Order by:
Sh.Mohinder Singh Brar, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that on 01.03.2023, the complainant suffered abdomen pain and heaviness in chest and he went to Dayanand Medical Hospital, Ludhiana for check-up and on the same day Dr.Gurpreet Singh Wander conducted the ECG and another test of complainant and told to the complainant that there is no heart problem. On 24.03.2023, the complainant again suffered pain in abdomen and chest and went to Parminder Hospital, Jalandhar for check-up and on the same day doctor conducted various tests of the complainant and ultimately on 29.03.2023 the complainant was admitted in the said hospital and discharge from the hospital on 01.04.2023 and after the discharge from the hospital, the complainant handed over the entire documents alongwith bills to the Opposite Parties, but on 11.05.2023 the claim of the complainant was rejected by the Opposite Parties. Thereafter complainant again on 18.07.2023 went to Shriman Super Specialty Hospital, Jalandhar and remained admitted in the said hospital for the period 18.07.2023 to 21.07.2023 and on 17th July, 2023, the said hospital applied for cashless treatment for the complainant, but the said claim was repudiated by the Opposite Parties. The complainant somehow arranged the amount of Rs.2,39,921/- and got deposited the said amount in the hospital at the time of discharge. The complainant approached the Opposite Parties many times and requested to pay the amount of treatment expenses, but to no effect. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay a sum of Rs.2,39,921/-.
b) To pay an amount of Rs.1,00,000/- as compensation on account of mental tension and harassment and for deficiency in service.
c) To pay an amount of Rs.50,000/- as litigation expenses.
d) 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 Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present false complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Parties as per the insurance policy terms and conditions. Averred that the present complaint pertains to insurance claim under “Family Health Optima Insurance Plan-2021 bearing no.P/211222/01/2023/011152 valid from 20.01.2023 to 19.01.2024 covering the complainant self for a sum of Rs.5,00,000/-. However it is submitted that the aforesaid insurance policy was issued to the insured by the answering Opposite Parties 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 preferred first claim in the 3rd month of the policy. The insured requested for the reimbursement of the medical expenses towards the treatment of AOE HT Carotid PLQ at Parminder Hospital, Jalandhar on dated 17.04.2023.The claim amount as per the claim form under this claim is Rs.59,631/-. On scrutiny of the documents, the Opposite Parties observed various discrepancies in the documents submitted by the insured. The company found all the details regarding the investigation and treatment of the insured patient are not transparently evident. The full facts of the case may not have been presented to the company. Therefore, the company was not in a position to admit the claim, as per terms and specific conditions no.18 of the policy. Hence the claim was repudiated and conveyed to the insured vide letter dated 11.05.2023.
Averred further that again the insured requested a cashless claim for the medical expenses towards the treatment of CAD i.e. Coronary Artery Disease, at Shrimann Superspeciality Hospital, Jalandhar. The claim amount as per the claim form under this claim is Rs.1,70,824/-. On scrutiny of the documents, the company is unable to ascertain the duration of the disease based on the documents/details submitted by the insurer. It requires further evaluation. Hence the approval for cashless treatment of the above diagnosed disease was denied on 17.07.2023. Thereafter, the insured submitted the claim documents for reimbursement of medical expenses. It is observed that the findings of investigation report confirm triple vessel disease i.e. chronic, longstanding heart disease. Based on this finding and available medical records, the medical team of Opposite Parties is of the opinion that the insured patient has the above heart disease prior to inception of the medical insurance policy. Hence it is a pre existing disease. The present admission and treatment of the insured patient is for the pre existing disease. Further, as per the documents and details available with Opposite Parties, the insured patient has bronchial asthma (BA) for the past one year, which is prior to inception of the medical insurance policy. As per Exclusion – Pre-existing disease –Code Excl-01 of the policy issued, the company is liable to make payment for any pre-existing disease only after the expiry of 48 months from 16.09.2023. Averred further that the PED has been found while scrutiny of present claim documents. Averred further that the complainant availed policy through online and has deliberately answered ‘None’ to the query raised in the online proposal form regarding health history of insured patient, which is reproduced as under:-
“Health History:
Do you have any health problems (if any) in the below field. “None”
Have you or any member of your family proposed to be insured, suffered or are suffering from any disease/ailment/adverse medical condition of any kind especially Heart/Stroke/Cancer/Renal disorder/Alzheimer’s disease/Parkinsons’ disease - ‘No’.
From the above findings, it is clearly evident that the insured is well aware of the past medical history of the insured person and failed to disclose the same in the proposal form, which amounts to non disclosure of material facts thus violating the Cardinal Principle of the Insurance, making the Contract of Insurance voidable and unenforceable. As per the contract of Insurance, it is the duty of the proposer to disclose all the material facts to the insurer so that the insurer has the opportunity to evaluate the material facts and to decide whether to accept the proposal or not,. Averred further the no deficient services have been rendered by the answering Opposite Parties as alleged by the complainant; the complainant has not come with clean hands and he has not disclosed the entire true facts. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. In order to prove his case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C37.
4. On the other hand, Opposite Parties have placed on record affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. as Ex.OP1,2/A alongwith copies of documents Ex.OP1,2/1 to Ex.OP1,2/18.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. It is well proved on record that the complainant is the holder of Insurance policy namely “Family Health Optima Insurance Plan” bearing no.P/211222/01/2023/011152 for the period 20.01.2023 to 19.01.2024 covering the complainant self for a sum of Rs.5,00,000/-. It is also proved that during the policy period, the complainant suffered AOE HT Carotid PLQ and for the treatment of same, he got admitted in Parminder Hospital, Jalandhar on 29.03.2023 and after treatment got discharged from the hospital on 01.04.2023. Thereafter, the complainant lodged the claim for reimbursement of the expenses incurred by him in the said hospital, but the Opposite Parties vide letter dated 11.05.2023, repudiated the claim of the complainant. It is also proved on record that during the policy coverage, the complainant again suffered chest pain and dyspne and got admitted in Shrimann Superspeciality Hospital, Jalandhar on 18.07.2023, where he was diagnosed as CAD, Angina on Exertion, Normal LV Function and after treatment got discharged from the hospital on 21.07.2023. Thereafter the complainant applied with cashless treatment with the Opposite Parties, but the Opposite Parties rejected the cashless request of the complainant, vide letter dated 17.07.2023. After discharge from the hospital, the claimant lodged the claim with Opposite Parties, but the Opposite Parties again repudiated the claim of the complainant vide letter dated 19.09.2023. The aforeasaid repudiations are challenged by the complainant through this complaint.
7. The perusal of the record reveals that the Opposite Parties repudiated the first claim of the complainant, vide letter dated 11.05.2023. The contents of said letter are reproduced as under:-
“We have processed the claim records relating to the above insured patient seeking reimbursement of hospitalization expenses for treatment of AOE, hypertension, Carotid PLQ.
We observe various discrepancies in the documents submitted to us. We find all the details regarding the investigation and treatment of the insure patient are not transparently evident. The full facts of the case may not have been presented to us. Therefore, we regret we are not in position to admit your claim as per the terms and Specific conditions No.18 of the policy issued to you.
We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.
But the repudiation of the claim of the complainant on the aforesaid grounds raised by the Opposite Parties is not genuine, as they failed to explain clearly which document shows the discrepancy. However, if the Opposite Party has found any type of discrepancy in medical record of the complainant and complainant failed to clarify about the same, the Opposite Party should have get it verified from the hospital concerned. Had they got verified the same from the hospital concerned about the discrepancies, they noticed, then they would have been justified in repudiating the claim. Hence, in the absence of any concrete evidence, the repudiation of the claim of the complainant on discrepancy and misrepresentation of facts by the Opposite Parties is unjustified.
8. The perusal of the record further reveals that the Opposite Parties vide letter dated 19.09.2023, the Opposite Parties repudiated the second claim of the complainant. The contents of said letter are reproduced as under:-
“We have processed the claim records relating to the above insured patient seeking reimbursement of hospitalization expenses for treatment of CAD.
It is observed that the findings of investigation report confirm triple vessel disease i.e. chronic, longstanding heart disease. Based on this finding and available records, our medical team is of the opinion that the insured patient has the above heart disease prior to inception of the medical insurance policy. Hence it is a pre existing disease. The present admission and treatment of the insured patient is for the pre existing disease. Further, as per the documents and details available with us, the insured patient has bronchial asthma (BA) for the past one year, which is prior to inception of medical insurance policy.
As per Exclusion- Pre existing disease – Code Excl-01 of the policy issued to you, the Company is liable to make payment for any pre-existing disease only after the expiry of 48 months from 16.09.2023.
We wish to bring to your kind attention that the above Pre-Existing Disease/s is/are found while processing the claim of the above insured patient.
The repudiation of the claim by the Opposite Parties on the abovesaid ground is also not genuine. 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.
9. Further as per policy document (Ex.C3) placed on record by the complainant reveals that in the said document, the complainant has mentioned his date of birth as 21.01.1973 and in the said document date of inception of first policy is mentioned as 20.01.2023, 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.”
10. 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. From the discussion above, we are of the concerted view that Opposite Party illegally and wrongly repudiated the genuine claim of the complainant.
11. Vide instant complaint, the complainant claimed the amount of Rs.2,39,931/-, but however, the complainant has placed on record medical bills amounting to Rs.2,31,121/-. Hence, we allow the said amount.
12. In view of the discussion above, we allow the instant complaint in part and direct the Opposite Parties to make the payment of Rs.2,31,121/- (Rupees Two Lakh Thirty One Thousand One Hundred Twenty One only) to the complainant. Opposite Parties are also directed to pay compository costs of Rs.20,000/-(Rupees Twenty 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 this order, failing which, they are further burdened with Rs.20,000/- (Rupees Twenty 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 cost. File be consigned to record room after compliance.
Announced in Open Commission
