Delhi

East Delhi

CC/372/2016

SUNIL - Complainant(s)

Versus

STAR HEALTH - Opp.Party(s)

24 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. No.372/2016

 

	Sunil Jain S/o Late Sh. Sultan Singh Jain 4-C, Flag Staff Road, Civil Lines, Delhi – 110006.	….Complainant
Versus
	The Branch Manager Branch Office, East Delhi Star Health and Allied Insurance Co. Ltd. 209-210, Laxmi Deep Building, Distt. Centre, Laxmi Nagar, Delhi – 110092.	……OP

Date of Institution: 22.07.2016

Judgment Reserved on: 16.03.2023

Judgment Passed on: 24.03.2023

               

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms. Rashmi Bansal (Member)

 

 

Order By: Shri Ravi Kumar (Member)

 

JUDGEMENT

1. The Complainant has alleged deficiency in service on the part of OP in not settling his medical claim despite of having valid Insurance Policy.
2. The Complainant has contended in his complaint that he is holder of ‘Family Health Optima Insurance Plan’ of the OP (Policy No. P-16.11.11-01-2015-010331) for an amount of Rs.5,00,000/- which was for the period 06.02.2015 to 05.02.2016.
3. During the validity of the policy he suffered from ‘IHD-Acute Anterior-Wall MI in Savior Single Vessal Coronary Arteries’ disease for which he was admitted in Indraprastha Apollo Hospital, Delhi on 21.08.2015.
4. At the time of admission in the Hospital pre-authorization request for cashless treatment was made which was denied by the OP.
5. The Complainant underwent treatment at the Hospital whereas ‘Angioplasty’ was done at 21.08.2015 and he was discharged on 22.08.2015. The Hospital raised bill of Rs.2,86,761/- which was paid by the Complainant. Thereafter, he made claim before the OP for reimbursement of the amount in terms of the said Insurance Policy which was again denied for the reason that as per Exclusion Clause No.1 of the Policy treatment of pre existing disease (PED) are not permitted. Complainant issued legal notice to the OP which was replied. The Complainant has made following prayer in his complaint:-

• OP to pay entire claim amount as per bills raised by Hospital amounting to Rs.2,80,761/- alongwith interest for the period of delay @18% p.a. and pre/post expenses incurred by him and Rs.5500/- as cost of the notice issued to OP with compensation etc. as deemed fit and proper by this Commission.

6. Alongwith his complaint, the Complainant has filed following documents:-

• Insurance policy bearing No. P-16.11.11-01-2015-010331 issued by OP for the period from 06.02.2015 to 05.02.2016.
• Letter dated 22.08.2015 of the OP denying pre authorization for cashless treatment.

-  Discharge Summary dated 22.08.2015 of Indraprastha   Apollo Hospital.

- Final Interim Bill of Indraprastha Apollo Hospital dated 22.8.2015 for Rs.280761/-.

- Bill No.INT239605 of Indraprastha Apollo Hospital for Rs.2,86,060.76.

- Copy of legal notice dated 16.02.2016 issued by the Complainant.

- Copy of letter dated 11.03.2016 of OP to the reply of the legal notice.

7. Notice was issued and OP has filed its reply wherein it has been contended that while processing the claim of the Complainant it was found that Hospitalization in question was related to a disease which was pre-existing in nature and had been endorsed under the Policy under ‘Exclusion Clause’. Since, the treatment was related to the pre-existing disease therefore claim was found hit by ‘exclusion clause’ hence was rejected. The Complainant himself has declared about the ‘Diabetes Mellitus’ in the Proposal Form and accordingly the Policy coverage was not extended to cover Diabetes and its related treatment. As per the terms and conditions of the  policy “Pre-existing disease means any condition, ailment or injury or related condition (s) for which the insured person has signs or symptoms and/or was diagnosed and/or received medical advice/treatment within 48 months prior to the insured person’s first policy with any Indian insurer.” Since, the claim of the Complainant was beyond the scope of policy and the same was relating to the disease for which admittedly coverage was not there and therefore the same was rejected vide letter dated 22.08.2015.
8. Further the Complainant had not submitted any Bill or Claim records for reimbursement of medical expenses. Hence, OP is not aware of the expenses incurred by the Complainant. ‘Diabetes Mellitus’ is closely associated with Cardio Vascular disease and as the main cause of death in patients is not only with Type 2 Diabetes but Type 1 Diabetes also. Apart from traditional risk factor such as Arterial Hypertension, Dyslipidemia and Obesity, Hyperglaysiaemia are the risk factor for the development of Ischemic Heart Diseases (IHD). Since, Diabetes Mellitus is major risk factor for heart disease, the Complainant is not entitled for relief as made in the complaint.
9. Complainant has filed Rejoinder to the reply of the OP denying the contention of the OP and has re-iterated his complaint. He has also stated that it is wrong that he had under gone treatment which was in relation to Diabetes and it has got no relation with any pre-existing disease and his claim is well covered and maintainable. The medicine prescribed by the Medical Officer do not support the stand of the OP that his admission was due to complication of Diabetes. He has also denied that he had not submitted any claim regarding reimbursement of medical expenses and OP also did not raise any objection of non receipt of claim records in their Reply to Legal Notice also and the medical records of the Complainant can be taken from the Hospital by the OP.
10. The Complainant has filed his evidence by way of affidavit whether he exhibit the following documents:

• Copy of Insurance Policy No. P-16.11.11-01-2015-010331 as exhibit C-1.
• Copy of letter dated 22.08.2015 of OP as exhibit C-2.
• Copy of Discharge Summary of the Hospital as exhibit C-3.
• Copy of Legal Notice dated 16.02.2016 as exhibit C-4

11. OP has filed its evidence by way of affidavit wherein its has enclosed following documents:-

• Proposal form with regard to the policy issued to the Complainant by the OP – Annexure 1.
• Copy of policy schedule of Policy No. P-16.11.11-01-2015-010331 issued by OP – Annexure 2.
• Copy of policy ‘Family Health Optima Insurance Plan’ –Annexure 3.
• Document relating to claim No.140625 – Annexure 4.
• Copy of request for cashless Hospitalization submitted to OP – Annexure 5.
• Querry on Pre-authorization dated 22.08.2015 – Annexure 6.
• Copy of Casualty Card of Sant Parmanand Hospital relating to Complainant. Advising admission alongwith ECG Report – Annexure 7.
• Letter dated 22.08.2015 denying of Pre-authorization for cashless treatment of the Complainant – Annexure 8.

12. This Commission has heard the arguments of both the sides and has perused the documents on record.
13. The Complainant is seeking settlement of his medical claim by the OP in terms of the Insurance Policy (Exhibit C-1) he had taken for the period 06.02.15 to 05.02.16 for Rs.500000/-. The facts relating to the issuance of above Insurance Policy and admission of the Complainant in Indraprastha Apollo Hospital and his Discharge on 22.08.2015 are not disputed. OP is relying upon the Terms and Conditions of the Policy by taking the stand that since the Complainant had declared in the Proposal Form (Annexure 1 of OP Evidence) that he suffering from pre existing disease of ‘Diabetes Mellitus’ therefore, his case is hit by exclusion clause as per the policy and therefore his claim cannot be settled.
14. On perusal of the ‘Proposal Form’ it is observed that the Complainant while applying for the Policy had declared that he is a patient of ‘Diabetes Mellitus’ since last 5 years and this fact was well known to the OP and in the Policy Schedule also (Annexure 2 of OP evidence) it was clearly mentioned Pre-Existing Disease i.e. Diabetes Mellitus and its complications.
15. The Discharge Summary of the Hospital (Exhibit C-3)reveals that the Complainant was admitted in Indraprastha Apollo Hospital on 21.08.2015 and the diagnoses done at the time of admission was as follows: “ DIAGNOSIS : IHD Acute Anterior Wall MI Severe Single Vessel Coronary Artery Disease, Mild LV dysfunction, Normal Renal Arteries and in further investigation ‘Severe Single Vessel Coronary Disease’ was revealed by doing Angiography and procedure done was Angioplasty on the same day i.e. 21.08.2015.
16. From the said report it is very clear that Complainant suffered  from acute Heart Disease and his Angioplasty was done. The stand of the OP that this was result of Complainant suffering from ‘Diabetes Mellitus’ which he had declared in his Proposal Form and was also written in the Policy Schedule is not of much consequence and is untenable as no such observation was made by treating Doctor.
17. Hon’ble NCDRC in the case of Neelam Chopra Vs. LIC (Revision Petition No. 4461 of 2012) has held  ‘…insurance claim cannot be denied on the ground of life style diseases that are so common’ and also confirmed this view in ICICI Lombard General Insurance Co. Ltd. Vs. Neema Saini (Appeal No.746/2021) while upholding the orders of Hon’ble Delhi State Commission Disputes Redressal Commission and relying upon the judgment in Neelam Chopra Case, ‘that life style disease like Diabetes, Hypertension cannot be the ground for repudiation of claim by Insurance Companies’.   
18. The diagnosis by the Hospital was Single Vessel Coronary Disease and it cannot be said that the same was directly on account of only Diabetes Mellitus and there can be many factors for it. If the person is suffering from Diabetes Mellitus and he is taking treatment from the doctor and he is keeping the Diabetes under control by way of medicine, exercise and diet control then it has been seen in many cases that such patient live a long trouble free life without facing acute Heart Disease. The Complainant had also sincerely declared in his health condition in the proposal form and stated that he was suffering from ‘Diabetes Mellitus’ for last 5 years and then also policy was issued to him by the OP and in the Policy Schedule also the same was mentioned and therefore relying upon the above judgments of Hon’ble NCDRC (Supra) this Commission  holds OP deficient in service in not settling the medical of the Complainant which amounts to deficiency in service and direct as follows:

• OP to pay Rs.280761/- along with interest @ 7% p.a. to the Complainant from 21.08.2015.
• OP to pay Rs.10000/- towards mental harassment and agony to the Complainant.

This order shall be complied with within 30 days from the date of receipt of the order and in case of failure OP shall pay the above said amounts with interest @ 9% p.a. till the date of realization.  

Copy of the order be supplied/ sent to the parties free of cost as per rules.

File be consigned to Record Room.  

Announced on 24.03.2023.