Haryana

Karnal

CC/42/2023

Neerja Sharma - Complainant(s)

Versus

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

Manjul Mishra

17 Jul 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                          Complaint No. 42 of 2023

                                                          Date of instt.17.01.2023

                                                          Date of Decision 17.07.2023

 

Neerja Sharma wife of late Shri Jai Parkash Sharma, resident of house no.1424, MIG, Sector-6, Housing Board Colony, Karnal.

 

                                                 …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Company Ltd. SCF-137, Sector-13, second floor, near ICICI Bank through its Manager/authorized signatory.

 

2. Star Health and allied Insurance Company Ltd. Sri Balaji Complex, 14, whites Road, Chennai-600014 through its authorized signatory.

 

                                                                      …..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 Manjul Mishra, counsel for complainant.

                    Shri Sarthak Singhal, counsel for the OPs.

 

                    (Dr.Rekha Chaudhary, Member)

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 had purchased a health insurance policy bearing no.211114/01/2023/001904 alongwith her daughter by paying premium amount of Rs.19,185/-, the same was valid from 18.05.2022 to 17.05.2023 and the basic sum assured is Rs.10,00,000/-. The said policy is a cashless policy. Prior to the above mentioned policy, complainant purchased the insurance policy from the Oriental Insurance Company ltd. Since 2015. The details of which are as under:-

Policy no.	Period from	Period to	Insurer name	Sum assured
261301/48/2016/547	27-May-2015	26-May-2016	The Oriental Insurance Co. Ltd.	5,00,000/-
261301/48/2017/516	27-May-2016	26-May-2017	The Oriental Insurance Co. Ltd.	5,00,000/-
261301/48/2018/677	27-May-2017	26-May-2018	The Oriental Insurance Co. Ltd.	5,00,000/-
261301/48/2019/396	27-May-2018	26-May-2019	The Oriental Insurance Co. Ltd.	5,00,000/-
261301/48/2020/405	27-May-2019	26-May-2020	The Oriental Insurance Co. Ltd.	5,00,000/-
261300/48/2021/129	27-May-2020	26-May-2021	The Oriental Insurance Co. Ltd.	6,00,000/-

 

The complainant was fully satisfied with the service rendered by the Oriental Insurance Company Ltd. But the OPs approached to the complainant and the policy ported to the OPs. On 21.09.2022, complainant fell ill and got herself checked at Civil Hospital, Karnal, as the complainant was feeling problem in her spine and the complainant was feeling band like sensation over the abdomen in the umbilitical region. The complainant was feeling inability to pass her urine as well as stool and the complainant took medical treatment from Civil Hospital, Karnal and various body tests has been conducted alongwith ultrasound of abdomen and Pelvis but complainant could not recover. Then complainant also checked herself from Virk Hospital, Karnal on 29.09.2022 and there also various tests have been conducted and the doctors advised the complainant for MRI and the complainant got done MRI. Due to inability to pass urine and stool,  the complainant had to visit Haryana Nursing Home regularly for passing the urine. But the complainant could not recover there. On 10.10.2022, complainant also checked herself from Arvind Hospital, Karnal and where Dr. Vineet Bhai advised for MRI and advised her to admit in his hospital but she also could not recover there. Lastly, on 04.10.2022, complainant went to Paras Hospital, Panchkula for treatment and after checking doctor advised there to complainant to come on 06.10.2022 after getting MRI. On 05.10.2022 MRI of spinal, cervical spine with contract MRI was conducted there. As per MRI impression was Multifocal enhancing spinal cord lesions with focal T2 hyperintensity involving the promimal dorsal cord (owl eye sign). The financial condition of the complainant was not good so the Paras Hospital advised the complainant to go PGI Chandigarh for treatment, where the complainant can get the same treatment at the lower rate. On 10.10.2022, complainant got admitted at PGI Chandigarh after taking pre-approval from OPs and remain admitted upto 10.11.2022 (for one month) and spent Rs.5,01,184/- at PGI Chandigarh and Rs.26,565/- in various hospitals at Karnal totaling Rs.5,27,545/- during admission and during treatment. After discharge from PGI Chandigarh, complainant applied for reimbursement, vide claim no.CIA/2023/211114/0948375 after completing all formalities of OPs, vide receipt given by OP on 17.11.2022 and the claim form has also been submitted with these documents. Thereafter, OPs made some queries and demanded certain documents from the complainant, vide letter dated 28.11.2022 and same documents has been provided by the complainant and answer of queries sent to OPs on 12.12.2022 but OPs repudiated the claim of the complainant, vide letter dated 20.12.2022 on the ground of pre-existing disease whereas there was no pre-existing disease to the complainant. Feeling aggrieved the complainant moved representation before “Corporate Grievance Department” of Star Health and they had not entertained the representation of the complainant due to ID of the applicant was not registered. In this way there is deficiency in service on the part of the OP. Hence this complaint.

 2.            On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that complainant has lodged a claim of Rs.5,27,851/- with the OPs on account of reimbursement of medical expenses for her treatment and on examination and verification of medical record, it was found that as per the discharge summary of Postgraduate Institute of Medical Education and Research Chandigarh for the period of 10.10.2022 to 10.11.2022, insured has history of seizure, cholecystectomy in 2019. The Outpatient Department Record of District Civil Hospital, Karnal, discharge summary, operation note, progress notes dated 02.01.2019 confirms the history of cholecystectomy. The Pre Anesthetic Report of Civil Hospital states that the insured had history of seizure. Thus, from the documents submitted by the complainant, it is clearly evident that the insured has history of seizure, cholecystectomy in 2019 which is prior to inception of medical insurance policy. At the time of inception of the policy which is from 18.05.2022 to 17.05.2022 the complainant has not disclosed the above mentioned medical history/health details in the proposal form which amounts to mis-representation/non-disclosure of material facts and thus, the claim was not payable as per condition no.1 of the policy. The condition no. is reproduces as under:-

“If there is any mis-representation/non-disclosure of material facts whether by the insured person or any other person acting on his/her behalf, the insurance company is not liable to make any payment in respect of any claim.”

It is further pleaded that the insured had taken a policy for the period 18.05.2022 to 17.05.2023 for a sum of Rs.10,00,000/- insuring herself and her dependent child and the policy was issued and all the terms and conditions of the insurance were explained to the complainant at the time of proposing policy and the same were served to the complainant alongwith schedule. It is the duty of the insured to disclose all material facts in proposal while buying an insurance policy. It is further pleaded that the insured had policy with the Oriental Insurance Company Ltd. Since 27.05.2016 to 26.05.2021 but the same was not disclosed in the proposal form during the commencement of the policy and hence OPs were no aware of the coverage with Oriental Insurance Company Ltd. The insured had policy with Oriental Insurance Company and without disclosing the same, opted the policy with the OPs and hence the concept of portability does not arise. The complainant had taken policy with the insured as fresh policy on 18.05.2022 and hence the terms and conditions of the policy applied afresh to the complainant. It is further pleaded that complainant has concealed the pre-existing disease at the time of obtaining the policy in question and has violated the terms and conditions of the policy of insurance. Thus, the OPs have rightly repudiated the claim of the complainant. 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.

3.             Parties then led their respective evidence.

4.             Learned  counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy of star health from 18.05.2022 to 17.05.2023 Ex.C1, copy of policy with receipt Ex.C2, copy of discharge summary Ex.C3, copy of repudiation letter Ex.C4, copy of letter dated 28.11.2022 by OPs to complainant Ex.C5, copy of admission card dated 21.09.2022 of Civil Hospital, Karnal Ex.C6, copy of OPD slip of Virk Hospital dated 29.09.2022 Ex.C7, copy of OPD slip dated 30.09.2022 of Haryana Nursing Home Ex.C8, copy of OPD slip dated 11.10.2022 of Arvind Hospital Ex.C9, copy of MRI report dated 01.10.2022 Ex.C10, copy of MRI report dated 04.10.2022 Ex.C11, copy of OPD prescription of Paras Hospital, Panchkula Ex.C12, copy of receiving letter of medical bills Ex.C13, copy of claim form with pre-hospitalization bills Ex.C14, copy  of bills details Ex.C15, copy of medical bills Ex.C16 to Ex.C134, copy of certificate of doctor Ex.C135, copy of receipt of Rs.40290/- Ex.C136, copy of bank pass book Ex.C137, copy of medical bill Ex.C138, copy of medical bills Ex.C139 and closed the evidence on 06.07.2023 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.OPW1/A, copy of proposal form Ex.OP1, copy of insurance policy Ex.OP2, copy of terms and conditions of the insurance policy Ex.OP3, copy of claim form Ex.OP4, copy of discharge summary of PGIMER dated 10.11.2022 Ex.OP5, copy of OPD card of Civil Hospital dated 02.01.2019 Ex.OP6, copy of discharge summary of Civil Hospital dated 07.01.2019 Ex.OP7, copy  of indoor case of civil hospital Ex.OP8, copy of prescription slip of Arvind Hospital Ex.OP9, copy of prescription slip of  Virk Hospital Ex.OP10,  copy of final bill of PGIMER dated 10.11.2022 Ex.OP11, copy of claim repudiation letter Ex.OP12, copy of billing assessment sheet Ex.OP3 and closed the evidence on 24.05.2023 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 complainant had purchased a health insurance policy from the OPs and the basic sum assured is Rs.10,00,000/-. The said policy is a cashless policy. Prior to the said policy, complainant purchased the insurance policy from the Oriental Insurance Company limited since 2015. On 21.09.2022, complainant fell ill and has taken treatment from Civil Hospital Karnal, then she has taken treatment from various hospitals i.e.  Virk Hospital, Karnal, Haryana Nursing Home, Karnal, Arvind Hospital, Karnal, but she also could not recover there. On 04.10.2022, complainant went to Paras Hospital, Panchkula for treatment. The financial condition of the complainant was not good so she has taken the treatment from PGI Chandigarh. On 10.10.2022, complainant got admitted at PGI Chandigarh after taking pre-approval from OPs and remain admitted upto 10.11.2022 and spent Rs.5,01,184/- on her treatment and Rs.26,565/- in various hospitals at Karnal totaling Rs.5,27,545/- during admission and during treatment. After discharge from PGI Chandigarh, complainant lodged the claim with the OPs for reimbursement of the said amount but OPs did not pay the same and repudiated the claim of the complainant on false and frivolous ground of pre existing disease. He further argued that during the pendency of the present complaint, the complainant also admitted in an hospital and spent Rs.40,290/- and in this regard placed on record copies of documents Ex.C136 to Ex.C139 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 complainant purchased the policy in question for a period of 18.05.2022 to 17.05.2023. Complainant was hospitalized in Virk Hospital, Karnal, Haryana Nursing Home, Karnal, Arvind Hospital, Karnal, Paras Hospital, Panchkula  and lastly PGI Chandigarh for treatment and submitted a request for cashless authorization. OPs received a claim and on scrutiny of the documents, it was revealed that insured has history of seizure, cholecystectomy in 2019, which is prior to inception of medical insurance policy. At the time of inception of the policy, complainant has not disclosed the above mentioned medical history/health details in the proposal form which amounts to mis-representation/non-disclosure of material facts and thus, the claim was not payable and OPs have rightly repudiated the claim of the complainant. He further argued that the insured had policy with Oriental Insurance Company and without disclosing the same, opted the policy in question hence the concept of portability does not arise. The complainant had taken policy with the insured as fresh policy on 18.05.2022 and hence the terms and conditions of the policy applied afresh to the complainant. Complainant has concealed the pre-existing disease at the time of obtaining the policy in question 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 Star Health & Allied Insurance Co. It is also admitted that during the subsistence of the insurance policy complainant was admitted PGI, Chandigarh and in other hospitals at Karnal and was discharged on 10.11.2022. It is also admitted that the complainant lodged the claim for reimbursement.

11.           The claim of the complainant has been denied by the OPs, vide repudiation letter Ex.OP12 dated 20.12.2022 on the grounds which reproduced as under:-

“We have proposed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of transverse myelitis.

It is observed from the medical records submitted in response to our query that the insured patient has history of seizure, cholecystectomy in 2019,which is prior to inception of medical insurance policy.

At the time of inception of policy which is from 18.05.2022 to 17.05.2023 you have not disclosed the above mentioned medical history/health details of the insured-person in the proposal form which amounts to misrepresentation/non-disclosure of material facts.

As per Condition No.1, of the policy issued to you, if there is any misrepresentation/non-disclosure of the material facts whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim.”  

12.           The claim of the complainant has been denied by the OPs on the ground that complainant is having history of seizure, cholecystectomy in 2019, which was not disclosed by her in the proposal form at the time of purchasing of the policy. The OPs rejected the claim of the complainant on the ground that on examination and verification of the medical record, it was found in the discharge summary of PGI, Outpatient Department Record of District Civil Hospital, Karnal, Pre Anesthetic Report and other documents Ex.OP5 to Ex.OP10 that the complainant was history of seizure since 2019 but to prove its version the OPs neither has examined nor tendered affidavit in its evidence of those who have made the alleged remarks upon the medical record, thus the evidence of the OPs goes unproved. If for the sake of arguments, if it is believed that the complainant had previous history of seizure since 2019, in that eventuality, the claim of the complainant cannot be repudiated as the complainant has placed on record the observation Ex.P135 dated 30.05.2023 of Sr.Medical Record Officer, Nehru Hospital, PGIMER, Chandigarh, wherein it has been clarified that “current NMOSD disease does not have any correlation with the previous disease (cholecystectomy). Since, there is no nexus between the treatment taken by the complainant with the alleged pre-existing disease (cholecystectomy) since 2019, therefore, the question for concealment on the part of the complainant regarding the pre-existing disease does not arise at all.      

13.  

“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”.

 14.          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 in service and unfair trade practice.

15.           The complainant has claimed Rs.5,27,545/- and in this regard he has placed on file claim form Ex.C14 and medical bills Ex.C15 to Ex.C134. During the pendency of the complaint, the complainant was under treatment and as alleged that she spent Rs.40,290/- but the complainant has placed on record only the bills for an amount of Rs.16,793/- Ex.C138 and Rs.1951 Ex.C139 and nothing has been placed on record regarding spending of remaining amount. The said claim form/bills have not been rebutted by the OPs. Hence, the complainant is entitled for Rs.5,46,289/- (Rs.5,27,545 + Rs.18,744) alongwith interest, compensation for mental agony, harassment and litigation expenses etc.

16.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.5,46,289/- (Five lac fourty six thousand two hundred and eighty nine only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the 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.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:17.07.2023

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

 

        (Vineet Kaushik)        (Dr. Rekha Chaudhary)     

              Member                       Member