DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

                                                                        Complaint No. 421

 Instituted on:  05.08.2019

                                                                         Decided on  :  23.12.2022       

1. Kamlesh  Kumari Wife of Sh. Kewal Krishan Goyal S/o Sh. Faqir Chand, Resident of #66,67, Partap Nagar, Sunami Gate, Sangrur 148001 Punjab.                                          

                                                            …. Complainant.                                     Versus

1. Star Health and Allied Insurance Co. Ltd., No.15, Sri Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai-600014 through its Managing Director
2. Star Health and Allied Insurance Co. Ltd., Ist Floor, Above IDBI Bank, Sangrur-148001 through its Branch Manager/ Authorized Signatory

….Opposite parties. 

QUORUM                                       

JOT NARANJAN SINGH GILL: PRESIDENT

KANWALJEET SINGH             : MEMBER

For the complainant  : Shri K.C.Sharma Adv.              

For the Ops              : Shri Rohit Jain, Adv.

ORDER BY

JOT NARANJAN SINGH GILL, PRESIDENT.

1. Complainant has alleged in the complaint that she is a consumer of Ops by availing the services of Ops by getting insured herself through her husband for Rs. 5,00,000/- bearing policy number P-1211223/01/2019/000496 for the period from 29.10.2018 to 28.10.2019 by paying the premium of Rs. 22,066/- to the Ops, Where under this policy the Ops covered all the diseases of the complainant. The complainant of 03.05.2019 during the subsistence of the insurance policy suddenly fell down from the stairs at her residence in the morning and due to difficulties in walking she become bed ridden and as such approached to Dr. Amit Gupta of Global Health Care, Bathinda, who advised her emergency surgery. As such, the complainant was taken to Paras Hospital, Gurgaon, where she remained admitted from 04.05.2019 to 12.05.2019 and spent an amount of Rs. 4,74,072/- on her treatment. The complainant immediately after discharge from the hospital lodged the claim with the Ops for reimbursement. But the Ops wrongly and illegally repudiated the rightful claim on 19.06.2019 of the complainant on the ground that she was suffering from a pre existing disease, Which is clear cut case of deficiency in service and unfair trade practice on the part of Ops. The Ops neither explained the terms and conditions of the policy nor any copy of the same was provided to the complainant or her husband, who was the proposer for getting the insurance policy for his wife (Complainant). Complainant was not medically examined as the Ops felt that the complainant is fit to get the policy without getting medically checkup. The complainant has made so many request to Ops to pay the claim of Rs. 4,74,072/- but all in vain. Lastly, prayed that the complaint may kindly be accepted and the Ops may kindly be directed to pay to the complainant a sum of Rs. 4,74,072/- along with interest @18% per annum from the date of repudiation of the claim i.e. 19.06.2019 to till final payment is made and Rs. 44,000/- as compensation for mental tension, agony, harassment and Rs. 15,000/- as litigation expenses.
2. Upon notice, Ops appeared and filed written reply. Ops taking preliminary objections and submits that the reliefs are claimed against Op.no.2 only and admittedly there are no personal allegations or relief claimed as against Op.no.1. On merits complaint is admitted to be corrected to the extent that the complainant is consumer of Ops by availing service of Ops by getting herself insured through her husband for Rs. 5,00,000/- vide med claim insurance policy number P-1211223/01/2019/000496 for the period from 29.10.2018 to 28.10.2019 by paying the premium of Rs. 22,066/- to the Ops and as per record provided by the complainant the complainant approached Dr. Amit Gupta at Bathinda and got herself operated in Paras Hospital, Gurgaon, where she remain admitted from 04.05.2019 to 12.05.2019 for the treatment of injury of spinal cord which was caused due to falling from the stairs and spent an amount of Rs. 4,74,072/- on her treatment and her claim was repudiated on the ground that she was suffering from a pre-existing disease. It is denied that on 03.05.2019 the complainant fell down from the stairs at her residence in the morning and due to difficulty in walking she became bed ridden. Complainant after going through the proposal form and after accepting the same as true and correct, signed the proposal form. There is no deficiency in service, negligence and unfair trade practice on the part of Ops. The policy is contractual in nature and the claims arising therein are subject to terms and conditions forming part of the policy.
3. The complainant has sought for pre authorization approval was hospitalized towards the admission at Paras Hospital on 04.05.2019 for the treatment of L-4-L-5, L5-S1 PIVD in the 7^th month of the policy. On the scrutiny of the documents submitted by the complainant, it is observed that the MRI spine does not correlate with the acute injury sustained, hence the opponent are not able to ascertain the duration of the disease based on the documents. Thus, the pre auth was denied vide letter dated 06.05.2019. Insured submitted claim documents for the reimbursement of medical expenses for Rs. 4,74,072/- on scrutiny of the claim documents, It is noted that

1. MRI report dated 03.05.2019 chronic, longstanding degenerative change and no evidence of any acute injury.
2. The insured patient has undergone treatment for the above said disease during first year of the policy.
3. Expert opined that, Mild narrowing of bilateral neural foramina is also noted at this level, ligamentum flavum hypertrophy are features producing compression of nerve roots of non traumatic cause. So the problem is not due to trauma and related to non traumatic age related degenerative condition.

It is observed that the insured was diagnosed with L4, L5, L5-S1 PIVD, which is degenerative disease which is not payable till continuous coverage of 24 months as per exclusion 3a. Complainant has concealed material fact from the Ops at the time of getting the policy as per policy terms and conditions. She is not entitled for any benefit under the policy. That without prejudice to whatever has been stated earlier in this written statement even assuming without conceding that the company is liable to pay the claim in terms of the contract of insurance issued to the claimant-petitioner, it is submitted that the maximum quantum of liability under the terms of the policy shall be Rs. 4,50,988/-and prayed that the complaint may kindly be dismissed with special costs.

4. Complainant tendered into evidence affidavit Ex.C-2 and documents Ex.C-1 Copy of repudiation letter, documents Ex.C-3 to Ex.C-7 and closed the evidence. Similarly, Ops tendered into evidence affidavit, documents Ex.Ops.1 and Ex.Ops.2 to Ex. Ops.18 closed the evidence.
5. We had heard the learned counsels of both the parties and gone through the record file carefully with the valuable assistance of the learned counsels for the parties. During arguments the contentions of the learned counsels are similar to their respective pleadings. So, there is no need to reiterate the same to avoid the repetition. Now come to major controversy Whether the complainant is liable for medical reimbursement claim or not?  Further, no doubt it is admitted by both the parties that the complainant purchased a medi-claim insurance policy for a period from 29.10.2018 to 28.10.2019 for an amount of Rs. 5,00,000/- by paying a premium of Rs. 22,066/-. During subsistence of the policy the complainant fell from the stair on 03.05.2019 and she was unable to walk. She was immediately to taken to Dr. Amit Gupta, of Global Health Care, Bathinda, where the doctor on the basis of MRI report which is Ex.C-7 referred the complainant to Dr. Somit Sinha of Paras Hospital, Gurgaon for emergency Surgery as per Ex.C-6. Complainant was admitted from 04.05.2019 to 12.05.2019 for emergency surgery in the light of Ex.C-3. Complainant has alleged that she paid a sum of Rs. 4,74,072/- for her treatment. As per Ex.C-4 complainant requested to Ops for cashless treatment authorization, but the Ops denied the request of the complainant.  As per Ex.C-6 report of Dr. Amit Gupta's observed that the patient is bedridden and difficulty in walking due to fall on stairs in the morning. Ops admitted in their reply at para no.3 on merits that the complainant is a consumer and also mentioned the opponent are not able to ascertain the duration of the disease based on the documents. The Ops did not provide pre-authorization approval to the complainant for treatment.
6. On the other hand, the learned counsel for Ops argued that the medi-claim policy is contractual in nature and the claim arising therein are subject to terms and conditions of the policy. Complainant has sought for pre-authorization approval was hospitalized towards the admission at Paras Hospital on 04.05.2019 for the treatment of L4-L5, L5-S1 PIVD during the 7^th month of policy. Ops observed that the MRI spine does not correlate with the acute injury sustained. Ops are not able to ascertain the duration of the disease based on the documents. Hence, the pre-authorization was denied vide letter dated 06.05.2019.
7. The Ops has alleged that the complainant concealed material facts from the Ops at the time of receiving the policy. This Commission observed the document proposal form which is Ex.Ops-4 generally filled by the official of the Ops in routine matter. The detail of the form regarding major information mentioned as "No" in a stereo type manner by the official of Ops. It is the duty of the Ops to medically examine the insured person before issuance of medi-claim policy. Present case in hand, the Ops neither medically examined the insured consumer nor produced any cogent evidence to prove this factum that the complainant was suffered from pre existence disease.
8. It is writ large on the file in reply on merits at para 3 that the complainant is a consumer of Op by availing the service from Ops by getting herself insured through her husband for Rs.5,00,000/- vide medi-claim policy number P12111223/01/2019/000496 for the period from 29.10.2018 to 28.10.2019 by paying the requisite premium of Rs. 22,066/- to the Ops. This Commission observed that the Ops are duty bound to  examine and not to issue medi-claim policy when the consumer is suffering from pre-existing disease, Ops firstly assess the fitness of the person and after complete satisfaction, then they should issue the policy. The learned counsel for complainant referred the judgment Civil Appeal No.7437 of 2011 titled as P.Vankat Naidu Vs LIC of India. The Hon'ble Supreme Court of India held that Since the respondents had come out with the case that the deceased did not disclose correct facts relating to his illness, it was for them to produce cogent evidence to prove the allegation. The appeal is allowed. Another case LPA No. 1537 of 2011 titled as Iffco Tokio General Insurance Company Ltd. Vs Permanent Lok Adalat Gurgaon and others 2012(1)R.C.R.(Civil) 901:2012(2)PLR 547 decided on 26.08.2011. The Hon'ble Punjab and Haryana High Court held that the law is well settled with regard to the standard form of contracts. When the bargaining powers of the parties is unequal and consumer has no real freedom to contract the Courts would strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power. It was also held that claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the Policy. It was for insurance company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. Claim cannot be denied.
9. "A man can lie but document can't." The Ops in his reply admitted that the maximum quantum of liability under the terms of the policy shall be Rs. 4,50,988/- from this angle the Ops himself admitted this fact that they are liable to pay Rs. 4,50,988/-. It is well settled principle of law is that admission is best evidence.
10. Resultantly, Keeping in view the facts and circumstances of the complaint in hand we partly allow the present complaint of the complainant and direct the Ops to reimbursement the Medi-claim of the complainant (as per Ex.C-4 page 10) of Rs. 4,61,758/- and Further the Ops are directed to pay a consolidated amount of Rs.5500/- as compensation and litigation expenses.
11. This order be complied by Ops within a period of 60 days from the date of receipt of order.
12. The complaint could not be decided within the statutory time period due to heavy pendency of cases.
13. Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance.       

                                Announced.

                                December 23, 2022.

( Kanwaljeet Singh)                   (Jot Naranjan Singh Gill)

    Member                                              President