Haryana

Karnal

CC/243/2023

Pawan Kuma Gupta - Complainant(s)

Versus

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

Kanav Deep Singh

16 May 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 243 of 2023

                                                        Date of instt.25.04.2023

                                                        Date of Decision:16.05.2024

 

Pawan Kumar Gupta, age 78 years son of Shri Jagan Nath Gupta, resident of house no.831, near Tagore School, sector-6, Urban Estate, Karnal. Aadhar card no.8820 0949 2032.

 

                                                                        …….Complainant.

                                              Versus

 

Star Health and Allied Insurance Company Ltd. SCO no.137, 2^nd floor, Sector-13, Urban Estate, Karnal though its authorized signatory/person.

 

                                                                         …..Opposite Party.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr.  Suman Singh…..Member

 

 Argued by: Shri Kanavdeep Singh, counsel for the complainant.

                    Shri Naveen Khetarpal, counsel for the OP.

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant purchased a Health Insurance Policy bearing no.P/900000/01/2022/00000039, valid from 07.07.2021 to 06.07.2022 for Rs.19587/- and also renewed for the next year and the policy of insurance is still going on with the OP. Under the abovesaid policy, complainant and his wife was covered and sum insured was Rs.5,00,000/-. In the said policy first year and second year exclusion were waived and any pre-existing disease was also covered because earlier complainant was covered under Oriental Mediclaim policy. Thereafter, complainant switched the policy form OBC and ported the same with the OP. Complainant got admitted in PGI Chandigarh on 02.05.2022 in emergency as he was having acute abdominal pain and was suffering from loose motion, during his treatment in PGI Chandigarh it was found by the doctors that his prostate size was enlarged abnormally and he was referred to Urology Department and further treatment was given. Complainant was suggested to have prostatic biopsy as it was necessary found by the doctors. In biopsy report dated 12.05.2022, it was found that the complainant was having prostate cancer, on which he was medico legally examined and treated by the concerned doctors in PGI. Complainant spent Rs.83615/- on his treatment. After discharged from the hospital, complainant submitted his claim with all the original documents with the OP, which was repudiated by the OP on the false and frivolous ground. It is further alleged that on 14.08.2022, complainant again suffered from loose motion and vomiting for which he was admitted in Amritdhara Hospital Karnal on 14.08.2022. the complainant applied for cashless policy, which was declined by the OP without any valid reason. Complainant discharged from the hospital on 17.08.2022 and spent Rs.45000/- on his treatment. On 07.10.2022, complainant was suffering from acute pain in urinal area because of which he was admitted in Shree Hari Hospital Karnal on 07.10.2022 in emergency where he was examined and treated and urinal pipe was inserted in the body of complainant and was discharged on 08.10.2022. Amount of Rs.41385/- was paid by the complainant in cash to the hospital. Complainant also again tried to get his claim but again OP refused to pay the claim amount. It is further alleged that every three months complainant needs to take one injection namely Androbar 22.5 mg for the treatment of prostate cancer, which is very expensive and cost around Rs.14,000/- and till date complainant is taking the doses of abovesaid injection after three months and still getting the treatment and medicines for the abovesaid diagnosed disease but OP had not make any reimbursement till date. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

 2.            On notice, OP 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 availed the Star Group Health Insurance Policy-Gold (For bank customers) through Branch office covering Pawan Kumar Gupta-self, Harsh Lata-spouse for the sum insured Rs.5,00,000/-, vide policy no.P/211114/01/2022/002823, valid from 07.07.2021 to 06.07.2022. The complainant had ported his policy from OBC-Oriental Medical Policy to the OP. The complainant had a policy from 2013 and subsequently thereon. The policy was incepted is 2013, ported to Star Health and Allied insurance Co. Ltd. from 09.07.2021. Present admission for CA prostate with CKD. 3 claims pending for the query reply. As per customer declaration, complainant is a c/o prostate problem from past 3 years and under treatment. Inspite of queries he has not submitted related papers, so being not maintainable, claims of the complainant are not maintainable, same were repudiated. It is further pleaded that it is clearly stated in the policy schedule “The insurance Coverage is subject to terms and conditions, exclusion stated in the Master Policy P/900000/01/2022/000039 available with the Group Administrator/Proposer”. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. The insured preferred 3 connected claim in the following manner:

First Claim no.CIG/2023/211114/0897381.

Facts of the case:

The complainant was admitted Post Graduate Institute of Medical Education and Research for the period from 02.05.2022 to 11.05.2022 for the Diagnosis Prostate Cancer with Abdominopenic Lymphnode, left Supraclavicular Lymphnodes and Skeletal Metastasis. The complainant had submitted the claim for reimbursement of the medical expenses towards the treatment at Post Graduate Institute of Medical Education and Research on 11.10.2022. On scrutiny of claim documents, OP company has raised a query vide letter dated 17.10.2022 to submit the following documents:

.       A letter from treating doctor about exact duration of CA prostrate, CKD, HTN, any previous hospitalization of similar episode, past consultation papers, past investigation reports (serial creatinine reports) and related to above ailment.

.       Submit treatment details of cholecystectomy and hernia and sigmoidoscopy reports.

.       Complete set of indoor case papers.

Despite repeated reminders, vide letter dated 01.11.2022, 16.11.2022 the claim was rejected on the grounds that the complainant had failed to submit the requested query documents, vide letter dated 01.12.2022.

Second Claim no.CIG/2023/211114/0609939

Facts of case

The complainant had been admitted in Amritdhara Hospital for the period from 14.08.2022 to 17.08.2022 for the diagnosis towards Acute Gastroentitis. The complainant has requested for cashless and submitted the medical expenses towards the treatment Acute Gastroentritis at Amritdhara Hospital Pvt. Ltd. on 14.08.2022 to 17.08.2022.

Subsequently, insured has submitted the same in reimbursement, on scrutiny of claim documents, OP company has raised the following queries to submit:-

.       As per submitted documents CA prostrate-since 3 months; kindly submit first consultation reports for CA prostrate, past consultation papers, past hospitalization records, past investigation reports since 3 months related to ca prostrate to process.

Even after reminders dated 01.10.2022, 16.10.2022, 31.10.2022 and another query letter was raised vide letter dated 10.11.2022.

.           As per submitted documents CA prostrate-since 3 months; kindly submit first consultation reports for CA prostrate, past consultation papers, past hospitalization records, past investigation reports since 3 months related to ca prostrate to process.

Subsequently, query reminders were communicated vide letters dated 25.11.2022, 10.12.2022 and 25.12.2022.

Third Claim no.CIG/2023/211114/1184454 reported on (P/211114/01/2023/004635)

Facts of cases:

The complainant was hospitalized at Shree Hari Hospital (Super Specialty Hospital and Trauma Centre) for the period 07.10.2022 to 08.10.2022 towards the treatment Arec Bleeding Percreture Strureture. The complainant had raised a request for cashless benefit which was denied and subsequently complainant had approached the OP for reimbursement. On scrutiny of claim documents, OP had raised a query, vide letter dated 14.12.2022 to submit:-

.       Kindly submit a letter from treating doctor exact duration CA prostate, CKD complaints, all past consultation papers and investigation reports, histopathology reports previous hernia surgery hospitalization documents.

.       Submit investigation reports taken that time and all past treatment details.

Even after reminders vide letter dated 29.10.2022 and 13.01.2023 the complainant failed to submit the Query documents. Hence, claim was rejected and conveyed to insured vide letter dated 28.01.2023. 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 affidavit of complainant Ex.CW1/A, copy of insurance policy and certificate of insurance Ex.C1 and Ex.C2, detail of receipt Ex.C3, copy of letters dated 07.12.2022 and 13.08.2022 Ex.C4 and Ex.C5, copy of reconsideration of claim letter and its reminder Ex.C6 Ex.C7, copy of letter regarding rejection of claim Ex.C8 and Ex.C9, copy of cashless treatment Ex.C10, discharge and followup card Ex.C11, copy of card of urology department Ex.C12, copy of claim form Ex.C13, PGI declaration of biochemistry Ex.C14, MRI report Ex.C15, copy of surgical pathology reports Ex.C16 to Ex.C18, copy of antibiotic report Ex.C19, bill cum receipt Ex.C20, copy of blood report Ex.C21, copy of outpatient bill Ex.C22, copy of counciling form Ex.C23, outpatient department (first assessment) Ex.C24, copies of bills and receipts Ex.C25 to Ex.C70, copy of health investigation report Ex.C71, CT scan report Ex.C72, copy of detail Annexure-1 Ex.C73, copy medical receipts Ex.C74 and Ex.C75, copy of query report Ex.C76, copy of cash receipt Ex.C77, discharge summary dated 17.08.2022 Ex.C78, ultrasound report Ex.C79 and C80, copy of claim form Ex.C81, copy of claim form Ex.C82, copy of Covid Antigen Test Ex.C83, copy of Transthorsis Echo Report Ex.C84, copy of claim form Ex.C85, copy of discharge summary Ex.C86, copy of final bill and receipt Ex.C87 and Ex.C88, copy of discharge summary and declaration of discharge Ex.C89 and Ex.C90, copy of patient history report Ex.C91, copy of progress report dated 14.08.2022 Ex.C92, copy of Progress Report Ex.C93, copies of Nurses Notes Ex.C95 to Ex.C101, copy of critical Care Flow Sheet dated 14.08.2022 Ex.C102 to Ex.C104, copies of test reports  dated 14.08.2022, 15.08.2022, 16.08.2022, 17.08.2022 Ex.C105 to Ex.C108, copy of details of payment receipt Ex.C109, copy of Discharge Summary of Hari Hospital Ex.C110, copy of report of Haematology dated 07.10.2022 Ex.C111, copy of report dated 07.10.2022 Ex.C112, copies of bills, receipts, authorization letter and claim form Ex.C113 to Ex.C136, copy of star health policy Ex.C137, copy of aadhar card of complainant Ex.C138 and closed the evidence on 16.08.2023 by suffering separate statement.

6.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.RW1/A, copy of Insurance policies Ex.R1, Ex.R2 and Ex.R5, copy of certificate of insurance Ex.R3, terms and conditions of the insurance policy Ex.R4, copy of discharge and follow-up card Ex.R6, copy of treatment record Ex.R7, copy of bill-cum-receipt Ex.R8, copy of letter dated 17.10.2022, 01.11.2022, 16.11.2022 regarding requirement of Additional Documents/Details Ex.R9 to Ex.R11, copy of letter regarding Rejection of Reimbursement claim dated 01.12.2022 Ex.R12, copy of  request letter regarding cashless hospitalization for health insurance Ex.R13, copy of denial of pre-authorization for cashless treatment Ex.R14, copy of insurance policy Ex.R15, copy of discharge summary Ex.R16, copy of statement of complainant Ex.R17, copy of patient history Ex.R18, copy of final bill Ex.R19, copies of letters dated 01.10.2022, 16.10.2022 and 31.10.2022  regarding requirement of additional document Ex.R20 to Ex.R22, copy of query reply Ex.R23, copies of letters dated 10.11.2022, 25.11.2022 and 10.12.2022  regarding requirement of additional document Ex.R24 to Ex.R26, copy of rejection letter dated 25.12.2022 Ex.R27, copy of bill detail Ex.R28, copy of insurance policy Ex.R29, copy of discharge summary Ex.R30, copy of bill of Shree Hari Hospital Ex.R31, copies of letters dated 14.12.2022, 29.12.2022, 13.01.2023 regarding requirement of additional document/information Ex.R32 to Ex.R34, copy of rejection letter dated 28.01.2023 Ex.R35, copy of bill detail Ex.R36 and closed the evidence on 03.10.2023 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 complainants, while reiterating the contents of the complaint, has vehemently argued that complainant  purchased a Health Insurance Policy from the OP for insuring a sum of Rs.5,00,000/-. Earlier complainant had purchased the Oriental Mediclaim policy from OBC in the year 2013and thereafter ported the same with the OP in the year 2021 without any break. On 02.05.2022, complainant got admitted in PGI Chandigarh due to acute abdominal pain and during his treatment it was found that the complainant was having prostate cancer. Complainant spent Rs.83615/- on his treatment. Complainant submitted his claim but same was repudiated on the false and frivolous ground. On 14.08.2022, complainant again admitted in Amritdhara Hospital, Karnal on 14.08.2022, the complainant applied for cashless policy, which was declined by the OP without any valid reason. Complainant spent Rs.45,000/- on his treatment. On 07.10.2022, complainant was again admitted in Shree Hari Hospital Karnal and spent an amount of Rs.41385/- but the said claim was also denied by the OP. He further argued that every three months complainant needs to take one injection for the treatment of prostate cancer and the cost of the said injection is around of Rs.14,000/- and till date complainant is taking the doses of abovesaid injection after three months and still getting the treatment and medicines for the abovesaid diagnosed disease but OP had not make any reimbursement till date. Complainant submitted his claim with the OPs for reimbursement but OPs did not pay the claim and repudiated the same 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 complainant has availed the Star Group Health Insurance Policy-Gold covering-self, and his spouse Harsh Lata for the sum insured Rs.5,00,000/-. The complainant had ported his policy from OBC-Oriental Medical Policy to the OP. The complainant was admitted in PGI, Chandigarh and for the Diagnosis Prostate Cancer and thereafter admitted in Amritdhara Hospital and lastly in Shree Hari Hospital. The complainant submitted the claim cashless as well as for reimbursement of the medical expenses towards the treatment and on scrutiny of claim documents, OP company has raised queries through various letters and reminders, but complainant not replied the said letter and reminders so the claim was rightly rejected and lastly prayed for dismissal of the complaint.

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

11.           Admittedly, initially complainant purchased the health insurance policy from OBC Oriental Mediclaim Policy in the year 2013 and same was ported with the OP Company in the year 2021. It is also admitted that medical policy is without any break since 2013. It is also admitted that during the subsistence of the insurance policy complainant had taken the treatment from PGI, Chandigarh, Amritdhara Hospital, Karnal and Shree Hari Hospital, Karnal and spent an amount of Rs.2,04,632/-.

12.           The insured submitted three claims. Firstly, complainant was admitted PGI Chandigarh for the period from 02.05.2022 to 11.05.2022 for the Diagnosis Prostate Cancer with Abdominopenic Lymphnode, left Supraclavicular Lymphnodes and Skeletal Metastasis. The complainant had submitted the claim for reimbursement of the medical expenses incurred by him in the said hospital. The said claim has been repudiated by the OP, vide repudiation letter Ex.R12 dated 01.12.2022 on the grounds, which are reproduced as under:-

1.     “A letter from treating doctor about exact duration of CA prostrate, CKD, HTN, any previous hospitalization of similar episode, past consultation papers, past investigation reports (serial creatinine reports) and related to above ailment.

2.     Submit treatment details of cholecystectomy and hernia and sigmoidoscopy reports.

 3.    Complete set of indoor case papers.

               

                The second claim lodged by the complainant for the hospitalization of Amritdhara Hospital for the period from 14.08.2022 to 17.08.2022 for the treatment of Acute Gastroentitis but the said claim has also been repudiated by the OP, vide repudiation letter Ex.27 dated 25.12.2022 on the grounds, which are reproduced as under:-.   

“As per submitted documents CA prostrate-since 3 months; kindly submit first consultation reports for CA prostrate, past consultation papers, past hospitalization records, past investigation reports since 3 months related to ca prostrate to process.

Even after reminders, you have not sent us the above documents. We therefore, presume that you are not interested in preferring the claim and therefore the same is rejected.

           

        The third claim was lodged by the complainant for hospitalization of Shree Hari Hospital for the period from 07.10.2022 to 08.10.2022 for the treatment of Arec Bleeding Percreture Strureture.. The said claim has also been repudiated by the OP, vide repudiation letter Ex.R35 dated 28.01.2023 on the ground, which is reproduced as under:-

“Kindly submit a letter from treating doctor exact duration CA prostate, CKD complaints, all past consultation papers and investigation reports, histopathology reports previous hernia surgery hospitalization documents.

.       Submit investigation reports taken that time and all past treatment details.

Even after reminders, you have not sent us the above documents. We therefore, presume that you are not interested in preferring the claim and therefore the same is rejected.

13.           The claims of the complainant have been repudiated by the OP on the abovesaid grounds. The policy in question has been ported from OBC to OP company. The portability defined by the IRDA vide its circular Reference No. IRDA/HLT/MISC/CIR/209/ 09/2011) is as under:-

Portability:  Portability means the right accorded to an individual health insurance policyholder (including family cover) to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policyholder chooses to switch from one insurer to another insurer or from one plan to another plan of the same insurer, provided the previous policy has been maintained without any break.              

14.           There is no break in the medical insurance policy issued by the OBC, prior to portal of the same in the OP company. The OP has ported the insurance policy and issued the fresh policy C1 dated 07.07.2021. In the said policy OP has himself covered the pre-existing disease and waived off thirty days period, first and second year in exclusion clause. Furthermore, no treatment has been taken by the complainant prior to abovesaid period. Then the question for submission of the previous treatment record does not arise at all. Thus, in view of the above, the plea taken by the OP regarding pre-exist disease, has no force at all. 

 15.          We further fortified with the observation of Hon’ble National Commission in case titled as Mrs. Rubi Chandra Dutta Versus M/s United India Insurance Co. Ltd., (2011) 3 scale 654, decided on 16.12.2016 wherein it is held that “It was 2 years before switching over the policy with the OPs. Therefore, once portability scheme was accepted by OPs then they had no right to decline the claim upto the amount of sum assured of previous insurance policy in case it was within the terms and conditions of the policy. The policy with New India Assurance Company was continuing since 2001 and counsel for OPs was unable to pin point how the claim to the extent of Rs.1,30,000/- allowed by the District Forum was not payable under the policy. Clause 1 of the policy speaks that under portability right accorded to an individual health insurance policy holder to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policy holder chooses to switch from the one insurer to another insurer or from one plan to another plan. Under that scheme whatever has been gained by the insured under the policy insured by the previous insured will be gained by the insured under the portability scheme. Therefore, we do not agree with the plea raised by the OPs. Even otherwise, the policy was continuing one since 2001.

16.              Furthermore, if for the sake of arguments, if it is presumed that complainant was having any pre-existing disease.  The onus to prove same was relied upon the OP, but OP has miserably failed to prove the same by leading any cogent and convincing evidence. OP has relied upon the discharge summary Ex.R30, on perusal of the said discharge summary, it is nowhere mentioned that complainant was taking treatment prior to inception of the insurance policy. Except the said record, there is no other medical record on the file to ascertain that the complainant was having any pre-existing disease. Moreover, in para no.1 of the written statement OP has alleged that the policy was incepted from 2013. The portability has not been disputed. Hence, plea taken by the OP has no force and the repudiation of claim of complainant is only on the basis of presumption and assumption.

17.             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”.

18.           Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, the act of the OP while repudiating the claim of the complainant amounts to deficiency in services, which is otherwise proved genuine one.

19.           The complainant claimed Rs.2,04,632/-. The said amount has not been denied and rebutted by the OP. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

20.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.2,04,632/- (Rs.two lakhs four thousand six hundred thirty two only) to the complainant alongwith interest @ 9% per annum from the date of repudiations letters till its realization. We further direct the OP 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:16.05.2024                                     

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

       

                (Vineet Kaushik)        (Dr. Suman Singh)    

                      Member                        Member