Haryana

Karnal

CC/461/2022

Manmohan Singh - Complainant(s)

Versus

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

Apaar Singh Bedi

28 Aug 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                          Complaint No. 461 of 2022

                                                          Date of instt.08.08.2022

                                                          Date of Decision 28.08.2023

 

Manmohan Singh son of Shri Balwant Singh, resident of house no.359, sector-14, Urban Estate, Karnal. Aadhar no.4562 4167 6875. Mobile no.94165 66668.

 

                                                 …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Co. Ltd. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034, through its authorized signatory.

 

2. Star Health and Allied Insurance Co. Ltd. 2^nd floor, SCF-137, Sector 13 Urban Estate Karnal-132001, through its Branch/Divisional Manager.

 

                                                                      …..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary…..Member

 

 Argued by: Shri Apaar Singh Bedi, 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 obtained a Family Health Optima Insurance Policy from the OPs on 29.12.2019 and regularly paying the renewal amount from time to time and current insurance policy bearing no.P/211114/01/2022/0119551, valid from 28.12.2021 to 27.12.2022. The said policy is a cashless policy. The complainant was admitted on 16.06.2022 with disease condition Right Leg Chronic Limb Ishemia+Health Gangrene in Fortis Hospital Sector 62, Phase 8, Mohali and treatment of Right Leg Angioplasty +Debridement Under SA done on 16.06.2022 and his date of discharge was 18.06.2022 and complainant spent a huge amount of more than Rs.4,50,000/- on his treatment and other expenses including travelling and diet and after Angioplasty Treatment. Complainant informed the OPs in this regard and applied for reimbursement of hospitalization and other expenses which were incurred on treatment of the complainant, vide claim no.CIR/2023/211114/0407764 and given Bills of Rs.3,03,952/-, but very surprisingly, OP rejected/repudiated the claim of the complainant vide letter dated 11.07.2022 on the false and frivolous ground.

2.             It is further averred that on previous policy no.P/211114/01/2020/010734, complainant was admitted in Asirwad Hospital Karnal on 18.08.2020 with Left Sideed Chest Pain with Sweating and treatment of Primary PTCA+stent to LAD Pharmacoinvasive therapy was done on 18.08.2020 and complainant was discharge on 19.08.2020 and claim for reimbursement was initiated and claim was full and final settled regarding the same. In that claim also the Type 2 Diabetes Mellitus is also mentioned and claim was successfully given and first policy is on 29.12.2019 and as per OP 48 months have already passed. OPs have wrongly cancelled/repudiated the claim of complainant whereas complete document was submitted to the OP alongwith discharge summary, hospital bills, medical bills and other expenses but they ignored the same and have wrongly rejected the claim of complainant by giving wrong excuse. The complainant requested the OPs so many times to settle the claim of complainant but they did not pay any heed to the request of complainant and ultimately refused to pay the claim. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

3.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; locus standi; jurisdiction and concealment of true and material facts. On merits, it is pleaded that insured availed Family Health Optima Insurance Plan, vide policy no.P/211114/01/2022/011951 covering Mr. Manmhan Singh self (PED-Diabetes Mellitus and its complications) and Mrs. Parvinder Kaur-Spouse (PED-All complications directly or indirectly related to the surgeries or procedures performed previously-hernia repair/Diabetes Mellitus and its complications) for the sum insured of Rs.5,00,000/- for the period from 28.12.2021 to 27.12.2022. The insured complainant was hospitalized on 16.06.2022 at Fortis Hospital Mohali for the treat of Right Leg Chronic Limb Iscemia+Heal Gangrena and discharged on 18.06.2022. Procedure for Right Leg Angioplasty +Debridement was performed under SA on 16.06.2022. The insured submitted medical documents in support of his claim during reimbursement of medical expenses. On scrutiny of the claim documents, it was observed that,

        The insured patient has undergone treatment for Right Leg Chronic Limb Iscemia +Heal Gangrene which is a complication of diabetes mellitus which is already incorporated in the above policy as one of the pre-existing disease at the time of inception of the first medical insurance policy.

As per Exclusion clause 3-Pre-existing disease-Code Excl-01 of the policy issued to you, “The company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by the insured person in connection with or in respect of expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer”. Hence, claim was repudiated and communicated to the insured vide letter dated 11.07.2022. It is further pleaded that policy issued to the complainant under whom the dispute has been raised is governed by limits of liability as per various clauses. The maximum quantum of liability under the terms of the policy shall be Rs.2,22,286/-. 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.

4.             Parties then led their respective evidence.

5.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of aadhar card Ex.C1, copy of repudiation letter dated 11.07.2022 Ex.C2, copy of claim form Ex.C3, copy of detail of amount Ex.C4, copy of discharge summary Ex.C5, copy of summary of bill Ex.C6, copy of deposit receipt Ex.C7, copy of outpatient bill Ex.C8, copy of lab bill Ex.C9, cop of OPD bill Ex.C10, copy of discharge summary of Fortis Hospital Ex.C11, copy of medical bill Ex.C12, copy of discharge summary from Ashirdwad Hospital Ex.C13, copy of bill assessment of Star Health of Ashirdwad hospital Ex.C14 and closed the evidence on 06.02.2023 by suffering separate statement.

6.             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 proposal form Ex.R1, copy of insurance policy Ex.R2, copy of term and conditions of the insurance policy Ex.R3 and closed the evidence on 05.06.2023 by suffering separate statement.

7.             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.

8.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that complainant had purchased a Health Insurance policy from the OPs, which continued year by year from 2019 to 2022. On 16.06.2022, complainant was admitted in Fortis Hospital, Mohali and taken the treatment for Right Leg Chronic Limb Ischemia_Health Gangrene and spent Rs.3,03,952/- on his treatment. Thereafter, complainant lodged his 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.

9.             Per contra, learned counsel for OPs, while reiterating the contents of the written version, has vehemently argued that complainant was hospitalized in Fortis Hospital Mohali on 16.06.2022 towards the treatment of Right Leg Chronic Limb Ischemia_Health Gangrene and discharged on 18.06.2022. Complainant lodged the claim with the OPs for reimbursement of the medical expenses. 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. The claim of the complainant was rightly repudiated, vide letter dated 11.07.2022 by the OPs and lastly prayed for dismissal of the complaint.

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

11.           Admittedly, insured had availed the health insurance policy from the OPs. It is also admitted that during the subsistence of the said policy complainant was admitted in Fortis Hospital Mohali 16.06.2022 and was discharged on 18.06.2022.

12.           The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.C2 dated 11.07.2022 on the grounds 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 Right Leg Chronic Limb Iscemia+Heal Gangrene.

It is observed from the submitted records that the insured patient has undergone treatment for the complication of diabetes mellitus, which is already incorporated in the above policy as one of the pre-existing disease at the time of inception of the first medical insurance policy.

As per Exclusion-Pre-existing disease-Code Excl-01 of the policy issued to you, expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer.

We, therefore, regret to inform you that for the reasons stated above we are unable to settle your claim under the abovesaid policy and we hereby repudiate your claim”.

 

13.           The claim of the complainant has been repudiated by the OPs on the above mentioned ground. The onus to prove its version was relied upon the OPs, but OPs have miserably failed to prove its version by leading any cogent and convincing evidence. There is nothing on the file to prove that complainant was suffering from Diabetes Mellitus and was under treatment. OPs have not placed on file any medical record in this regard. Moreover, OPs have alleged that the maximum quantum of liability under the terms of the policy shall be Rs.2,22,286/- but OPs have failed to place on record any documents to prove that as to why complainant is entitled for Rs.2,22,286/- instead of Rs.3,03,952/-.

14.           Further, for the sake of arguments, if it be presumed that the complainant was suffering from Diabetes Mellitus at the time of obtaining the insurance policy, in that case also the claim of the complainants cannot be repudiated 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”.

15.           Further in United India Insurance Co. Ltd. & Anr. Versus S.K. Gandhi, 2015 (2) CLT 71 (NC)  the insurance company had not placed on record either the discharge summery of the complainant or any medical document signed by the doctors who treated him in Bhatnagar Eye Centre, Karnal and Arpana Hospital, Madhuban to show that the complainant when he was admitted to the said hospital, had himself stated that he was suffering from hypertension from last 8 years. In that case it was held that it is quite possible that the complainant, despite suffering from diabetes was not actually aware of the same and he cannot be accused of mis-statement or concealment. Onus was upon the insurance company to prove that he had made a mis-representation while obtaining the insurance policy and since the insurance policy failed, it was held that it was liable to pay to the complainant to the extent a sum insured by it.

16.           Further in case titled as Satish Chander Madan Vs. M/s Bajaj Allianz General Insurance Co. Ltd. 2016(1) CPJ 613 (NC) it was held that diabetes 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. It was further held that treatment for heart problem cannot be termed as claim in respect of pre-existing disease and the insurance company was held liable

17.           Further, in case titled as Oriental Insurance Co. Ltd. Vs. Naresh Sharma & Ors 2015 (2) PLR 75 the Hon’ble Punjab and Haryana High Court held that the exclusion clause has to be read to the benefit of patient in genuine circumstances. Where respondent was admitted in hospital suffering from headache, giddiness and hypertension, his claim cannot be rejected on the basis of exclusion clause.

18.          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”.

19.           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. 

20.           The sum insured of the policy in question is Rs.5,00,000/-. The complainant claimed Rs.3,03,952/- on account of hospital bill, medical bill and amount incurred on treatment and also claimed Rs.1,50,000/- travelling expenses, special diet, etc. The complainant has placed on file claim form Ex.C3 and copy of details of medical bills Ex.C4, medical bills Ex.C6 to Ex.C12, which only proves that complainant spent Rs.3,03,952/- on the treatment. The said claim form and medical bills have not been rebutted by the OPs. There is nothing on file to prove that the complainant had spent Rs.1,50,000/- on the travel, special diet etc. Thus, the complainant is not entitled for Rs.1,50,000/-. Hence, the complainant is only entitled for Rs.3,03,952/- alongwith interest, compensation for mental harassment and litigation expenses etc.

21.           Thus, as a sequel to abovesaid discussion, we partly allow the present complaint and direct the OPs to pay Rs.3,03,952/- (Rs. Three lacs three thousand nine hundred fifty two only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of claim till its realization. We further direct the OPs to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs.11000/- 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:28.08.2022.

                                                                       

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

 

                (Vineet Kaushik)        (Dr. Rekha Chaudhary)      

                      Member                        Member