Haryana

Karnal

CC/36/2022

Himanshu Pahwa - Complainant(s)

Versus

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

Parshant Pahwa

25 Sep 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No. 36 of 2022

                                                        Date of instt.20.01.2022

                                                        Date of Decision:25.09.2023

Himanshu Pahwa son of Shri Ram Lal, resident of house no.142, Pahwa Mohalla, ward no.11, village Kunjpura, Tehsil and District Karnal.

                                               …….Complainant.

                                              Versus

Star Health and Allied Insurance company Ltd., having its branch office at SCF no.137, 2^nd floor, above ICICI bank, Sector 13, Karnal.

                                                                      …..Opposite Party.

 

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 Parshant Pahwa, counsel for complainant

                   Shri Mohit Goyal, counsel for the OP.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant purchased a health insurance policy known as Family Health Optima Insurance-2017 for himself and his family from the OP, vide insurance policy no.P/211114/01/2021009666, valid from 17.12.2020 to 16.12.2021. The sum insured under the policy is Rs.5,00,000/-. In the night of 10/11.09.2021, the wife of complainant started suffering some problem in lower part of her abdomen and she on 12.09.2021 was taken to Sarvotam Hospital, Sector-6, Karnal where her tests were conducted and found that she was suffering from Jaundice. Her treatment was started by the doctor but her illness could not be cured hence on 15.09.2021 she was referred to higher medical centre. On 15.09.2021, she was shifted to Virk Hospital, Karnal where after medical examinations and several tests, doctor observed that she has been suffering from Viral Hepatitis. She remained admitted there from 15.09.2021 to 25.09.2021. The complainant has spent an amount of Rs.1,05,961/- on her treatment and the payment of said billed amount was approved and paid by the OP. Still the illness of the complainant was not cured and as such she was shifted to the Alchemist Hospital, Panchkula where she remained admitted from 27.09.2021 to 13.10.2021. The said hospital authorities handed over the bill of Rs.356439/- to the complainant. The said policy is cashless but OP refused to approve the said billed amount and advised the complainant firstly to pay the same from his own pocket and then submit the bill and the detail of other relevant document to the office concerned and then the billed amount will be transferred in the account of the complainant. Accordingly, complainant paid the said amount. After discharge from the hospital, complainant lodged the claim with the OP for reimbursement of the abovesaid amount and submitted all the relevant documents with the OP but OP did not pay any claim  and lastly, OP repudiated the claim of the complainant, vide  letter dated 13.11.2021 on the ground that the insured patient has undergone treatment for the abovesaid disease within the first two years waiting period. The said plea taken by the OP is totally illegal, null and void because the said illness is a viral hepatitis and not an old illness.

2.             It is further averred that if there was any such hitch in reimbursing the amount, then why the bills of Virk Hospital has been reimbursed to the complainant. On receipt of the said letter, complainant approached the OP and requested for making payment of the insured amount but the OP did not pay the same and postponed the matter on one pretext or the other and lastly refused to pay any amount to the complainant. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence this complaint.

3.             On notice, OP appeared and filed its written version, raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that OP issued Family Health Optima Insurance Plan, vide policy no.P/211114/01/2021/009666 for the period of 17.12.2020 to 16.12.2021. It was further renewed vide policy no.P/21111/01/2019/006508 for the period of 08.11.2018 to 07.11.2019. It was further renewed vide policy no.P/21111/01/2020/008211 for the period of 08.11.2018 to 07.11.2020, covering risk of Mr. Himanshu Pahwa-self, Mrs. Nancy and Ayaansh Pahwa-dependent children for the sum insured of Rs.5,00,000/-. It is further pleaded that vide claim no.CIR/2022/211114/3220116, the insured Mrs. Nancy raised a request for pre-authorization for cashless treatment at Alchemist Hospital-Panchkula on 27.09.2021 for the treatment Hepatitis. On scrutiny of cashless request, it is noted that the opponent is unable to ascertain the duration of the ailment. Hence, the pre-authorization was initially denied. Complainant submitted the claim for reimbursement of the medical bills alongwith medical records. It was observed from the submitted records that as per the discharge summary dated 27.09.2021, the insured was diagnosed with Acute Hepatitis with Prolonged Cholestatis-Autoimmune Hepatitis (AIH). The previous claim for acute viral hepatitis was settled to the insured as per terms and conditions since the claim pertains to viral disease and it is payable. However, in the present hospitalization, as per discharge summary, the course in hospital shows that HAV, HEV, HBV and HCV were negative and ANA positive (as positive ANA test indicates that your immune system has launched a misdirected attack on your own tissue- in other words, an autoimmune reaction) and he was diagnosed with Acute Hepatitis with Prolonged Cholestatis-Autoimmune Hepatitis (AIH). Thus, the present claim falls under Hepatopancreatobiliary disease. The insured patient had undergone treatment for the above disease within the first 2 years waiting period. As per exclusion-specified disease/procedure waiting period-code Ex.cl.02 of the above policy, expenses incurred by the insured person for treatment of the above mentioned disease shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy. A waiting period of 24 consecutive months of continuous coverage from the inception of this policy will apply to the following specified ailments/illness/disease-All treatments (conservative, interventional, laparoscopic and open) related to Hepatopancreato-biliary diseases including Gall bladder and Pancreatic calculi. All types of management for Kidney and Genitourinary tract calculi. Hence, the reimbursement claim was rejected and the same was informed to the insured, vide letter dated 13.11.2021. 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.

4.             Parties then led their respective evidence.

5.             Learned counsel for the complainant has tendered into evidence his affidavit Ex.CW1/A, copy of statement of account Ex.C1, copy of medical bills of Alchemist Hospital Ex.C2, copy of repudiation letter dated 13.11.2021 Ex.C3, copy of hospital receipt Ex.C4 and Ex.C5, copy of reference slip Ex.C6, copy of bill assessment sheet Ex.C7 and closed the evidence on 25.08.2022 by suffering separate statement.

6.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Sumit Kumar Sharma Ex.OPW1/A, copy of insurance policy Ex.OP1, copy of terms and conditions of the policy Ex.OP2, copy of proposal form Ex.OP3, copy of pre-authorization request Ex.OP4, copy of Field Visit Report Ex.OP5, copy of query letter dated 28.09.2021 regarding authorization for cashless treatment Ex.OP6, copy letter dated 05.10.2021 regarding denial of preauthorization request for cashless treatment Ex.OP7, copy of claim form Ex.OP8, copy of discharge summary Ex.OP9, copy of medical  tests report Ex.C10, copy of test report status Ex.C11, copy of medical bills Ex.C12, copy of repudiation letter dated 13.11.2021 Ex.C13, copy of bill assessment sheet Ex.C14 and closed the evidence on 13.07.2023 by suffering separate statement.

7.             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.

8.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant purchased a health insurance policy from the OP. In the night on 11.09.2021, the wife of complainant has suffered some problem in lower part of her abdomen and she was taken to Sarvotam Hospital, Karnal Karnal and had taken the treatment but the condition of the complainant’s wife was not improved so that she was taken to Virk Hospital, Karnal and complainant spent Rs.105961/- on her treatment. The said amount has been paid by the OP. He further argued that the condition of the insured patient was not improved, so she was taken to Alchemist Hospital, Panchkula where she remained admitted from 27.09.2021 to 13.10.2021 and spent Rs.356439/- on her treatment. The pre-authorization request of complainant was denied by the OP. After discharge from the hospital of his wife, complainant submitted the claim with the OP for reimbursement of the abovesaid amount but OPs did not pay the claim and repudiated the same vide letter dated 13.11.2021 on the false and frivolous ground and lastly prayed for allowing the complaint.

9.             Per contra, learned counsel for the OP, while reiterating the contents of written version has vehemently argued that the insured Mrs. Nancy raised a request for pre-authorization for cashless treatment at Alchemist Hospital-Panchkula on 27.09.2021 for the treatment of Hepatitis. On scrutiny of cashless request, the OP is unable to ascertain the duration of the ailment, so the pre-authorization request was  denied. Complainant submitted the claim for reimbursement of the amount of Rs.3,65,439/-.  On scrutiny of the documents, it was observed that the insured was diagnosed with Acute Hepatitis with Prolonged Cholestatis-Autoimmune Hepatitis (AIH). Thus, the present claim falls under Hepatopancreatobiliary disease. The insured patient had undergone treatment for the above disease within the first two years waiting period. Hence, the reimbursement claim was rejected, vide letter dated 13.11.2021.  He further argued that the previous claim for acute viral hepatitis was settled to the insured since the claim pertains to viral disease and it is payable and lastly prayed for dismissal of the complaint.

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

11.           Admittedly, the complainant had purchased the policy in question from the OP. It is also admitted that the policy in question is continuing from the year 2017. It is also admitted that wife of complainant was hospitalized in various hospitals during the subsistence of the insurance policy. 

12.           The claim of the insured has been repudiated the by the OP, vide letter Ex.C3/Ex.OP13 dated 13.11.2021 on the ground which is reproduced as under:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of Acute Hepatitis with Prolonged Cholestatis-Autoimmune Hepatitis (AIH).

It is observed from the submitted records that the insured patient has undergone treatment for the above disease within the first 2 years waiting period. As per exclusion-specified disease/procedure waiting period-code Ex.cl.02 of the above policy, expenses incurred by the insured person for treatment of the above mentioned disease shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy.

We regret to inform your that we are unable to settle your claim under the above policy and we hereby repudiated your claim”.

13.           The claim of the insured has been repudiated by the OP on the abovesaid ground. 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. OP itself admitted in its written version that the complainant has purchased the policy in question in the year 2017 and still continued. The insured patient admitted in the hospital first time for the abvoesaid disease on 15.09.2021. Meaning, thereby, waiting period of 24 months is not applicable in the present case. Hence, the plea taken by the OP has no force. Moreover, the medical bills of Virk Hospital have been reimbursed by the OP to the complainant for the same disease. Thus, OP has denied the subject claim without any reason. It is not a case of the OP that the policy in question is not continuous position since 2017 and there is break in the policy.

14. 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”.

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 OP while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

16.           The complainant claimed Rs.3,65,439/- and in this regard he has submitted the medical bills  on record Ex.C2/Ex.OP12. The said bills have not been rebutted by the OP. The sum insured is Rs.5,00,000/- Hence, the complainant 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 OP to pay Rs.3,65,439/- (Rs.three lakhs sixty five thousand four hundred thirty nine only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of claim i.e. 13.11.2021 till its realization. We further direct the OP to pay Rs.20,000/- 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: 25.09.2023

                                                                President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

             (Vineet Kaushik)     (Dr. Rekha Chaudhary) 

                   Member                  Member