Order by:
Smt.Priti Malhotra, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant availed a Happy Family Floater Policy named as ‘PNB-Oriental Royal Mediclaim-Policy’ with a sum insured Rs.5,00,000/- in the year 2016-17 and continued the same without any break upto 2020-21. Thereafter Oriental Insurance Company discontinued their tie-up with PNB in 2021 and then the complainant ported his policy to the policy of Opposite Party i.e. Star Health and Allied Insurance Co. Ltd. and availed the policy of Opposite Party, which was renewed for the period 20.07.2023 to 19.07.2024. In May, 2023, wife of the complainant felt pain in her both knees and consulted with Dr.M.S. Somanna, Orthopedic Surgeon of Aster CMI Hospital, Bengaluru on 04.07.2023. She was advised X-ray of both knees & Lumbosacral spine. Doctor prescribed her some medicines and advised Total Knee Replacement of both knees. Then She consulted Dr.Prashanth R (Orthopaedic Surgeon) for 2nd opinion at Specialist Hospital, Bengaluru on 08.07.2023. She advised MRI LS Spine for her back pain and saw the previous knees x-ray, then she was diagnosed as osteoarthritis both knees and advised bilateral TKR. On 22.07.2023, the hospital submitted a request for cashless hospitalization for health insurance on a prescribed Performa to Opposite Party. On 24.07.2024, Opposite Party issued a cashless authorization letter with claim no.CIG/2024/211222/0529249. On 30.07.2023, she was admitted to the hospital for bilateral TKR. The complainant paid Rs.5000/- as advance payment via UPI. The hospital also purchases implants to replace both knees of wife of the complainant from Medi Ortho Line vide invoice dated 31.07.2023 amounting to Rs.1,68,100/- and on 31.07.2023 she was operated for bilateral TKR by Dr. Prashanth R (Orthopedic Surgeon) of Specialist Hospital, Bengaluru. Thereafter on 04.08.2023, Opposite Party issued a letter of withdrawal of authorization letter to the hospital and rejection of pre authorization to complainant. The hospital made the final bill of Rs.4,51,683/-, then the complainant made the payment of said bill from his own pocket. The complainant also contacted Grievance redessal office at Chennai, who told the complainant to contact Insurance Ombudsman Chandigarh and they further told the complainant to approach insurance company through letter or email. On dated 19.12.2023, the complainant sent notice through registered post at the head office of Opposite Party requesting them to pay the expenses incurred on the treatment, but to no effect. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Party may be directed to pay a sum of Rs.4,67,325/- alongwith interest.
b) To pay an amount of Rs.2,00,000/- as compensation on account of mental tension and harassment and for deficiency in service.
c) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite Party appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present Pre Mature complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Party on the ground of Pre-existing disease & Non-Disclosure of material facts. Averred that the present complaint pertains to insurance claim under “Star Group Health Insurance Policy-Gold (For Bank Customers) bearing no.P/211222/01/2024/002693 valid from 20.07.2023 to 19.07.2024 covering the complainant self and his spouse Sunaina Gupta for a sum of Rs.5,00,000/- for the first time. However it is submitted that the aforesaid insurance policy was issued to the insured by the answering Opposite Party subject to the terms and conditions of the insurance policy. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Averred further that the insured has requested for cashless and submitted the medical expenses towards the treatment of OA Knee at Specialists Health Systems Pvt. Ltd. on 29.07.2023. Initially Opposite Party has given an approval of Rs.50,000/-. Averred that as per internal verification, the insured patient had knee pain since 3 years which is prior to portability and the insured patient has not disclosed this in proposal form. Again Opposite Party had received reconsideration request and on scrutiny of claim documents again, it was found that further evaluation is required to ascertain the duration of the ailment, therefore the claim was withdrawn and denied. Moreover it was observed by the medical team of Opposite Party that as per FVO report, patient had B/L Knee pain for 2-3 years; as per PAC record, h/o Hysterectomy in the past. Details not available; X-ray films are s/o Chronic, Long-standing changes, including reduction of joint spaces. Hence, it is case of pre-existing disease existing prior to porting of the policy, which has not been informed to Opposite Party at the time of porting. Moreover, the history of previous surgery of Hysterectomy was also not disclosed to the Opposite Party by the insured. Hence, the claim was rejected and the intimation in this regard was sent to him vide letter dated 17.08.2023. Averred further that the complainant has got no cause of action and locus-standi to file the present complaint; the instant complaint is false, malicious, incorrect and with malafide intent and is nothing but an abuse of the process of law and is an attempt to waste the precious time of this Commission; the instant complaint is neither maintainable in law nor on facts; no deficient services have been rendered by the answering Opposite Party as alleged by the complainant. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. Complainant has also filed replication to the written reply of Opposite Party denying the objections raised by them in their written reply.
4. In order to prove his case, the complainant has placed on record his affidavit Ex.C1/A alongwith copies of documents Ex.C1 to Ex.C16.
5. On the other hand, Opposite Party has placed on record affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. as Ex.OP/A alongwith copies of documents Ex.OP1 to Ex.OP10.
6. We have heard the ld. counsel for both the parties and also gone through the record.
7. It is well proved on record that the complainant is the holder of Insurance policy namely “Star Group Health Insurance Policy-Gold” having no.P/211222/01/2024/002693 for the period 20.07.2023 to 19.07.2024 covering the complainant self and his spouse Sunaina Gupta . It is also proved that during the policy period, the wife of the complainant got admitted in Specialists Health System Private Limited with complaints of Pain in both knees and remained admitted in the hospital for the period 30.07.2023 to 04.08.2023, where he was diagnosed as ‘Osteoarthritis Bilateral Knee’. From the perusal of the record it transpires that before taking the treatment, the complainant requested the Opposite Party for cashless authorization and on receiving the cashless authorization, then Opposite Party issued cashless authorization letter dated 24.07.2023, vide which they approved the amount of Rs.50,000/-, but thereafter vide letter dated 04.08.2023 (Ex.OP9), they rejected the pre authorization for cashless treatment on the ground of pre existing disease. The said pre authorization rejection has been challenged by the complainant, through this complaint.
8. The Opposite Party rejected the pre authorization for cashless treatment, vide letter dated 04.08.2023. The contents of which are reproduced as under:-
“As per internal verification, the insured patient had knee pain since 3 years which is prior to portability and the insured patient has not disclosed this in proposal form. Hence it is a pre-existing disease. As per Exclusion-Pre-existing disease- Code Excl-01 of the policy issued to you. Hence auth withdrawn and claim rejected. Auth stands null and void.
9. After due consideration of the admitted and proved facts on record, we have also considered the rival contentions of ld. Counsels for both the parties and have gone through the record. We have also perused the discharge summary of Specialist Hospital, Bangalore. In the said discharge summary nowhere it is mentioned that the complainant has any history of ‘Osteoarthritis Knee’ prior to admission in the hospital and in the said discharge summary it is mentioned that the complainant was diagnosed as ‘Osteoarthritis Bilateral Knee” and in the ‘Past Medical History’ column it is mentioned as ‘Nothing Significant’, the contents of discharge summary are reproduced as under:-
Diagnosis
Osteoarthritis Bilateral Knee
Chief Complaints
Pain in both knees
Difficulty in walking and climbing stairs
Past Medical History
Nothing Significant
H/o Presenting Complaints
Mrs.Sunaina Gupta a case of osteoarthritis (right>left) came with above mentioned. Patient is being admitted for further evaluation and management.
10. Observing the above discharge summary, we are of the concerted view that the said discharge summary of the treating hospital is sufficient enough to prove that complainant has no prior history of ‘Osteoarthritis Knee’ as there is nothing mentioned that complainant has prior history of OA Knee.
11. It is proved on record that the complainant has been availing the insurance policies from Oriental Insurance Company since the year 2017 continuously without any break (Ex.C1) and thereafter, they ported their policy from Oriental Insurance Company to Star Health & Allied Insurance Company i.e. opposite party in the year, 2023. So, if the complainant ported his insurance policy from the previous insurance company to the present insurance company of the Opposite Party, then it is mandatory for the Opposite Party to get the details with regard to the health status of the complainant and treatment taken by him during the policy coverage, from the previous insurance company, but the Opposite Party failed to do the same. Further perusal of the record reveals that the complainant has been obtaining the policy from the Opposite Party since the year, 2017 without any break, meaning thereby that the policy in question is in its 7th year of continuation, so it cannot be said that complainant is suffering from pre-existing disease. Further the onus to prove that the complainant was suffering from a pre-existing disease as per settled law is on the Opposite Party, but the Opposite Party has not produced any documentary evidence/expert medical opinion in support of its case. For this observations we are well guided by judgments of Hon’ble National Consumer Disputes Redressal Commission in case titled Reliance Life Insurance Co. Ltd & Anr. v. Tarun Kumar Sudhir Halder in Revision Petition No. 2097 of 2019 has also held so:-
"The Insurance Company has not filed any evidence to show that the DLA was taking treatment for the disease prior to filling up of the proposal form. Even if there was disease inside the body, but the life insured did not know about the disease and was not taking any treatment for the same, the insurance claim cannot be denied on mere presumption that the life assured might be suffering from pre-existing disease. Thus, on merits, I am convinced on the (FA-383/2016) PAGE 8 OF 10 basis of the entries in the Medical Attendant Certificate that the disease was complained for the first time by the DLA on 22.06.2011, which is much after the date of the proposal form. The onus to prove the pre-existing disease lies on the Insurance Company and no supporting documents have been filed by the Insurance Company in support of their assertion. Moreover, in case of diabetes of late, this Commission has been taking a view that diabetes is a life style disease and is so common in India that the whole insurance claim cannot be rejected on this ground."
12. Further perusal of the policy document (Ex.C2) placed on record by the complainant reveals that in the said document, the complainant has mentioned his date of birth as 01.01.1954 and in the said document date of inception of first policy is mentioned as 20.07.2017, meaning thereby that at the time availing the first policy, the age of the complainant was more than 45 years, so it was the bounden duty of the Opposite Party-Insurance Company to get the life assured medically examined before issuing the policy in his/her name who was above the 45 years of age. As per the I.R.D.A.I Rules and Instructions with regard to thorough medical examination if the insured is more than 45 years which is reproduced as under:-
“As per instructions issued by the Insurance Regulatory and Development Authority of India (IRDAI), it was bounded duty of the insurer to put insured to thorough medical examination in case Mediclaim insured was more than 45 years and if insurance company failed to do so then insurance company has no right to decline the insurance claim on account of non disclosure of the facts of pre existing disease when the policy was taken. The above observations is supported by law cited in SBI General Insurance Company Limited Vs. Balwinder Singh Jolly” 2016(4) CLT 372 of the Hon’ble State Commission, Chandigarh.”
However, the Opposite Party-Insurance Company has not placed on record any evidence that before issuing the policy they ever got medically examined the insured. Further perusal of policy document Ex.C2 clearly reveals that wife of the complainant i.e. insured is also covered for pre-existing disease. From the discussion above, we are of the concerted view that Opposite Party illegally and wrongly repudiated the genuine claim of the complainant.
13. Vide instant complaint, the complainant claimed the amount of Rs.4,67,325/-, which is duly proved on record vide Ex.C11 and Ex.C15. Hence we allow the said amount.
14. From the above discussion, we allow the instant complaint in part and direct the Opposite Party to pay an amount of Rs.4,67,325/- (Rupees Four Lakh Sixty Seven Thousand Three Hundred Twenty Five only) to the complainant. Opposite Party is also directed to pay compository costs of Rs.15,000/-(Rupees Fifteen Thousand only) as compensation and litigation expenses to the complainant. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Party within 30 days from the date of receipt of copy of this order, failing which, the Opposite Party is further burdened with additional cost of Rs.10,000/-(Rupees Ten Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission
