National Commission as well as State Commission, U.T. Chandigarh:-

1.      Kamla Devi versus LIC of India, 2016(2) C.P.J. 649

2.      SBI General Insurance Company Limited versus Balwinder Singh Jolly 2016(4) CLT 372 (Chandigarh State Commission)

3.      Satish Chander Madan versus M/s Bajaj Allianz General Insurance Company Limited, 2016(1) C.P.J. 613

12.              I have closely perused the above cited case laws. Cited case laws above fully support the version of the complainant. As per facts of case law referred above Kamla Devi versus LIC of India (Supra), the insurance claim of the complainant was declined by the State Commission, Haryana on the basis of a certificate issued by a doctor that the deceased was treated for Chronic Renal Failure (CRF) before providing the insurance policy. The revision petition was allowed by the Hon’ble National Commission holding that the complainant was entitled to receive insurance claim as the certificate issued had neither been supported by any other doctor nor hospital record was placed to substantiate that the deceased was treated for Chronic Renal Failure.

13.              In case law Satish Chander Madan versus M/s Bajaj Allianz General Insurance Company Limited (Supra), findings were given by the Hon’ble National Commission that hypertension is a common ailment and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack. Findings were given that the claim was wrongly repudiated.

14.              I have closely perused the cited case law SBI General Insurance Company Limited versus Balwinder Singh Jolly (Supra). In that case findings were given that as per instructions issued by Insurance Regulatory & Development Authority of India (IRDAI), it was the duty of the insurer to put insured to thorough medical examination. Claim raised after issuance of the insurance policy could not be declined on account of non disclosure of the fact of the pre-existing disease. In that case also, findings were given in favour of the claimant.  Cited case laws above fully support the version of the complainant.

15.              The disease of diabetes and hypertension is very common in our society.  In fact, the disease of diabetes and hypertension are not considered as disease of serious nature. The people in large number most of them above the age of about 40-45 years, are suffering from diabetes and hypertension or both.  Diabetes and hypertension are not considered as dangerous to life more particularly during early years. Despite suffering from diabetes and hypertension people in large number are enjoying their lives by taking routine medicines and using necessary precautions. Moreover, it is also not so difficult to get information regarding pre-existing disease of diabetes and hypertension at the time of providing insurance policy.  Information can be obtained regarding diabetes and hypertension within few minutes by a doctor by using apparatus having latest technology. Information can be obtained by blood test also regarding diabetes and hypertension during the previous six months or more than that within few hours. It is strange that knowing fully well  the officers or agents of the insurance company do not want to take trouble to obtain correct information regarding such type of pre-existing disease. 

16.              In fact, at the time of providing insurance policy, the officers as well as agents of the insurance company are always found in haste to receive premium amount and to increase the business of the insurance company. As and when the claimant submits his/her claim, the insurance company starts deep investigation and inquiries regarding pre-existing disease as well as regarding age and income of the insured etc. to save the Insurance Company from its liability to pay the insurance claim. It appears that in the beginning, the insurance companies themselves do not want to get correct information regarding such type of ailments at the time of providing insurance policies.

17.              At the time of providing insurance policy, the insured is also got examined from a doctor on the panel of the Insurance Company. I feel if a doctor cannot get information regarding diabetes and hypertension, then what is the purpose of examination of the insured from the doctor on the panel of the Insurance Company and to make payments to the doctor un-necessarily. In the case in hand, in the case summary mentioning past history, the treating doctor mentioned that the complainant was suffering from diabetes and hypertension for the last about three years without mentioning his source of knowledge in this regard. It is also not mentioned that the patient had himself told the treating doctor that he was suffering from the above mentioned ailments. As per discussions above in detail, keeping in mind all these circumstances, I am of the firm opinion that repudiation of the Insurance Claim submitted by the complainant was not justified. The claimant is entitled to receive the total amount spent for his treatment.

18.              Learned counsel for the opposite parties argued that in the hospital bill Exhibit R-6, the package amount is mentioned as Rs.1,04,150/-. The complainant should not have made payment to the hospital more than the package amount Rs.1,04,150/-.  Learned counsel for the opposite parties argued that the complainant is not entitled to receive the amount spent for his treatment more than Rs.1,04,150/-. It is evident from the bill Exhibit R-6 that an amount of Rs.7,13,209/- was paid by the complainant for his treatment in Fortis Hospital. The amount paid by the complainant more than the package amount of Rs.1,04,150/- is mentioned in detail in the bill Exhibit R-6.  Moreover, the complainant got admitted in Fortis Hospital and information was given to the Insurance Company on the same day.  I feel if the Insurance Company was not satisfied with the bill Exhibit  R-6, the Insurance Company itself should have raised objection before Fortis Hospital authorities after proper investigation. As per facts of the case in hand, the Insurance Company was informed on the date, the insured was admitted in the hospital. I feel the complainant when admitted in Fortis Hospital, certainly was not in a position to resist and to refuse to make payment of the total hospital bill amount. Anyhow, if the Insurance Company feels any grievance in this regard, the Insurance Company can initiate process regarding the remaining disputed amount against Fortis Hospital authorities if the provisions of law permit the insurance company to do so.

19.              As a sequel as per discussions above in detail, I have no hesitation to hold that the repudiation of the insurance claim of the complainant was totally illegally and unjustified. I feel learned District Forum has committed an error while passing the impugned order in favour of the Insurance Company. The impugned order dated 15^th December, 2016 passed by the learned District Forum is held to be illegal, invalid and is liable to be set aside. Hence, the appeal filed by the appellant-complainant is allowed. 

20.              Resultantly, the complaint filed by the complainant stands allowed. The opposite parties are directed to pay the balance amount of Rs.4,41,940/- spent by the complainant for his treatment with interest at the rate of 9% per annum from the date of filing of the complaint and to pay an amount of Rs.25,000/- as compensation on account of un-necessary harassment, mental agony as well as litigation expenses. 

 

Announced: 23.05.2018

(Balbir Singh) Judicial Member

CL