DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/319

Date of Institution : 25.04.2018/29.11.2021

Date of Decision : 04.07.2022

Harkirat Singh aged 30 years son of Harmanjit Singh, resident of House No. C-33, Krishna Nagar, Gali Murabbe Wali, Tarn Taran Road, Amritsar.    …Complainant

Versus

1. The New India Assurance Company, Court Road, Amritsar through its Principal officer/Person over all Incharge. 

2. Raksha TPA Private Limited, SCO 359-360, First Floor, Sector 44-D, Chandigarh. 

3. Baba Deep Singh Life Care Hospital, Taran Taran Road, Amritsar.

…Opposite Parties

Complaint U/S 11, 12 and 14 of The Consumer Protection Act

Present: Sh. Anil Sharma counsel for complainant.

Sh. Naresh Behal Adv counsel for the opposite party No. 1.

Opposite parties No. 2 and 3 exparte.

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Sh. Navdeep Kumar Garg : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant Harkirat Singh filed the present complaint under Section 11, 12 and 14 of the Consumer Protection Act against New India Assurance Company, Amritsar and others. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant has been taking medical health insurance policy for himself and his family for last so many years from the opposite parties and he got renewed his health insurance policy from the opposite parties in the month of June 2016 against consideration. This policy No. 36050134162500000141 for the period 20.6.2016 to 19.7.2017 which cover the medical health risk of the complainant, his father Harmanjit Singh and mother Jatinder Kaur for sum insured of one lac each. 

3. On 1.11.2016 due to medical ailment father of the complainant was got hospitalized and admitted in Baba Deep Singh Ji Life Care Hospital where he remained under treatment from 1.11.2016 to 9.11.2016. Then father of the complainant was referred to Shri Guru Ram Dass Charitable Hospital, Amritsar and patient remained under treatment from 9.11.2016 to 21.11.2016. The complainant incurred expenditure of Rs. 1,03,424/- on the treatment of his father. The complainant lodged medi claim within time and submitted all the requisite documents, original bills and reports with the opposite parties No. 1 and 2. But the claim of the complainant was repudiated by the opposite parties vide letter dated 1.2.2017 on the ground that the patient is suffering from genetic disease as such claim is non payable as per clause 4.4.6.1 of the policy. The other claim with respect to the treatment give at Baba Deep Singh Ji Life Care Hospital was also repudiated by the opposite parties vide letter dated 9.3.2017 on the ground that as per investigation it was found that hospital do not maintain any medical record of the patient, medicine bills from Indian Health Care but no shop of such name of region, investigation done from the different labs in absence of medical records and discrepancy of medical bills, claim falls out of scope of the policy therefore, claim is not payable as per clause 2.18 CELIAC disease with Pancypopenia. The objections of the opposite parties are illegal and unlawful which amounts to deficiency in service and unfair trade practice. Father of the complainant was not suffering from any genetic disease. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to pay to the complainant insured amount of Rs. 1,00,000/- alongwith 18% from 1.11.2016 till date. 

2) To pay Rs. 50,000/- on account of compensation for mental agony and harassment. 

3) To pay Rs. 20,000/- as litigation expenses.

4) Any other relief to which the complainant is found entitled. 

4. Upon notice of this complaint, the opposite party No. 1 filed written statement taking preliminary objections that the complainant has suppressed material facts from this Commission and complaint is without any cause of action. 

5. On merits, it is submitted that the treatment of Harmanjit Singh was done from 1.11.2016 to 9.11.2016 at Baba Deep Singh Life Care Hospital who does not cover the minimum standards of a hospital as per the medi claim 2012 policy. The record of the treatment was not made available for verification to the investigator of the insurance company. No such medical store by the name of Indian Health Care exist from where the medicines were purchased and bills are found to be forged and fabricated. The labs from where the test of the patient are conducted are far situated from the hospital more than a distance of 40 Kms or 10 Kms respectively from the hospital. The bills of the labs are found to be forged and fabricated. So the claim was repudiated vide letter dated 1.2.2017. Secondly the treatment from 9.11.2016 to 21.11.2016 was alleged to be done at Sri Guru Ram Dass Hospital is for the celiac disease which is a genetic disorder so the same is not covered under the claim policy as such the claim is repudiated under 4.4.6.1 of the policy vide letter dated 9.3.2017. The father of the complainant is suffering from Celiac Disease with Pancypopenia which is a genetic disease and is not cover under the policy. The complainant has violated the terms and conditions of the insurance policy. The claim was repudiated under the exclusion clause contained in Mediclaim 2012 policy vide clause 4.4.6.1 which reads as Convalescence, general debility, run down condition or rest cure, obesity treatment and its complications, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, venereal disease, intentional self injury and illness or injury caused by the use of intoxicating drugs/alcohol. Lastly, the opposite party No. 1 prayed for the dismissal of the present complaint with costs.

6. The opposite parties No. 2 and 3 preferred to remain exparte.

7. The complainant tendered in evidence his own affidavit Ex.CW-1/A, affidavit of Harmanjit singh Ex.CW-2/A, documents Ex.C-1 to Ex.C-86, original bills as well as treatment record Ex.C-87 to Ex.C-165, study notes Ex.C-166 and closed the evidence. 

8. To rebut the case of the complainant the opposite party No. 1 filed affidavit of SK Sharma Divisional Manager Ex.OP-1/A and documents Ex.OP-1/1 to Ex.OP-1/6.  

9. We have heard the learned counsel for the parties and gone through the record on the file. 

10. It is admitted fact between the parties that the complainant has obtained health insurance policy from the opposite parties and renewed the same from time to time for himself and his family members. It is also admitted by the opposite party No. 1 that the treatment of Harmanjit Singh was done from 1.11.2016 to 9.11.2016 at Baba Deep Singh Life Care Hospital. Further, it is also admitted that secondly the treatment of Harmanjit Singh was done from 9.11.2016 to 21.11.2016 at Sri Guru Ram Dass Hospital. From the copy of policy Ex.OP-1/1 it is proved on the file that the policy was valid from 20.6.2016 to 19.6.2017 for sum insured of Rs. 1,00,000/- for each member of the policy. 

11. Learned counsel for the complainant argued that the complainant lodged the mediclaim of treatment of his father within time and submitted all the requisite documents and bills of both the hospitals but the opposite parties repudiated the genuine claim of the complainant vide letter dated 1.2.2017 on unreasonable and baseless grounds which is deficiency in service on their part. 

12. Learned counsel for the opposite party No. 1 argued that the first claim was repudiated as Baba Deep Singh Life Care Hospital does not cover the minimum standards of a hospital as per policy. Further, the record of the treatment was not made available for verification to the investigator of the insurance company. Further he argued that there is no medical store by the name of Indian Healthcare  from where medicines was purchased and labs from where tests were conducted are situated from hospital more than a distance of 40 Kms or 10 Kms respectively. The second claim was repudiated as the patient was suffering from celiac disease which is a genetic disorder and same is not covered under the policy so the claim was repudiated vide letter dated 9.3.2017. 

13. We have perused the record on the file. The opposite party No. 1 not tendered any document in support of his stand the Baba Deep Singh Life Care Hospital does not cover the minimum standards of a hospital. Further, they have not file the affidavit of investigator to support that the hospital has not supplied the treatment record of the patient when he visited the hospital for investigation. Further, it is the wish of the patient that he can purchase medicines from any shop and also can got conducted his tests from any lab and this plea of the opposite parties is also no force. In this way, the repudiation of the first claim vide letter dated 1.2.2017 is not justified, unreasonable and baseless grounds. 

14. With regard to second claim the opposite party No. 1 taken a stand that the patient was suffering from celiac disease which is a genetic disorder and same is not covered under the policy so the claim was repudiated vide letter dated 9.3.2017. Learned counsel for the complainant argued that symptoms of celiac disease can appear at any age from infancy well into senior adulthood. The average age of diagnosis is between the 4th and 6th decades of life, with approximately 20% of cases diagnosed in those who are more than 60 years of age. To support his stand the learned counsel for the complainant also filed some documents in this regard on the file, which proved that when the complainant purchased or renewed the policy the complainant or patient has no knowledge about his celiac disease. 

15. Learned counsel for the complainant relied upon citation of Hon'ble Supreme Court of India titled P Vankat Naidu Versus Life Insurance Corporation of India and another reported in IV (2011) CPJ-6 (SC) in which the Hon'ble Apex Court held that “Suppression of material facts. Pre-existing disease. Forum allowed complaint. State Commission dismissed appeal. National Commission allowed revision. Hence special leave to appeal. Contention deceased suppressed information relating to his illness. Not accepted. Respondents did not produce any tangible evidence to prove that deceased withheld information about his hospitalization and treatment. Order of National Commission set aside.”

16. Learned counsel for the complainant also relied upon citation of Hon'ble Delhi High Court in case titled United India Insurance Company Limited Versus Jai Parkash Tayal reported in 2018 (5) RCR (Civil)-109 in which the Hon'ble High Court held that “Health Insurance Policy. Exclusion of genetic disorder. Discrimination. Right to health is a fundamental right, as integral part of Article 21 and Right to Healthcare is also a Fundamental Right. Excluding any particular category of individuals i.e. those with genetic disorders, from obtaining health insurance or having their claims honoured, based on genetic disposition would be per se discriminatory and violative of citizen's Right to Health.”

Both these citations are fully applicable to the facts and circumstances of the present matter as in present matter also the complainant has not concealed any facts about the health of his father from the insurance company and secondly he also not concealed that his  his father is also suffering from celiac disease which is a genetic disorder. Therefore, the opposite party No. 1 repudiated the claim of the complainant on both these grounds are not justified. There is clear cut deficiency in service and unfair trade practice on their part. 

17. In view of the above discussion, present complaint is partly allowed against the opposite party No. 1 and opposite party No. 1 is directed to pay the amount of Rs. 1,00,000/- to the complainant on account of insurance claim for the treatment of his father alongwith interest at the rate of 6% per annum from the date of filing of present complaint till actual realization. The opposite party is also directed to pay Rs. 3,300/- to the complainant as compensation for mental tension and harassment and Rs. 2,200/- as costs and litigation expenses. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order will be supplied to the parties by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

        4th Day of July 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Navdeep Kumar Garg)

Member