Haryana

Karnal

CC/620/2019

Mrs. Pankaj Bhatia - Complainant(s)

Versus

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

Rishi Chalia

14 Jul 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                       Complaint No. 620 of 2019

                                                        Date of instt.11.09.2019

                                                        Date of Decision:14.07.2022

 

Mrs. Pankaj Bhatia, aged 42 years, wife of Shri Rajesh Kumar, resident of VPO Janeshro, Tehsil Indri, District Karnal.

 

                                               …….Complainant.

                                              Versus

 

1.     Star Health and Allied Insurance Company Limited, through its Divisional Manager, near Bus Stand, Karnal.

 

2.     Religare Health and Allied Insurance Company Limited, Sector-12, near Hospital Chowk, Karnal 132001.

 

                                                                      …..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.

              Shri Vineet Kaushik……Member

      Dr. Rekha Chaudhary…….Member

                   

Argued by: Shri Rishi Chalia, counsel for the complainant.

   Shri Naveen Khetarpal, counsel for the OP no.1.

                   Shri Rohit Gupta, counsel for the OP no.2.

 

                    (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 purchased the Mediclaim Health Insurance Family Policy from the OP no.2, bearing no.11260427. The said policy ported to Star Health and allied i.e. OP no.1. The said policy was approved after the thorough medical examination done by the representative of the OP no.2 and the same was ported and accepted by the OP no.1 after their full satisfaction and consent regarding the documents as well as the medical report as provided by OP no.2. The complainant fell ill and admitted in a private hospital, Karnal from where she was referred to Delhi and she got admitted in Sir Ganga Ram Hospital, New Delhi. The complainant spent a huge amount of Rs.3,50,000/- on her treatment. She remained admitted there for about 12 days. After discharge from the hospital she visited the said hospital as an OPD patient. After the treatment, the complainant submitted all the necessary documents i.e. claim form, bills etc. for the settlement of the claim to the OPs. Thereafter, complainant requested the OPs so many times to settle the claim but OP did not pay any heed to the request of complainant and on 12.07.2019, he received a letter from the OPs in which they have cancelled the claim of the complainant on the false and frivolous ground. After that complainant visited the office of OPs so many times and requested for settlement of the claim, but did not do so and in the month of March, 2019 he received an email, vide which they totally refuse to give any claim. In this way there is deficiency in service on the part of the OPs. Hence this complaint.

2.             On notice, OP no.1 appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; mis-joinder and non-joinder of parties; cause of action and concealment of true and material facts. On merits, it is pleaded that Mrs. Pankaj Bhatia availed the Family Health Optima Insurance Plan covering Mrs. Pankaj Bhatia-self, Mr. Rajesh Kumar-spouse, for the sum insured of Rs.5,00,000/-, vide policy no.P/161133/01/2020/000074 for the period from 03.05.2019 to 02.05.2020.The complainant had insurance policy earlier with the Religare Health Insurance and ported his policy to OP no.1 under portability. The details of earlier polices with previous insurer are given below:-

11260427 for a period of 03.05.2017 to 02.05.2018 (Religare Health Insurance)

11260427 for a period of 03.05.2018 to 02.05.2019 (Religare Health Insurance)

 

The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant alongwith the policy schedule. It is further pleaded that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. It is further pleaded that complainant was admitted on 08.06.2019 and discharged on 20.06.2019 at Sir Ganga Ram Hospital, Delhi for the diagnosis of Hypersplenism/Severe Pancytopenia. Then the complainant sought for the pre-authorization request for the cashless treatment and the same was denied vide letter dated 11.06.2019 stating that the claim required further evaluation. Subsequently, the complainant submitted claim records for reimbursement of the medical expenses. On scrutiny of the documents, it is observed that the Consultant Report dated 18.04.2019 of Dr. Raj Kumar that the complainant patient is presented with HB of 5.0 and has been referred to higher centre which confirms the complainant is symptomatic of the above disease prior to the policy. It is further pleaded that complainant has earlier taken medical insurance policy from OP no.2 for the period from 2017-2018 to 2018-2019 and subsequently taken policy from OP no.1 from 03.05.2019 to 02.05.2020 under portability. At the time of porting the policy, the complainant did not disclose the above mentioned medical history/health details in the proposal form and other documents submitted to answering OP which amounts to misrepresentation/ non-disclosure of material facts. As per condition no.6 of the policy, the company shall not be liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be incorrect or false or such claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation whether by the insured person or by any other person acting on his behalf. Hence, the claim was repudiated and the same was communicated to the complainant, vide letter dated 17.07.2019.

3.             It is further pleaded that as per condition no.12 of the policy, “The company may cancel this policy on grounds of misrepresentation, fraud, moral hazard, non-disclosure of material fact as declared in the proposal form and/or claim form at the time of claim and non-cooperation of the complainant by sending the complainant 30 days notice by registered letter at the complainant person’s last known address. No refund of premium will be made except where the cancellation is on the ground of non-cooperation of the complainant, in which case the refund of premium will be on prorate basis. The complainant may at any time cancel this policy and in such event the company shall allow refund after retaining premium at Company’s short period rate only provided no claim has occurred upto the date of cancellation”. Hence, the policy was cancelled with effect from 31.08.2019 by passing endorsement dated 23.08.2019. There is no deficiency in service on the part of the OP. The other allegations made in the complaint have been denied by the OP and prayed for dismissal of the complaint.

4.             OP no.2 filed its separate written version maintainability; jurisdiction; locus standi; cause of action and concealment of true and material facts. On merits, it is pleaded OP no.2 has no role in the present complaint as the policy had already ported from OP no.2 to OP no.1. Now the complainant is not insured with the OP no.2 and therefore, no liability arises against the OP no.2.  It is submitted that complainant and her husband were issued a policy bearing no.11260427 for a period from 21.10.2016 to 20.10.2017 and further renewed from 03.05.2017 to 02.05.2018 for a sum insured of Rs.5,00,000/-. The policy was again renewed from 03.05.2018 till 02.05.2019. The complainant and her husband were insured with the OP only till 02.05.2019. Thereafter, the said policy was not renewed by the complainant and the said policy got expired. There is no deficiency in service on the part of the OP. The other allegations made in the complaint have been denied by the OP and prayed for dismissal of the complaint.

5.             Parties then led their respective evidence.

6.             Learned counsel for complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy plan Ex.C1, copy of insurance policy Ex.C2, copy of non-disclosure letter Ex.C3, copy of mediclaim policy Ex.C4, copy of policy certificate Ex.C5, copy of acknowledgement letter Ex.C6, copy of medical bills of Sir Ganga Ram Hospital Ex.C7, copy of insurance plan Ex.C8, copy of tax invoice Ex.C9, copy of non-disclosure letter of Star Health Ex.C10, copy of mediclaim policy Ex.C11, policy certificate Ex.C12, copy of premium acknowledgment Ex.C13 and closed the evidence on 19.03.2021 by suffering separate statement.

7.             On the other hand, OP no.1 has tendered into evidence copy of proposal form Ex.R1, copy of application for portability of policy Ex.R2, copy of policy schedule Ex.R3, copy of terms and conditions of the policy Ex.R4, copy of pre-authorization request Ex.R5, copy of field visit report Ex.R6, copy of pre-authorization query letters dated 08.06.2019 and 10.06.2019 Ex.R7 and Ex.R8, copy of pre-authorization Denial letters dated 10.06.2019, 10.06.2019,  11.06.2019 and 11.06.2019 Ex.R9 to Ex.R12, copy of claim form Part-A and Part-B Ex.R13 and Ex.R14, copy of field visit details Ex.R15, copy of OPD slip of Karnal Nursing Home Ex.R16,  copy of discharge summary for the period of 12.06.2019 to 12.06.2019 Ex.R17, copy of discharge summary for the period of 08.06.2019 to 20.06.2019 Ex.R18,  copy of final bill Ex.R19 and Ex.R20, copy of repudiation letter dated 17.07.2019 and 23.08.2019 Ex.R21 and Ex.R22 and closed the evidence on 27.08   by suffering separate statement.

8.             Learned counsel for OP no.2 has tendered into evidence affidavit of Ravi Boolchandani Ex.OP2/A, copy of policy certificate Ex.OP2/1, copy of terms and conditions of insurance policy Ex.OP2/2, copy of certificate of Incorporation Pursuant to change of name Ex.OP2/3 and closed the evidence on 28.02.2022 by suffering separate statement.

9.             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.

10.           Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant purchased the Mediclaim Health Insurance Family Policy from the OP no.2. The said policy ported to Star Health and allied i.e. OP no.1. The complainant fell ill and admitted in a private hospital, Karnal from where she was referred to Sir Ganga Ram Hospital, New Delhi where she got admitted. The complainant spent amount of Rs.3,50,000/- on her treatment. After discharge from the hospital complainant submitted all the necessary documents with the OPs no.1. Thereafter, complainant requested the OPs so many times to settle the claim but OPs did not pay any heed to the request of complainant and repudiated the claim of the complainant on the false and frivolous ground and prayed for dismissal of the complaint.

11.           Per contra, learned counsel for the OP no.1 reiterating all the contents of written version, has vehemently argued that complainant availed the Family Health Optima Insurance Plan from the OP. The complainant had insurance policy earlier with the Religare Health Insurance and ported his policy to OP no.1 under portability. The complainant was admitted on 08.06.2019 and discharged on 20.06.2019 at Sir Ganga Ram Hospital, Delhi for the diagnosis of Hypersplenism/Severe Pancytopenia. Then the complainant sought for the pre-authorization request for the cashless treatment and the same was denied vide letter dated 11.06.2019. Subsequently, the complainant submitted claim records for reimbursement of the medical expenses. On scrutiny of the documents, it is observed that the Consultant Report dated 18.04.2019 of Dr. Raj Kumar that the complainant is having pre-existing disease prior to the policy. The claim of the complainant has rightly repudiated by the OP and lastly prayed for dismissal of the complaint.

12.           Learned counsel for the OP no.2 reiterating all the contents of written version, has vehemently argued that OP no.2 has no role in the present complaint as the policy had already ported from OP no.2 to OP no.1. Now the complainant is not insured with the OP no.2 and therefore, no liability arise against the OP no.2 is made out and lastly prayed for dismissal of the complainant qua OP no.2.

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

14.           Admittedly, complainant had insurance policy earlier with the Religare Health Insurance i.e. OP no.2 for the period of 03.05.2017 to 02.05.2018 and the same was renewed for the period of 03.05.2018 to 02.05.2019. Complainant has ported her policy to OP no.1 under portability for the period 03.05.2019 to 02.05.2020 for the sum insured of Rs.five lakhs.

15.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.R21 and Ex.R22 dated 17.07.2019 and 23.08.2019 on the grounds, which reproduced as under:-

“Our medical team has perused your representation and has noted the contents. The team which re-examined the claim records has observed that as per the consultation notes dated 18.04.2019, the patient’s HB level is mentioned as 5.1 and the patient has  been referred to higher center which is prior to porting the policy. The insured patient has complaints to prior to porting the policy which culminated to hypersplenism”.

We are, therefore, unable to consider your representation favourably and we inform you that repudiation of your claim is in order”.

16.           It is admitted fact that complainant was admitted in Sir Ganga Ram Hospital, New Delhi on 08.06.2019 and discharged on 20.06.2019. The pre-authorization request of the cashless treatment was denied by the OP on the ground that the claim required further evaluation. The claim for reimbursement is denied by the OP On the basis of consultation (OPD) report Ex.R16 dated  18.04.2019 of Karnal Nursing Home, Indri Karnal issued by Dr. Raj Kumar.  

17.           The whole case of the OP no.1 based upon the report Ex.R16. On perusal of the abovesaid report, it is nowhere mentioned that complainant was having any pre-existing disease. The said doctor has only referred to the complainant to the higher institute for better treatment. Only by referring to the patient to higher institute, does not mean that patient is having any pre-existing disease. Except that document there is no other opinion/documents on the file to ascertain that the complainant was having any pre-existing disease. The repudiation of claim of complainant is only on the basis of presumption and assumption and furthermore OP neither examined the said doctor nor tendered his affidavit in its evidence. Thus, the repudiation letter is totally arbitrarily, unjustified, biased, based on the presumptions and assumptions.  

18.           The OP has taken a plea that the policy was cancelled with effect from 31.08.2019 on grounds of misrepresentation, fraud, moral hazard, non-disclosure of material fact as declared in the proposal form and/or claim form at the time of claim either the onus to prove that plea lies upon the OP, but OP has miserably failed to prove the same by leading any cogent and convincing evidence. Rather, it has been proved on the record that complainant was not having any pre-existing disease then question of mis-representation of facts does not arise. Thus, the cancellation of the policy is totally arbitrary and unjustified.

19. 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.

 

 20.          Keeping in view the ratio of the law laid down in the abovesaid judgments, facts and circumstances of the complaint, we are of the considered view that act of the OP no.1 amounts to deficiency in service and unfair trade practice. 

21.           The complainant has claimed for Rs.3,50,000/-, but he has placed on file final bill(detail) Ex.C7 of Rs.2,90,965/-.  Hence the complainant is entitled for the Rs.2,90,965/- alongwith interest, compensation and litigation expenses etc.

22.           Thus, as a sequel to abovesaid discussion, we partly allow the present complaint and direct the OP no.1 to pay Rs.2,90,965/- (Rs.two lakhs ninety thousand nine hundred sixty five only)  to the complainant alongwith interest @ 9% per annum from the date of repudiation of claim 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.5500/- towards the litigation expenses. This order shall be complied with within 45 days from the receipt of copy of this order. Complaint qua OP no.2 stands dismissed. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated:14.07.2022     

                                                               

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)

                           Member                          Member