Haryana

Karnal

CC/306/2021

Gurdial Singh - Complainant(s)

Versus

Star Health And Allied Insurance Company Limited - Opp.Party(s)

Nikhil Goel

15 Sep 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No. 306 of 2021

                                                        Date of instt.05.07.2021

                                                        Date of Decision:15.09.2023

 

Gurdial Singh son of Shingara Singh age 61, resident of house no.158, Budha Khera District Karnal-132001, (Aadhar card no.5597 6131 2068).

                                               …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance company Ltd. registered office at 2^nd floor, SCF-137, sector-13, Urban Estate, Karnal-132001, through its Manager/authorized person.

 

2. Star Health and Allied Insurance Company Ltd. registered office no.15, Sri Balaji Complex, 1^st floor, whites lane, Royapettah, Chennai-600014.

 

                                                                      …..Opposite Parties.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.

              Shri Vineet Kaushik……Member

              Dr. Rekha Chaudhary…..Member

                   

Argued by: Shri Nikhil Goyal, counsel for complainant

                   Shri Naveen Khetarpal, counsel for the OPs.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant had purchased a medical insurance policy from OPs, vide first policy no.P/211114/01/2020/003798 and since two years i.e. from 18.07.2019, complainant is having medical insurance policy in continuation. The premium of the said policy was paid Rs.24142/-. On 10.11.2020, complainant became ill (pain in stomach) and for the said illness, complainant visited to Sanjeev Bansal Cygnus Hospital, Karnal and complainant was attended by Dr. Puneet Bansal. After checkup, doctor said that the was having acute virul gastritis and advised some medicines to complainant. The illness of the complainant was not controlled and pain in stomach becomes more virulent then complainant visited to Amritdhara Hospital, Karnal on 11.11.2020 and complainant was attended by Dr. Amit Sharma. After check up, doctor told that the complainant was having epigastric pain and advised by doctor to get conducted various tests so as to detect the exact reason for pain which includes endoscopy and histopathology, biopsy, small specimen. Both tests were conducted on 11.11.2020 and 14.11.2020 respectively. After seeing the test reports of the complainant OPD was done till 04.01.2021 and suggested to take the advised medicines. The health of the complainant was not controlled, so complainant visited to Sarvodaya Multispecialty Hospital, Karnal on 09.01.2021. After check up and seeing previous reports, the doctor suggested taking the advised medicines. On 19.01.2021, complainant visited to Dr. Kuldeep Singh clinic, 391, Mugal Canal, Karnal and complainant was attended by Dr. Kuldeep Singh. After checkup and seeing previous reports, doctor advised for ultra sound and full body checkup. These tests were done on 22.01.2021. No improvement was shown in the health of the complainant, complainant again visited in the hospital of Sanjeev Bansal Cygnus Hospital, Karnal. On 26.01.2021, as per advice of the doctor, complainant got admitted to hospital and remained admitted till dated 27.01.2021. During the course of treatment various tests were conducted and medicines/injections/infusions were given and for the same a sum of Rs.17013 has been spent by the complainant.

2.             It is further averred that when the health of the complainant starts getting worse, complainant visited to the Dayanand Medical College and Hospital, Ludhiana on 09.01.2021 and complainant was attended by Dr. Ajeet Sood. After checkup, doctor said that the complainant was having epigastric pain and advised tests to detect the reason for pain. The complainant also intimated to OPs for the said illness and admission of the complainant and hospital well in time and also after diagnose was completed, complainant lodged the claim with the OPs. OPs collected all the original documents. After that, complainant continuously requested to OPs to release the claim amount but on 27.01.2021, the claim of the complainant was rejected the cashless claim by mentioning necessary documents were not submitted by the hospital and said that to file the claim for reimbursement of claim. When complainant filed the claim for reimbursement of the claim alongwith necessary documents on dated 08.03.2021, the insurance company raised the enquiry by sending letter through mail for additional documents which includes past consultation, investigation reports, treating doctor self-declaration and first diagnostic details and  past hospitalization records. The complainant after receiving said letter submitted all the documents but, OPs vide letter dated 06.05.2021 rejected the claim of the complainant mentioning therein that at the time of obtaining of the policy, complainant had not disclosed the medical history. OP told that complainant was suffering from chronic Hepatitis B infection when the medical policy was taken by the complainant and OPs also told that chronic hepatitis B infection is equivalent to acute viral gastritis. In this way, there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

3.             On notice, OPs appeared and filed its written version, raising preliminary objections with regard to maintainability; limitation; jurisdiction; cause of action; locus standi; mis joinder and non-joinder of parties and concealment of true and material facts. On merits, it is pleaded that the insured availed the Family Health Optima Insurance Plan covering Mr. Gurdial Singh-self and Mrs. Swaranjeet Kaur-spouse, for the sum insured of Rs.5,00,000/-, vide policy no.P/211114/01/2020/003798, valid for a period from 18.07.2019 to 17.07.2020, the policy as reviewed, vide policy no.P/211114/01/2021/003665, valid for a period from 18.07.2020 to 17.07.2021. It is further pleaded that complainant requested for a cashless authorization for the treatment of acute viral Gastritis at Sanjiv Bansal Cygnus Hospital, Karnal. On scrutiny of cashless claim documents received in the office of OPs, medical team of OPs observed that the condition of the insured patient does not require hospitalization and he/she could have been treated as an outpatient. Hence, the cashless request was rejected, vide letter dated 27.01.2021. Subsequently, complainant submitted the claim documents for the reimbursement of medical expenses incurred on the treatment of acute viral Gastritis, chronic, hepatitis B infection for Rs.32,307/-.  It is further pleaded that on scrutiny of claim documents, medical team of OPs observed that although the present admission and treatment of the insured patient is for acute viral Gastritis, it is observed from the OPD card dated 05.02.2021 of Dayanand Medical College and Hospital submitted in response to query that the insured patient has chronic hepatitis B infection and has taken treatment for the same in the year 2015 for 3 month, which confirms that the insured patient has chronic hepatitis B infection prior to inception of medical insurance policy. At the time of inception of the policy which is from 18.07.2019 to 17.07.2020, complainant has not disclosed the abovementioned medical history/health details of the insured person in the proposal form which amounts to representation/non-disclosure of material facts. As per condition no.6, if there is any misrepresentation/non-disclosure of material facts whether by the complainant or any other person acting on his behalf, company is not liable to make any payment in respect of any claim. The rejection of the reimbursement claim is conveyed to the complainant, vide letter dated 06.05.2021. It is further pleaded that as per the complaint, complainants states that he spent an amount of Rs.46,361/- as treatment expenses but complainant has submitted bills for reimbursement of Rs.32,307/- only. There is no deficiency in service and unfair trade practice on the part of the OPs. 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 complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of repudiation letter dated 06.05.2021 Ex.C1, copy of letter dated 08.03.2021 Ex.C2, copy of letter dated 27.01.2021 regarding denial of pre-authorization Ex.C3, copy of insurance policy Ex.C4, copy of identity card Ex.C5, copy of PAN card of complainant Ex.C6, copy of OPD consultation slip dated 11.11.2020 Ex.C7, copy of bill dated 11.11.2020 Ex.C8, copy of payment receipt for endoscopy test Ex.C9, copies of medicine bills Ex.C10 and Ex.C11, copy of OPD slip of Dr. Amit Sharma dated 07.12.2020 Ex.C12, copy of consultation fee receipt Ex.C12/A, copy of medical bill Ex.C13, copy of ultrasound report Ex.C14, copy of payment receipt of ultrasound Ex.C14/A, copy of OPD slip dated 04.01.2021 Ex.OP15, copy of consultation fee receipt Ex.C15/A, copies of medicines bills Ex.C16 and Ex.C17, copy of surgical pathlogy report Ex.C18, copy of bill Ex.C19, copy of endoscopy report Ex.C20, cop of test report dated 22.01.2021 Ex.C21, copy of OPD slip Ex.09.01.2021 Ex.C22, copy of consultant fee receipt Ex.C22/A, copy of medicines bill Ex.C23, copy of OPD slip of Dr. Kuldeep Singh dated 19.01.2021 Ex.C24, copy of consultant fee receipt Ex.C24/A, copies of medicines bills Ex.C25 to Ex.C27, copy of payment receipt of Dr. Sanjeev Bansal Cygnus Hospital, Karnal Ex.C28, copy of final bills dated 27.01.2021 Ex.C29, copy of discharge summary dated 27.01.2021 Ex.C30, copy of discharge confirmation letter dated 27.01.2021 Ex.C30/A, copy of provision discharge Ex.C31, copy of tests reports dated 26.01.2021 and 27.01.2021 of Sanjeev Bansal Cygnus Hospital, Karnal Ex.C32 to Ex.C42, copy of ultrasound report Ex.C43, copy of OPD slip dated 10.11.2020 Ex.C44, copy of consultant fee Ex.C44/A, copy of medicine bill Ex.C45, copy of OPD slip dated 01.02.2021 alongwith consultant fee receipt Ex.C46 and Ex.C46/A, medicines bill Ex.C47 and Ex.C48, copy of OPD card of Dayanand Hospital dated 05.02.2021 Ex.C49, copy of OPD card dated 26.02.2021 Ex.C50, copy of consultant fee receipt Ex.C50/A, copies of medicines bills Ex.C51 and Ex.C52, copy of clinical test report dated 05.02.2021 Ex.C53, copy of consultant fee receipts Ex.C54 and Ex.C55, copy of OPD card of Dayanad Hospital  alongwith consultant fee receipt Ex.C56 and Ex.C56/A, copy of medical bill Ex.C57, copy of Fibroscan report alongwith payment receipt Ex.C58 and Ex.C58/A, copy of aadhar card of complainant Ex.C59 and closed the evidence on 19.01.223 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.RW1/A, copy of customer information sheet Ex.R1, copy of terms and conditions of the policy Ex.R2, copy of insurance policy Ex.R3, copy of endorsement schedule Ex.R4, copy of letter dated 07.05.2021 regarding cancellation of the policy Ex.R5, copy of proposal form Ex.R6, copy of request for cashless Ex.R7, copy of field visit report Ex.R8, copy of query letter dated 27.01.2021 on pre-authorization Ex.R9, copies of letters dated 27.01.2021 regarding denial  and rejection of pre-authorization Ex.R10 to Ex.R12, copy of claim form Ex.R13, copy of discharge summary Ex.R14, copy of final bill Ex.R15, copy of OPD slip Ex.R16, copy of prescription slip Ex.R17, copy of biochemistry report Ex.R18, copy of prescription slip Ex.R19 and Ex.R20, copy of repudiation letter Ex.R21, copy of calculation sheet Ex.R22 and closed the evidence on 03.04.2023 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 OPs. On 10.11.2020, complainant has suffered pain in his stomach and for that, he  visited to Sanjeev Bansal Cygnus Hospital, Karnal and had taken the treatment but the condition of the complainant was improved so that he went to various hospital for taking the treatment and spent Rs.46,361/- on his treatment. Complainant submitted the claim with the OPs for reimbursement of the abovesaid amount but OPs did not pay the claim and repudiated the same vide letter dated 06.05.2021 on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version has vehemently argued that at the time of obtaining the policy in question, the insured has chronic hepatitis B infection and has taken treatment for the same in the year 2015 for three months. Thus, the claim of the complainant has rightly been repudiated by the OPs, vide letter dated 06.05.2021 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 OPs. It is also admitted that complainant was hospitalized in various hospitals during the subsistence of the insurance policy. 

11.           The claim of the complainant has been repudiated the by the OPs, vide letter Ex.R1 dated 06.05.2021 on the grounds which is reproduced as under:-

“We have processed the claim records relating to above insured-patient seeking reimbursement of hospitalization expenses for treatment of acute viral gastritis, chronic hepatitis B infection.

Although the present admission and treatment of the insured patient is for acute viral gastritis, it is observed from the OPD card dated 05.02.2021 of Dayanand Medical College and Hospital submitted in response to our query that the insured patient has chronic hepatitis B infection and has taken treatment for the same in the year 2015 for the past 3 months which confirms that the insured patient has chronic hepatitis B infection prior to inception of medical insurance policy.

At the time of inception of your policy which is from 18.07.2019 to 17.07.2020, you have not disclosed the above mentioned medical history/health details of the insured-person in the proposal form which amount to representation/non-disclosure of material facts.

As per condition no.6, if there is any misrepresentation/ non-disclosure of material facts whether by the complainant or any other person acting on his behalf, company is not liable to make any payment in respect of any claim.

We are, therefore, unable to settle your claim under the above policy and we hereby repudiate your claim”.

 

12.           The claim of the complainant has been repudiated by the OPs on the ground of concealment of true and material facts with regard to health of insured at the time of obtaining the insurance policy.

13.            The onus to prove its version was relied upon the OPs but OPs have miserably failed to prove the same by leading any cogent and convincing evidence. The case of OPs is based upon the treatment i.e. OPD slip issued by doctor of Dayanand Medical College and Hospital, Ludhiana Ex.C49. In the said said OPD slip, issuing doctor has mentioned that insured patient has taken treatment for hepatitis B infection in the year 2015 for the  3 months, but OPs failed to obtain the treatment record, from where the complainant had taken the treatment for the said disease in the year 2105 as alleged by the OPs. OPs neither examined the doctor of Dayanand Medical College and Hospital, Ludhiana nor tendered his affidavit in evidence to prove its version. Furthermore, the said document is only an OPD slip, which is a photocopy. Thus, the same has no value in the eyes of law. It was the duty of the OPs, to verify the record from the hospital from where the complainant has taken the treatment as alleged by the OPs in its pleading. In this regard, we relied upon authorities titled as Sucha Singh Vs. Head Brach Office, HDFC Life and Another 2022 CJ 901 (NC) wherein Hon’ble National Commission held that death due to heart attack-claim repudiated on ground of pre-existing ailment-complaint dismissed by State Commission-Insurance Company cannot travel beyond grounds mentioned in repudiation letter-When policy has been revived, it revives from date when it was originally issued-Insurance Company had failed to prove that insured had concealed his medical conditions on the date when he took policy-There is nothing on record to show that deceased was suffering from chronic alcoholic condition and was suffering with chronic liver disease and that he submitted fake documents at the time of obtaining original policy-State Commission had adopted wrong approach while rejecting complaint-Respondent shall pay to complainant assured amount alongwith 9% interest. Further, in case titled as Bajaj Allianze Life Insurance Co. Ltd. and others Vs. Vinod Kumar Kaushik (since deceased) 2021 CJ 956 (NC) Hon’ble National Commission held that Mediclaim-Family Care First Plan (Medical Policy)- Surgery for total hip replacement- Non-settlement of claim by Insurance Company on ground of pre-existing condition-Complaint allowed by Fora below-Averments made by OP were noat supported by documentary evidence-OP relied on treatment record relating to past history of insured, which were neither verified no supported by proper evidence-In absence of any evidence, it cannot be said that insured was having any past history-Petitioners have failed to point any illegality or irregularity in order passed by State Commission, warranting interference in exercise of Revision-Revision Petition dismissed. Further in case titled as SBI Life Insurance Co. Ltd. Vs. Lakshiben Naginbhai Chauhan and others 2020 CJ 110 (NC) Hon’ble National Commission held that Insurance-SBI Home Loan Master Policy-Repudiation of death claim on ground of concealment of pre-existing disease-Complaint allowed by fora below-Both District Forum and State Commission had reached to conclusion after going through all documents that medical papers have not been properly proved since neither doctor has been duly examined nor his affidavit has been furnished-National Commission is not expected and required to re-appreciate and re-assess evidences-where on the basis of evidences Fora below have reached to a conclusion which is a possible conclusion, then such conclusion need not be disturbed in Revision Petition-Revision petition dismissed. Further in case titled as Bajaj Allianz Life Insurance Co. Ltd. and 2 others Versus Kanduru Gangadhara Rao in Revision Petition no.1054 of 2020 Hon’ble National Commission held that Insurance Law-concealment of disease-Death claim repudiated by insurer on ground that life assured suppressed her health condition of her taking treatment for  placed reliance on the treatment record, ‘Chronic non-specific cervicitis’ prior to obtaining the policy-Hence this complaint-Held, insurance company placed reliance on treatment record, which was a mere photocopy and not certified. The Doctor who treated the Life Assured was also not examined nor was his affidavit filed by the insurance company. Also, insurance company failed to satisfy this Commission that there was any co-relation between death of the Life Assured and the suppression of ailment "Chronic non-specific cervicitis". Complaint allowed.

14.  

“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”.

15.           Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OPs while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

16.           The complainant claimed Rs.46,361/- and in this regard he has submitted the medical bills  on record. The said bills have not been rebutted by the OPs. Hence, the he is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

17.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.46361/- (Rs. forty six thousand three hundred sixty one only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of claim i.e. 06.05.2021 till its realization. We further direct the OPs to pay Rs.10,000/- to the complainant on account of mental agony and harassment and Rs.5500/- 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: 15.09.2023

                                                                President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

             (Vineet Kaushik)     (Dr. Rekha Chaudhary) 

                   Member                  Member