Haryana

Karnal

CC/97/2020

Kaushaya Devi - Complainant(s)

Versus

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

Sanjay Gupta

16 Aug 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                       Complaint No. 97 of 2020

                                                        Date of instt.13.02.2020

                                                        Date of Decision:16.08.2022

 

Kaushalya Devi wife of Shri Birbal Kumar, resident of house no.243, Sector-12, Urban Estate, Karnal.

 

                                               …….Complainant.

                                              Versus

 

1.     Star Health and Allied Insurance Company Ltd. SCF-137, Sector-13, Second Floor, near ICICI Bank, Karnal through its Manager/Authorized Signatory.

 

2.     Star Health and Allied Insurance Company Ltd. Sri Balaji Complex, 15, Whites Road, Chennai-600014 through its authorized signatory.

                                                                      …..Opposite Parties.

 

Complaint Under Section 12 of the Consumer Protection Act, 1986 and after amendment Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.

      Dr. Rekha Chaudhary…….Member

                   

 Argued by: Sh. Sanjay Gupta, counsel for the complainant.

                   Sh. Ashok Vohra, counsel for the 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 complainant had purchased a health insurance policy no.P/211114/01/2019/002111 alongwith his husband, the same was valid from 28.06.2018 to 27.06.2019, basic sum assured was Rs.5 lakhs and paid an premium of Rs.24142/-. At the time of insurance the OPs have assured the complainant that the said policy is a cashless policy as the penal hospitals of the OPs. Prior to the abovesaid policy, complainant purchased insurance policy from New India Assurance Co. Ltd. since 2013, the details of which are as under:-

Name of Co.          Policy No.                                     Period of insurance

New India              35360034130600000023                  28.06.2013 to 27.06.2014

Ass. Co. Ltd.

 

New India              35360034142800000016                  28.06.2014 to 27.06.2015

Ass. Co. Ltd.

 

New India              35360034152800000025                  28.06.2015 to 27.06.2016

Ass. Co. Ltd.

 

New India              35360634162800000025                  28.06.2016 to 27.06.2017

Ass. Co. Ltd.

 

New India              35360434172800000037                  28.06.2017 to 27.06.2018

Ass. Co. Ltd.

 

The complainant was fully satisfied with the service rendered by the New India Assurance Co. Ltd. but the representative of the OPs approached to the complainant and the policy was ported to the OPs and OPs assured that they will render better services to the New India Assurance Co. Ltd. On 07.06.2019, the complainant fell ill and got herself admitted in Max Hospital, Shalimar Bag, New Delhi for the treatment of foot ulcer in emergency condition. The complainant remained admitted in the abovesaid hospital as indoor patient from 07.06.2019 to 11.06.2019 and spent Rs.1,18,895/-. During treatment in the said hospital, the complainant as well as hospital authorities informed the OPs about the illness and the seriousness of the disease. But the OPs had rejected the benefit on the same day i.e. 07.06.2019 on the ground of pre-existing disease. The complainant was not completely cured and ultimately she was shifted to Fortis Hospital, Mohali, where she remained admitted as indoor patient from 17.06.2019 to 18.06.2019 and paid an amount of Rs.1,25,418/-. After discharged from the hospital, complainant approached the OPs and completed all the formalities as required by the OPs and requested to pay Rs.2,44,313/- (118895+125418 =2,44,313/-), but OPs flatly refused to admit the claim of the complainant without any reason. The policy issued by the OPs and policies issued by the New India Assurance Co. Ltd., it is clearly mentioned that there is no pre-existing disease and OPs have rejected the cashless benefit and has refused to entertain the claim of the complainant with malafide intention. In this way there is deficiency in service on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; locus standi; cause action and concealment of true and material facts. On merits, it is pleaded that the husband of one Kaushalya Devi purchased the policy in question for a period of 28.06.2018 to 27.06.2019 by way of portability from New India Assurance Company Ltd. The husband of complainant namely Birbal Kumar (self) with declared ped Diabetes Mellitus and its Complications, and Kaushalya Devi (spouse) with declared PED Diabetes Mellitus and its complications obtained Family Health Optima Insurance Plan covering for a sum of Rs.5,00,000/-, vide policy no. P/211114/01/2019/002111 for the period 28.06.2018 to 27.06.2019 which was ported from New India Assurance Co. Ltd. for the sum assured of Rs.2,00,000/- only. The complainant has accepted the policy agreeing and being fully aware the terms and conditions of the policy. Not only this but the terms and conditions of the policy were explained to the complainant at the time of proposing policy and same was served to the complainant alongwith policy schedule. It is further pleaded that insured Kaushalya Devi was hospitalized in Max Super Specialty Hospital, Shalimar Bagh, New Delhi on 07.06.2019 towards the treatment of foot ulcer. The insured-Kaushalya Devi submitted a request on 07.06.2019 for cashless authorization for treatment of foot ulcer. The above disease/condition has been incorporated as a pre-existing disease in the policy schedule. The present admission was PED related complication. As per policy schedule; Diabetes Mellitus and its complications are declared pre existing disease and claim for treatment of the pre-existing disease/condition is not admissible until expiry of 48 months from the date of inspection of the first policy which is 28.06.2015. As such the OPs rejected of authorization for cashless treatment vide letter 07.06.2019 with the suggestion that if the complainant is not satisfied with the decision of OPs then she can approach to the Grievance Redressal Officer or to the concerned Insurance Ombudsman. It is further pleaded that the 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. It is further pleaded that complainant has not approached for reimbursement of medical expenses towards the above mentioned hospitalization to the OPs and directly filed the complaint. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied by the OPs 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 letter dated 07.06.2019 Ex.C1, copy of policy issued by OPs Ex.C2, copies of insurance policies issued by New India Assurance Co. Ltd. Ex.C3 to Ex.C6, copy of proposal form for New India Floater Mediclaim Policy Ex.C7, copy of insurance policy of OPs Ex.C8, copy of case history Ex.C9, copy of report Ex.C10, copies of medical bills Ex.C11 to Ex.C27 and closed the evidence on 23.07.2021 by suffering separate statement.

5.             On the other hand, learned counsel for OPs has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.OW1/A, copy of insurance policy Ex.O1, copy of policy schedule Ex.O2, copy of portability form Ex.O3, copy of proposal form Ex.O4, copy of request for cashless hospitalization for medical insurance policy Ex.O5, copy of Max Health Case report/consultation report Ex.O6, copy of progress notes Ex.O7, copy of Pre-authorization rejection Ex.O8 and closed the evidence on 08.06.2022 by suffering separate statement.

6.             We have heard the learned counsel of 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 complaint, has vehemently argued that initially complainant had purchased a Health Insurance policy from New India Assurance Company Ltd., which continued year by year upto five years from 2013 to 2018 and thereafter complainant ported the said policy to the OPs. He further argued that on 07.06.2019 complainant fell ill and got admitted in Max Hospital, New Delhi,  discharged on 11.06.2019 and spent Rs.1,18,895/-. Complainant was not completely cured and he was shifted to Fortis Hospital Mohali where she was admitted from 17.06.2019 to 18.06.2019 and spent Rs.1,25,418/- on her treatment. Thereafter, complainant lodged her claim with the OPs for reimbursement of the abovesaid amounts but OPs did not pay the claim and denied the same on the false and frivolous ground and prayed for allowing the complaint.

8.             Per contra, learned counsel for OPs, while reiterating the contents of the written version, has vehemently argued that the husband complainant purchased the policy in question for a period of 28.06.2018 to 27.06.2019 by way of portability from New India Assurance Company Ltd. The insured Kaushalya Devi was hospitalized in Max Super Specialty Hospital, New Delhi on 07.06.2019 towards the treatment of foot ulcer and submitted a request on 07.06.2019 for cashless authorization. The above disease/condition has been incorporated as a pre-existing disease in the policy schedule. The present admission was PED related complication. As per policy schedule-Diabetes Mellitus and its complications are declared pre existing disease and claim for treatment of the pre-existing disease/condition is not admissible until expiry of 48 months from the date of inspection of the first policy which is 28.06.2015. As such the OPs rejected of authorization for cashless treatment vide letter 07.06.2019 and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, insured has availed the health insurance policy from New India Assurance Co. Ltd., which was ported to the OPs. It is also admitted that during the subsistence of the insurance policy complainant was admitted in Max Hospital, Shalimar Bag New Delhi on 07.06.2019 and was discharged on 11.06.2019 and thereafter admitted in Fortis Hospital, Mohali on 17.06.2019 and discharged on 18.06.2019.

11.           The claim of the complainant has been denied by the OPs, vide Pre-authorization rejection letter Ex.C1/Ex.O8 dated 07.06.2019 on the grounds which reproduced as under:-

“We have scrutinized your request for approval for cashless treatment of the above insured patient for the diagnosed disease of Foot Ulcer.

The above disease/condition has been incorporated as a pre-existing disease in the policy schedule.

Present admission in PED RELATED COMPLICATION.

As per waiting period exclusion no.3 iii the claim for treatment of the pre-existing disease/condition is not admissible until expiry of 48 months from the date of inception of the first policy.

We are therefore unable to consider the approval for cashless treatment of the above diagnosed disease”.

 

12.           The pre-authorization request of complainant has been denied by the OPs on the ground that the present admission was PED related complication and as per policy schedule-Diabetes Mellitus and its complications are declared as pre existing disease and claim for treatment of the pre-existing disease/condition is not admissible until expiry of 48 months from the date of inspection of the first policy. The onus to prove its version lies upon the OPs, but OPs have miserably failed to prove its version by leading any cogent and convincing evidence. Rather it is evident from the insurance policies Ex.C3 to Ex.C6 and proposal form Ex.C7, the complainant had purchased the health insurance policy from the year 2013 till 2018 from New India Assurance Co. Ltd. and thereafter the policy in question had been ported to the OPs. Meaning thereby the policy in question was continuing from the year 2013 and not from the 28.06.2015 as alleged by the OPs. Thus, the plea taken by the OPs has no force.

13.           Further, for the sake of arguments, if it be presumed that the life assured was suffering from Diabetes Mellitus at the time of obtaining the insurance policy, in that case also the claim of the complainant cannot be denied on the said ground, because Hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension. In this regard, we are also fortified from the observations of the Hon’ble State Commission, New Delhi, titled as Life Insurance Corporation of India Versus Sudha Jain 2007 (2) CLT 423, in which Hon’ble State Commission has drawn conclusion in para 9 of the order and the relevant clause is 9 (iii), is reproduced as under:-

        “9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.” Taking into consideration the facts of the present case and law laid down by the Hon’ble Superior Fora in the above referred cases, we are of the view that OPs were not justified in repudiating the claim of the complainant and are thus liable to pay the amount which the complainant had incurred on his treatment”.

14.           The next plea taken by the OPs is that complainant has not approached for reimbursement of medical expenses towards the above mentioned hospitalization to the OPs. The complainant has specifically mentioned in para no.7 of her complaint and in her affidavit that after getting discharge from the hospitals she approached the OPs and submitted all the bills but OPs did not release her claim. In this regard, we are of the considered view that a person whose personal interest is involved in form of the huge claim amount, then, as to why, she would not filed the claim. Hence, plea taken by the OPs is having no force.   

15.  

                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.

 16.          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 denying the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

17.           The complainant claimed Rs.2,44,313/- and in this regard he has placed on file medical bills Ex.C11 to Ex.C27/-. The said bills have not been rebutted by the OPs. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

18.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.2,44,313/- (Rs. two lakhs forty four thousand three hundred thirteen only) to the complainant alongwith interest @ 9% per annum from the date of filing the complaint till its realization. We further direct the OPs 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:16.08.2022.

                                                                       

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

 

       

                (Dr. Rekha Chaudhary)      

                      Member