Complaint filed on:20-12-2023.

                                                      Disposed on:20-04-2024

BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, TUMAKURU

DATED THIS THE 20^th DAY OF APRIL, 2024

PRESENT

SMT.G.T.VIJAYALAKSHMI, B.Com., LLM., PRESIDENT

SRI.KUMARA.N, B.Sc. (Agri), LLB., MBA., MEMBER

SMT.NIVEDITA RAVISH, B.A., LLB. (Spl)., LADY MEMBER

CC.No.181/2023

Narasimhamurthy.DR S/o Late Rangappa,

Aged about 61 years,

Agriculturist, Resident of Gaana Nilaya,

Ring Road, Tumkur Town, Tumkur District.

……………….Complainant/s

(By Sri.Srinivasa Murthy.N.H, Advocate)

                                                V/s

The Manager,

STAR Health and Allied Insurance Co, Ltd.,

Office at 2^nd floor, Shiva Complex, 4^th cross,

MG-Road, KR Extension, Tumkur.

Phone No-0816 4014440.

……………….Opposite Party/s

(By Smt.Mamatha K.P – Advocate)

: O R D E R :

BY SRI.KUMARA.N., MEMBER

This Complaint filed by the complainant with the prayer of direct the OP to pay Rs.98,000/- towards medical reimbursement and other incidental charges Rs.10,000/- to the complainant. Further, complainant pray to direct the OP to pay Rs.25,000/- along with interest towards mental shock and agony.

2.       In this case the Opposite Party is The Manager, STAR Health and Allied Insurance Co, Ltd., Office at 2^nd floor, Shiva Complex, 4^th cross, MG-Road, KR Extension, Tumkur. (Hereinafter called the OP)

3.        It is the case of a complaint that the complainant obtained health insurance policy by paying premium of Rs.18,642/- from the Opposite party and same assured was Rs.6,00,000/-. The Opposite party issued Health Insurance Policy P/141211/01/2023/011638 issued policy number which was valid from 06.02.2023 to 05.02.2024. The complainant suffered from ill health due to LACUNAR INFRACT and on 22.10.2023 admitted in MC Orthopedic Arthroscopy and Joint Replacement Center as in patient underwent treatment from 22.10.2023 to 27.10.2023. The treated hospital not empanelled hospital, cash less scheme and the complainant paid Rs.98,000/- towards treatment done  and has advised  by the OP the complainant along with claim form and necessary documents submitted to the OP for reimbursement. The OP initially assured the complainant to settle the said medical claim but the OP not settled. The complainant on 29.11.2023 issued legal notice and said notice duly served on 03.12.2023 inspite of it the OP not settled the medical claim. Hence, this complaint.  

4.        After the complaint registered, Commission notice was issued to the OP and in turn the OP appeared through its counsel and filed the version admitting the fact the OP issued health insurance policy bearing No. P/141211/01/2023/011638 and which was filed period from 06.02.2023 to 05.02.2024. The OP submitted that the complainant declared Diabetes and Hypertension in the proposal form. Hence, Diabetes and Hypertension underwent complication or incorporated as PED (Pre-existing-disease). The OP contended that the above disease /condition and incorporated as a pre existing disease in the policy schedule at the time inception of the 1^st medical insurance policy and the expenses incurred at hospital for the treatment of the said disease/condition are not admissible as per exclusion Excl-38. Hence, the OP repudiated the claim. Hence, the OP prayed to dismiss the complaint against the OP.

5.       The complainant and the OP filed the affidavit evidences & the complainant filed documents which were marked as Ex.P1 to P8 and OP filed its documents which were marked as Ex.R1 to R10.

6. .  We have heard the arguments from both counsels & on perusal of pleadings, evidence and documents of both sides, the points that would arise for our consideration are:

7.       The points that would arise for our consideration are:-

1. Whether the complainant proves the deficiency in service on the part of OP?

2. Is complainant entitled to the reliefs sought for?

8.       Our findings on the aforesaid points are as follows:

Point No.1: Partly Affirmative

Point No.2: As per below order

:R E A S O N S:

Point Nos.(1) & (2):-

09.     The complainant counsel argued that, the complainant obtained health insurance policy by paying premium of Rs.18,642/- from the Opposite party and the sum assured was Rs.6,00,000/-. The Opposite party issued Health Insurance Policy bearing number P/141211/01/2023/011638 which was valid from 06.02.2023 to 05.02.2024. The complainant suffered from ill health due to LACUNAR INFRACT and on 22.10.2023 admitted in the MC Orthopedic Arthroscopy and Joint Replacement Center as in patient undergone treatment from 22.10.2023 to 27.10.2023. The treated hospital not empanelled hospital of the OP FOR cash less scheme OF TREATMENT and the complainant paid Rs.98,000/- towards treatment CHARGES  as advised  by the OP and the complainant along with the filled claim form and necessary documents submitted to the OP for reimbursement. The OP initially assured the complainant to settle the said medical claim, but the OP not settled. The complainant on 29.11.2023 issued legal notice and said notice duly served on 03.12.2023 in spite of it the OP not settled the medical claim. This is a second year of the medical insurance policy and inception of the first policy was on 25-06-2021 and the complainant submitted the claim No CIR/2024/041211/1039512 to the OP for settlement. The policy was in force at the time of taken the treatment, hence prayed to allow the complaint and award compensation. The complainant submitted documents, Ex.P1, copy of Health Insurance Policy-P/141211/01/2023/011638, Ex.P2 Discharge Summary, Ex.P3 Bill No.2049, Ex.P4 Repudiation of Claim, Ex.P5 Legal Notice by RPAD, Ex.P6 Acknowledgement cover, Ex.P7 Postal receipt, Ex.P8 Aadhaar Xerox.

10.     The OP counsel argued that, the complainant being the customer of the OP, obtained health insurance policy bearing No. P/141211/01/2023/011638 and which was in force from 06.02.2023 to 05.02.2024 and the complainant declared Diabetes and Hypertension in the proposal form. Hence, Diabetes and Hypertension underwent complication or incorporated as PED (Pre-existing-disease). The OP contended that the above disease /condition and incorporated as a pre existing disease in the policy schedule at the time inception of the 1^st medical insurance policy and the expenses incurred at hospital for the treatment of the said disease/condition are not admissible as per exclusion Excl-38.  As per exclusion – pre existing disease – code Excl – 01(A) of the policy issued, expenses related to the treatment of pre existing diseases (PED) and its direct complications shall be excluded  until the expiry of 48 months of continuous coverage after the date of inception of the first policy. The date of inception of the first policy of the policy was 25-06-2021 and the, this medi claim settlement submission is in the second year of the inception of the policy. Hence, the OP repudiated the claim. Hence, the OP prayed to dismiss the complaint against the OP. The OP counsel produced documents, Ex R1 a copy of Medi Classic Insurance Policy (Individual), Ex.R2 Health Insurance Policy–P/141211/01/2023/011638, Ex.R3 Details of the Third Party Administrator/Insurer/Hospital, Ex.R4 Rejection of Authorization for Cashless Treatment, Ex.R5 Claim Form-Part-A, Ex.R6 Claim Form-Part-B, Ex.R7 MRI Report-Brain (Plain), Ex.R8 Guidance for Known Diabetics, Ex.R9 Repudiation of Claim, Ex.R10 Standard Definitions,

11.     Lacunar infarction is closely related to arterial hypertension and lacunar stroke occurs due to a lack of blood flow in smaller arteries that supply deep brain structures. The most important risk factor for the development of lacunar stroke is chronic high blood pressure.

12.     The Hon'ble National Commission while dealing with a similar set of facts, in Sunil Kumar Sharma Vs. TATA AIG Life Insurance Company and Ors, bearing case no. RP no. 3557/2013 decided on 01.03.2021 & in the case of Reliance Life Insurance Co. Ltd. & Anr. vs Tarun Kumar Sudhir Halder held on 31 May, 2019 opinioned that, the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases. Wherein it was said that common lifestyle diseases like diabetes and hypertension cannot be treated as pre-existing diseases.

13.     Honorable SUPREME COURT OF INDIA, in the case of Om Prakash Ahuja versus Reliance General Insurance Co. Ltd, in CIVIL APPEAL NOS. 2769-2770 OF 2023; decided on July 04, 2023, held that, Medical Insurance - Once there is a valid insurance policy in favour of a person, the claim for reimbursement of the expenses incurred must be paid.

14.     In this case, it’s clear that the complainant had taken a medical insurance policy bearing No. P/141211/01/2023/011638 from the OP by paying premium of Rs 18,642/-, and which was in force from 06.02.2023 to 05.02.2024 and the complainant declared Diabetes and Hypertension in the proposal form at the time of obtaining the said policy & inception of the first policy was on 25-06-2021. The Complainant on 22.10.2023 admitted in the MC Orthopedic Arthroscopy and Joint Replacement Center as an inpatient and undergone treatment for lacunar infarction from 22.10.2023 to 27.10.2023. The treated hospital not having cash less scheme OF TREATMENT and the complainant paid Rs.98,000/- towards treatment CHARGES  as advised  by the OP and the complainant along with the filled claim form and necessary documents submitted to the OP for reimbursement is an admitted facts not disputed. The OP rejected the claim on the ground that the PED (Pre-existing-disease), the claimant had diabetes and hypertension, which was declared by the complainant in the proposal form at the time of inception of the first policy and it was a known case of lacunar infarction which is complication of diabetes and hypertension. The OP Contending that the complainant is entitled to claim treatment expenses within the limitation of policy condition i.e. until the expiry of 48 months of continuous coverage after the date of inception of the first policy. The defense of the OP is not considered since, the complainant i.e. life insured did not know about the lacunar infarction is closely related to arterial hypertension and diabetes and the OP not through light on this to the complainant at the time of inception of the policy and if so not produced any believable documents to prove the same. The object of seeking a health / medi-claim policy is to seek indemnification in respect of a sudden illness or sickness which is not expected or imminent and which may occur on any time or any stage. If the insured / complainant suffer a sudden sickness or ailment or disease, which is not expressly excluded under the policy, a duty is cast on the OP to indemnify the complainant for the expenses incurred there under. If the insured / complainant, had no knowledge of any ailment or diseases or disease due to complications of common lifestyle diseases, then its bound duty of insurer to pay the expenses incurred by the insured after the claim submitted, when the policy in force.  The OP repudiated the complainant claim by quoting the reason of (PED) pre-existing diseases. The claimant had diabetes and hypertension, and the complainant declared the same in the proposal form at the time of inception of the policy which, were common lifestyle diseases.

15.     In view of the above discussion, this commission relied on the Honorable Supreme court of India, judgment dated 04-07-2023 in the case of Om Prakash Ahuja Vs Reliance General Insurance Co. Ltd, and the Honorable National Consumer Disputes Redressal Commission (NCDRC), judgment in the case of Reliance Life Insurance Co. Ltd. & Anr. vs Tarun Kumar Sudhir Halder held on 31 May, 2019, this commission is opinioned that, repudiation (Ex P4) of the, medical expenses bill which was paid (Ex P3) by the complainant, for Rs.91368 /-by the OP is illegal and not in accordance with law, since the complainant paid the premium of Rs 18,642/-, towards health insurance policy bearing number P/141211/01/2023/011638 (Ex P1 & Ex R2)which was valid from 06.02.2023 to 05.02.2024. The complainant who is insured, suffered from ill health due to LACUNAR INFRACT and on 22.10.2023 admitted in the MC Orthopedic Arthroscopy and Joint Replacement Center  Tumkur as in patient undergone treatment from 22.10.2023 to 27.10.2023 (ExP2). and same informed by the complainant to OP and submitted the said medical claim along with original bills and documents for reimbursement to the OP, but the OP not settled the said medical bill even though the policy in force, this act of OP leads to deficiency of service on the part of OP and compelled the complainant to approach this commission, by repudiating claim, hence the OP is liable to pay the litigation cost of Rs.10,000/- and to pay Rs.91,368/- along with 8% interest per annum from 28.11.2023 (Repudiation date) to the complainant, accordingly we proceed to pass the order as;

:O R D E R:

Complaint filed by the complainant is allowed in part.

The OP is ordered to pay, Rs.91,368/- (Rupees Ninety one thousand three hundred sixty eight only) along with interest @ 8.00 % p.a from 28.11.2023 to till realization to the complainant. It is further ordered that OP to pay Rs.10,000/- (Rupees Ten Thousand only) towards litigation costs to the complainant.

The OPs are further directed to comply the above order within 45 days from the date of receipt/knowledge of the order, otherwise, it carries fine of 150/- per day till realization.