Haryana

Karnal

CC/214/2020

Hariom - Complainant(s)

Versus

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

Vishal Kundi

30 Nov 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL  COMMISSION, KARNAL.

 

                                                         Complaint No. 214 of 2020

                                                          Date of instt. 23.06.2020

                                                          Date of Decision: 30.11.2021.

 

Hariom son of Sh. Madan Lal, resident of House No. 269, Sector 5 Karnal, Aaadhar Card No. 3247 2062 4220, aged 60 years, Mobile No. 9255057777.

 

                                                 …….Complainant.

                                      Versus

 

1. Star Health and Allied Insurance Company Limited, 2^nd Floor SCF 137, Sector 13, Urban Estate Near ICICI Bank, Karnal, through its Branch Manager.

 

2. Star Health and allied Insurance Company Limited No.15 Sri Bala Ji Complex, 1^st Fllor Whites lane royapettah, Chennai 600014.

 

                                                                      …..Opposite Parties.

 

Complaint Under section 12 of the Consumer Protection Act, 1986 as amended Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

 

 Argued by: Shri Vishal Kundi, counsel for complainant.

                    Shri Ashok Vohra, counsel for opposite parties.

 

                    (Jaswant Singh President)

ORDER:

 

                The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 as after amendment Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that on 22.5.2019 complainant purchased a health policy from op no.1 at Karnal by paying an amount of Rs.24,142/-. After successful transaction and completion of all formalities, the ops generated policy no.P/211114//01/2020/001638 in which complainant and his wife were covered till 21.5.2020. It is further averred that at the time of issuance of policy, the complainant was hale and healthy. On 5.2.2020, complainant visited at his brother residence in Karol Bagh Delhi and at around 5.15 p.m., he fell ill as he was felling anxiety/ higher palpitation and retrosternal pain. The complainant informed his family members and without any delay his family members immediately transferred/ admitted him at Sir Ganga Ram Hospital, New Delhi for treatment. Thereafter, concerned doctor started treatment of complainant and admitted him for further management/ treatment. It is further averred that on the same day, son of complainant informed the ops about the illness and the ops generated a claim no.0879393 in this regard and the TPA sent a request for cashless hospitalization for health insurance. On 6.2.2020, a query on authorization for cashless treatment was received by the said Hospital and the treating doctor replied all the queries of the ops. On the same day i.e. 6.2.2020, for the longevity and risk of life of complainant, doctor completed his treatment procedure. It is further averred that on 7.2.2020, complainant received denial of pre authorization request for cashless treatment and the ops advised complainant to seek reimbursement with all treatment records on completion of treatment. On 8.2.2020, complainant and his family members deposited an amount of Rs.2,85,221/- to the said Hospital and complainant was discharged. After passing some days on 17.2.2020 at Karnal, complainant submitted his insurance claim alongwith all original treatment doctors and hospital bills to the office of op no.1 and the staff of op no.1 advised the complainant to wait for some days. On 29.2.2020, complainant received an email in which the ops falsely endorsed cardio vascular system disease as pre existing disease without any valid ground and finally on 3.3.2020 the ops repudiated the claim on fabricated and concocted grounds. The complainant requested the ops many times to settle the genuine claim of complainant but all in vain and ops have finally refused to pay any heed to the genuine requests of complainant. That due to act and conduct of the ops, the complainant has suffered harassment and mental agony and they have also caused deficiency in service towards the complainant. Hence, this complaint.

2.                 On notice, opposite parties appeared and filed written version taking certain preliminary objections. It is submitted that claim of complainant was duly processed, considered on merits and the same was not found payable due to the fact that complainant preferred claim in the ninth month of the policy obtained under Family Health Optima Insurance Plan for sum insured of Rs.5,00,000/- for the period w.e.f. 22.5.2019 to 21.5.2020. It is further submitted that policy is contractual in nature and claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. The complainant in the ninth month of the policy remained indoor patient on 5.2.2020 and was discharged on 8.2.2020 in Sir Ganga Ram Hospital, New Delhi for the treatment of Coronary Artery disease acute coronary syndrome critical LAD and branch vessel disease. The complainant requested a cash less of the medical expenses towards the treatment of CAD ACS and subsequently submitted claim documents for reimbursement. On scrutiny of the same, it is noted that coronary angiography report dated 6.2.2020 shows double vessel disease- LAD proximal to mid long segment calcified disease with severity of 90-95%, distal plaquing, D1 major diagonal, ostioproximal 60-70% stenosis, LCX, proximal plaquing and moderate aortic stenosis. The ECHO report dated 6.2.2020 and ECG report dated 5.2.2020 shows old anterior wall MI changes. It is further submitted that it is pertinent to mention here that complainant has longstanding heart disease which takes more than 9 months to develop, which is prior to inception of medical insurance policy. Hence, it is a pre existing disease and present admission and treatment of the insured patient is for pre-existing disease. That as per waiting period 3(iii) of the policy issued to the complainant, the ops are not liable to make any payment in respect of expenses for treatment of the pre-existing disease/ condition until 48 months of continuous coverage has elapsed since inception of the policy. Hence, the claim was repudiated and same was conveyed to the complainant vide letter dated 3.3.2020. It is further submitted that insurance in question is based on utmost good faith and both the parties i.e. insured as well as the insurer are bound by the terms and conditions of the contract of insurance. The liability of the insurance company/ ops has to be within the four corners of the contract of insurance alone. However, the complainant has breached the good faith by concealing the true facts and has also violated the terms and conditions of the policy of insurance. The complainant was duly informed by speaking letter dated 6.2.2020 through the referring hospital that his cashless authorization has been rejected for cash less treatment. It is further submitted that insurance policy issued to the complainant is governed by limits of liability as per its clauses and without conceding that company is liable to pay the claim in terms of the contract of insurance issued to complainant, it is submitted that maximum quantum of liability under the terms of the policy shall be Rs.2,56,868/- as per billing sheet. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.

3.             The parties then led their respective evidence.

4.             Complainant has tendered in evidence his affidavit Ex.C1, copy of insurance policy schedule Ex.C2, copy of customer card Ex.C3, copy of policy Ex.C4, copy of investigation summary of Sir Ganga Ram Hospital Ex.C5, copy of request for cashless hospitalization for health insurance Ex.C6, copy of letter of query on authorization for cashless treatment Ex.C7, copy of letter dated 7.2.2020 regarding denial of pre authorization request Ex.C8, copy of certificate of Sir Ganga Ram Hospital, Delhi regarding cost of treatment Ex.C9, copy of receipt of the amount of Rs.2,85,221/- Ex.C10, copies of advance receipts Ex.C11, Ex.C12, copy of coronary angiography report Ex.C13, copy of discharge- checklist Ex.C14, copy of discharge summary Ex.C15, copy of claim form Ex.C16.

5.             On the other hand, ops have tendered in evidence affidavit of Sh. Sumit Kumar Sharma authorized representative Ex.OP1/A, affidavit of Sh. Sunil Rangra, Zonal Underwriting Head as Ex.OP2/A, CD Ex.O1, copy of policy Ex.O2, copy of policy schedule Ex.O3, copy of proposal form Ex.O4, copy of request for cashless hospitalization Ex.O5, copy of field visit report Ex.O6, copy of query on authorization for cashless treatment Ex.O7, copy of claim form Ex.O8, copy of discharge summary Ex.O9, copy of coronary angiography report Ex.O10, echo Ex.O11, copy of echocardiogram report Ex.O12, copy of bill Ex.O13, copy of repudiation letter dated 3.3.2020 Ex.O14, copy of hospitalization expenses Ex.O15, copy of letter dated 4.10.2020 Ex.O16, transcription of conversation at the time of proposal form Ex.O17 and copy of denial letter of pre authorization request for cashless treatment dated 6.2.2020 Ex.O18.

6.             We have heard learned counsel for the parties and have perused the case file carefully.

7.             Admittedly, on 22.5.2019, the complainant purchased health insurance policy from ops by paying requisite premium of Rs.24,142/- to the ops and the ops issued policy in question to the complainant covering complainant as well as his wife namely Smt. Suraksha Rani and the period of coverage was 22.5.2019 to 21.5.2020. There is also no dispute that on 5.2.2020 i.e. during subsistence of policy in question, complainant was admitted in Sir Ganga Ram Hospital, New Delhi as he was feeling anxiety and chest pain. Intimation regarding admission in the said hospital and illness of complainant was also given and request for cashless treatment was also made to the ops by ops denied the said request for cashless treatment. From the copy of discharge summary of Sir Ganga Ram Hospital, Delhi placed on file by complainant as Ex.C15, it is evident that complainant was admitted in said hospital on 5.2.2020 and was discharged on 8.2.2020 and PTCA + 2 stents to LAD was done via the right radial route with good end result. According to complainant, on 7.2.2020 he received a denial of pre authorization request for cashless treatment and ops advised him to seek reimbursement with all treatment records on completion of treatment, so on 8.2.2020 they deposited an amount of Rs.2,85,221/- with the Sir Ganga Ram Hospital, New Delhi. Then on 17.2.2020 complainant submitted his claim alongwith treatment record and hospital bills. The ops however, have repudiated the claim of complainant on 3.3.2020 on the ground of pre-existing disease and said repudiation letter is placed on file by ops as Ex.O14. The ops have taken the plea that as per waiting period clause 3 (iii), the ops are not liable to make any payment in respect of expenses for treatment of the pre-existing disease/ condition until 48 months of continuous coverage has elapsed since inception of the policy. But we are of the considered view that ops have wrongly and illegally repudiated the claim of complainant. The ops have not placed on file any opinion of the doctor who have opined that complainant was having pre-existing heart disease. From the copy of proposal form filled in at the time of availing health insurance policy in question, it is evident that to the specific questions regarding health of both the insured and to the questions regarding suffering from disease, the complainant replied that his health is good and he is not suffering from any pre existing disease whereas he specifically answered that his wife is suffering from diabetes mellitus since 2005. Similarly, in the verification made on telephone by the ops, the complainant also replied the same answer to the questions put forth by ops to the complainant that he is not suffering from any disease whereas his wife is suffering from diabetes and said transcription of the recording has been placed on file by ops themselves as Ex.O17. The ops have not proved on record by leading convincing and cogent evidence that complainant was having any disease prior to inception of policy and that disease suffered by complainant in the month of February, 2020 i.e. after purchase of policy in question is a pre existing disease.

8.             The ops in their repudiation letter dated 3.3.2020 have mentioned that “It is observed that the submitted coronary angiography report dated 6.2.2020 shows double vessel disease- LAD proximal to mid long segment calcified disease with severity of 90-95%, distal plaquing, D1 major diagonal, ostioproxmial 60-70% stenosis, LCX, proximal plaquing and moderate aortic stenosis. The ECHO report dated 6.2.2020 and ECG report dated 5.2.2020 shows old anterior waqll MI changes. Based on these findings our medical team is of the opinion that the insured patient has longstanding heart disease prior to inception of medical insurance policy. Hence it is a pre existing disease. The present admission and treatment of the insured patient is for pre existing disease. As per Waiting period clause  3(iii) of the policy issued to you, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/ condition until 48 months of continuous coverage has elapsed, prior to date of commencement of first year policy on 22.5.2019.”. The ops have tried to prove their defence by relying upon medical record of Sir Ganga Ram Hospital. However, it needs to be emphasized that the said medical record pertains to the period 5.2.2020 to 8.2.2020 i.e. after taking the insurance policy from the ops. As such, the same cannot be taken into consideration for deciding the controversy involved in this case. The ops on the basis of above medical record which pertains to the period after issuance of the policy presumed that complainant has longstanding heart disease prior to inception of medical insurance policy. However, it is settled proposition of law that merely on the basis of presumption without any cogent and convincing evidence, it cannot be concluded that complainant was suffering from heart disease prior to taking the insurance policy. In this regard, we are also fortified from the observations of the Hon’ble National Commission made in judgment dated 31.05.2019 rendered in Rivision Petition No.2097 of 2017 case titled as Reliance Life Insurance Company Ltd. & Anr. Vs. Tarun Kumar Sudhir Halder in which it is observed as under:-

“12. From the above entry, it seems that either the doctor filling up this form has not clearly given the date or somebody has made cutting after the word ‘since’. Thus, no conclusion can be drawn in respect of the period since when the DLA was suffering from diabetes. From the entries in the Medical Attendant Certificate it is clear that the DLA first complained about illness only on 22.06.2021. This entry clearly denies pre existing disease of Diabetic Ketoacidosis. The insurance company has not filed any evidence to show that the DLA was taking treatment for the disease prior to filling up of the proposal form. Even if there was disease inside the body, but the life insured did not know about the disease and was not taking any treatment for the same, the insurance claim cannot be denied on mere presumption that the life assured might be suffering from pre-existing disease. Thus, on merits, I am convinced on the basis of the entries in the Medical Attendant Certificate that the disease was complained for the first time by the DLA on 22.06.2021, which is much after the date of the proposal form. The onus to prove the pre-existing disease lies on the Insurance Company and no supporting documents have been filed by the Insurance Company in support of their assertion.”

•  

                “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.

9.             The above said authorities are also fully applicable in this case. In the present case also, the ops have not placed any treatment record of complainant regarding receiving treatment of the above said disease prior to taking of policy in question. Rather it is proved on record that complainant was not having any past history of above said disease and the doctor of Sir Ganga Ram Hospital, New Delhi also mentioned this fact on the query of authorization for cashless treatment sought by ops. So, it is proved on record that ops have wrongly and illegally repudiated the claim of complainant. The complainant is entitled to the above said amount of Rs.2,85,221/-from the ops which has been deposited by him to Sir Ganga Ram Hospital, Delhi and non- payment of this amount clearly amounts to deficiency in service on the part of ops.

10.           In view of abovesaid discussion, we allow the present complaint and direct the OPs to pay claim amount of Rs.2,85,221/- to the complainant alongwith interest @9% per annum from the date of repudiation of claim till its realization. We also direct the OPs to pay a sum of Rs.20,000/- as compensation for harassment and mental agony suffered by him and to pay Rs.5500/- as litigation expenses to the complainant. This order shall be complied with within 45 days from the date of 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:30.11.2021

                                                                       

                                                                  President,

                                                       District Consumer Disputes

                                                       Redressal Commission, Karnal.

 

 

 

(Vineet Kaushik)       

                           Member