State Consumer Disputes Redressal Commission
Star Health And Allied Insurance Co. ... vs Parveen Kumar And Others on 5 July, 2022
STATE CONSUMER DISPUTES REDRESSAL COMMISSION
HARYANA, PANCHKULA
First Appeal No: 241 of 2022
Date of Institution: 09.06.2022
Date of Decision: 05.07.2022
1. Star Health and Allied Insurance Co. Ltd., Branch Office
through its Branch Manager, 930/8, R.J. Tower, 2nd Floor, G.T.
Road, IB College, Panipat-132103.
2. Star Health and Allied Insurance Company Ltd., corporate
office, # 1, New Tanks Street, Valluvar Kottam High Road,
Nugambakkam, Chennai-60034 through its M.D. or any other
authorized person.
3. Star Health and Allied Insurance Company Ltd., Branch Office
through its Branch Manager, # 3rd Floor, Minerva Complex,
Ambala Cantt.
...Appellants-Opposite Parties No.1, 4 and 5
Versus
1. Parveen Kumar son of Shri Kundan Lal, aged about 57 years,
resident of # 6117, Machhi Mohalla, Ambala Cantt.
...Respondent No.1-Complainant
2. Shri Rakesh Khanna, Insurance Agent, C/o Star Health and
Allied Insurance Company Ltd., 930/8, R.J. Tower, 2nd Floor,
G.T. Road, IB College, Panipat-132103.
3. Sh. Satender Malik, Sales Manager, C/o Star Health and Allied
Insurance Company Ltd., 930/8, R.J. Tower, 2nd Floor, G.T.
Road, IB College, Panipat-132103.
...Respondents No.2 and 3-Opposite Parties No.2 and 3
CORAM: Hon‟ble Mr. Justice T.P.S. Mann, President.
Mrs. Manjula, Member.
Present: Shri Ravinder Arora, counsel for the appellants.
ORDER
T.P.S. MANN J.
Delay in filing of the appeal is condoned for the reasons specified in the miscellaneous application.
F.A. No.241 of 2022 2
Star Health & Allied Insurance Co. Ltd. & Ors. Vs. Parveen Kumar & Ors.
2. Star Health and Allied Insurance Company Ltd. through its Branch Manager, Panipat along with its registered and corporate officer, Chennai and Branch Manager, Ambala Cantt.-opposite parties No.1, 4 and 5 respectively have filed the instant appeal under Section 41 of the Consumer Protection Act, 2019 for challenging the order dated 05.04.2022 passed by the District Consumer Disputes Redressal Commission, Ambala, whereby the complaint preferred by complainant Parveen Kumar under Section 12 of the Act was allowed against the appellants who were directed to pay Rs.1,49,221/- to the complainant alongwith interest @ 4% per annum from the date of repudiation of the claim till its realization; Rs.5,000/- as compensation for the mental agony and physical harassment caused to the complainant and Rs.3,000/- as litigation expenses. At the same time, the complaint was dismissed qua opposite party No.2- Rakesh Kumar, Insurance Agent and opposite party No.3-Satender Malik, Sales Manager, both C/o Star Health and Allied Insurance Company Ltd., respondents No.2 and 3 herein.
3. The case of the complainant, namely, Parveen Kumar as set up by him in the complaint under Section 12 of the Act was that he had purchased medi-claim policy No.P/211124/01/2017/002179 from opposite party No.2 at Ambala Cantt. effective from 31.03.2017 and paid premium along with service tax amounting to Rs.15,945/-. He got renewed the said policy on 31.03.2018 for one year on payment of premium of Rs.19,417/-. He further got the policy renewed on 31.03.2019 and paid premium of Rs.24,142/-. On the midnight of F.A. No.241 of 2022 3 Star Health & Allied Insurance Co. Ltd. & Ors. Vs. Parveen Kumar & Ors. 10th and 11th of July, 2019, he suddenly had a severe pain in chest with some sweating and his family immediately took him to Healing Touch Hospital, Ambala City and got him admitted in the said hospital. His Echo test was done which showed LVEF 40-45% with Hypokinesia of RCA and coronary Angiography was done which revealed DVD and he underwent PTCA with stunting to RCA via right radial route. On showing the insurance policy issued by the opposite parties to the hospital incharge, his claim was registered under registration No.0240719 dated 11th July, 2019 at about 01:00 AM for cashless facility but the opposite parties rejected the request for the approval of cashless treatment on false grounds that "the disease/condition has been incorporated as pre-existing disease". He himself paid the medical bills of Rs.1,49,221/-. In order to get the claim, he submitted all the original bills to the opposite parties. At the time of taking the policy, the complainant was thoroughly medically examined by the doctors of Leelawati Hospital, Ambala City, which was approved and authorized hospital of the opposite parties and on the instructions of the opposite parties on 07.04.2017, he got himself examined from the said hospital and detailed medical examination report was prepared. In the Clauses No.3, 4(a), (b), (c), (d), it stood mentioned that there was no past history of heart disease. The report was duly counter signed by the complainant and the doctor, who was on the panel of the opposite parties. After denying the cashless facility to the complainant, the opposite parties did not take any action with regard to the claim registered by the complainant. Finding no F.A. No.241 of 2022 4 Star Health & Allied Insurance Co. Ltd. & Ors. Vs. Parveen Kumar & Ors. response from opposite parties, the complainant sent a Regd. AD letter dated 01.11.2019 with its copy to the Chennai office of opposite parties but to of no effect. Thereafter, the complainant‟s son sent an e-mail dated 09.11.2019 to the grievances department of the opposite parties and in response to the same, the opposite parties sent an e-mail dated 13.11.2019 vide which they repudiated the claim. The son of the complainant also wrote an e-mail to the opposite parties, in response to which, they sent medical documents including copy of Aadhar Card duly signed by the complainant on 07.04.2017, his ECG report from Leelawati Hospital, other test report dated 07.04.2017 and also report dated 07.04.2017 duly signed by Dr. Jatin Garg with counter signatures of the complainant. The opposite parties sent the proposal form dated 31.03.2017 and consent letter dated 11.04.2017 prepared by opposite parties No.2 & 3. The said documents were bearing forged signatures of the complainant and there was no mention of any disease even in the proposal form but in the consent letter dated 11.04.2017, at Sr. No.2 "Treatment of disease related to Cardiovascular system" was written whereas complainant was not suffering from any such disease at the time of taking policy and the consent letter was totally false and fabricated. The signatures of the complainant put on the proposal form and consent letter did not tally with any other signatures of the complainant put on copy of Aadhar card given to Dr. Jatin Garg at Leelawati Hospital. Dr. Jatin Garg prepared the medical report dated 07.04.2017 just for the benefit for opposite party No.1 with the intention to cheat the F.A. No.241 of 2022 5 Star Health & Allied Insurance Co. Ltd. & Ors. Vs. Parveen Kumar & Ors. complainant and to extract money from him. This fraud was brought in the knowledge of the complainant only on receipt of the papers from the Chennai office through e-mail. Even in the discharge summery issued by the Healing Touch Hospital, there was no mention of pre-existing disease in the medical history of the complainant. The act of the opposite parties for repudiating the claim of the complainant amounted to deficiency in service. Hence, the complaint preferred by the complainant.
4. Upon notice, the opposite parties appeared before the District Consumer Commission and filed written version. It was pleaded by the opposite parties that the complainant had taken one Family Health Optima Insurance Policy for the period from 31.03.2017 to 30.03.2018 against a floater sum insured of Rs.5,00,000/- for himself and his wife Smt. Seema Rani. The insurance policy was issued by the opposite parties after pre-medical screening and based on the ECG report and medical check-up of the complainant. The cardiovascular disease was endorsed as pre existing disease in the policy qua the complainant according to his medical status with his prior consent and knowledge. Accordingly, endorsement in this regard was specifically made in the policy itself as "PED: Treat of diseases related to Cardiovascular System, Diabetes Mellitus and its Complications". The complainant accepted the said policy with its schedules, terms & conditions and he got his insurance policy renewed for the next period from 31.03.2018 to 30.03.2019 on the same terms and conditions. He further got it renewed with the same F.A. No.241 of 2022 6 Star Health & Allied Insurance Co. Ltd. & Ors. Vs. Parveen Kumar & Ors. terms & conditions for the period from 31.03.2019 to 30.03.2020. The complainant was hospitalized in Healing Touch Hospital, Ambala on 11.07.2019 as a case of Acute Inferior Wall Myocardial Infarction (Heart Attack) for which a request for cashless authorization for the treatment of Acute Inferior Wall MI disease related to Cardio Vascular System was received. Since, the said disease/condition was incorporated as pre-existing disease in the policy schedule, so, it was held „pre-existing disease related complication‟. Therefore, as per the terms and conditions of the policy, any claim for treatment of the pre-existing disease/condition was not admissible until expiry of 48 months from the date of inception of the first insurance policy which is 31.03.2017. The insurance policy is contractual in nature and the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same were sent to the complainant along with the policy schedule. The complainant accepted the policy after going through the terms and conditions and never objected to any of the endorsement or terms of the policy. As per waiting period/exclusion No.3(iii), the claim for treatment of the pre-existing disease was not admissible until expiry of 48 months from the date of inception of the first policy. After going through the complete treatment/claim record, the request for pre authorization for cashless treatment was rejected by the competent authority as per terms & conditions of the insurance policy and the same was communicated to the insured and the treating hospital vide letter dated 11.07.2019. The claim of the complainant was denied as per F.A. No.241 of 2022 7 Star Health & Allied Insurance Co. Ltd. & Ors. Vs. Parveen Kumar & Ors. law under the purview of the insurance policy schedule and terms & conditions. Thus the opposite parties could not be blamed in any manner. The claim of the complaint was rejected at cashless level and the insured had not approached for reimbursement of the expenses incurred on the medical treatment and had not produced the medical bills. Thus, the complainant be put to strict proof of the expenses incurred towards the treatment. The request for pre-authorization for cashless treatment of the complainant was rejected by the competent authority after thorough scrutiny of all the papers regarding the treatment of the complainant and the decision was taken by the competent authority as per the terms and conditions of the policy. Accordingly, the opposite parties prayed for dismissal of the complaint with costs.
5. In support of his case, the complainant tendered his affidavits Annexures CA and CB along with documents Annexures C-1 to C-38. On the other hand, the opposite parties tendered affidavit of Shri Rajiv Jain, Chief Manager, Star Health & Allied Insurance Company Limited Annexure OPA and power of attorney of authorized signatory Annexure OPB along with documents Annexures OP-1 to OP-10.
6. After hearing counsel for the parties and on going through the evidence led by the parties, the District Consumer Commission allowed the complaint against opposite parties No.1, 4 and 5 and directed them to pay the various amounts to the complainant as mentioned above.
F.A. No.241 of 2022 8
Star Health & Allied Insurance Co. Ltd. & Ors. Vs. Parveen Kumar & Ors.
7. Aggrieved of the impugned order passed by the District Consumer Commission, opposite parties No.1, 4 and 5 filed the present appeal.
8. Counsel for the appellants has submitted that the complainant was suffering from heart disease and diabetes mellitus at the time of inception of the policy. In this regard, he referred to the endorsement made in the policy schedule as PED:- treatment of diseases related to Cardio Vascular System Diabetes Mellitus and its complications. The complainant had taken treatment of disease related to Cardio Vascular System. Since, the disease was incorporated as pre-existing disease in the policy schedule. Therefore, as per the terms & conditions of the policy, claim of the complainant for treatment of pre-existing disease was not admissible until the expiry of 48 months from the date of inception of the first insurance policy. Accordingly, it has been submitted that the appeal be accepted, impugned order be set aside and the complaint preferred by the complainant be dismissed.
9. Having heard counsel for the appellants and on going through the impugned order, the State Commission finds that the complainant was duly insured with the opposite parties under the policy for the period from 31.03.2017 to 30.03.2018 and got renewed the policy from 31.03.2018 to 30.03.2019 and thereafter for the period from 31.03.2019 to 30.03.2020. On the intervening night of 10th/11th July, 2019, he got himself treated in the Healing Touch Hospital, Ambala and coronary Angiography was done. He underwent PTCA with F.A. No.241 of 2022 9 Star Health & Allied Insurance Co. Ltd. & Ors. Vs. Parveen Kumar & Ors. stenting to RCA via right radial route. The complainant had got himself insured for the first time on 31.03.2017 and before that he had got himself medically examined from the empanelled hospital/doctors. From the perusal of medical examination report dated 07.04.2017 Annexure OP-4, it is apparent in the column No.3, past history, Diabetes Mellitus for the period of 12 months have been mentioned. In the column No.4(a) "if the person is to be insured presently, suffering from any of the following disease, please give details", NAD has been mentioned. In the ECG report dated 07.02.2017, it is evident that ECG was normal. In the discharge summary (Annexure C-10), no past history has been recorded. No document was produced by the opposite parties to show that before the issuance of the policy for the first time on 31.03.2017, the complainant was suffering from CAD or any complication for which, stent was required to be implanted in him.
10. The insurance company had issued the policy for the first time on the basis of the medical report of the empanelled doctor. As such the opposite parties could not plead that endorsement was made in the policy schedule. Mere bald allegation in this regard is of no value in the eyes of the law. Therefore, the insurance company committed deficiency in service by not paying the amount, which the complainant had incurred on his treatment. The appellants i.e. opposite parties No.1, 4 & 5 were thus rightly made liable to pay Rs.1,49,221/- to the complainant, which amount had been incurred by him on his treatment besides Rs.5,000/- as compensation to the F.A. No.241 of 2022 10 Star Health & Allied Insurance Co. Ltd. & Ors. Vs. Parveen Kumar & Ors. complainant for the mental agony and physical harassment besides Rs.3,000/- as litigation expenses.
11. In view of the above, no case is made out for any interference in the impugned order. The appeal is devoid of any merit and, accordingly, dismissed.
12. The statutory amount of Rs.87,122/- deposited by the appellants at the time of filing of the appeal be disbursed in favour of complainant Parveen Kumar against proper receipt and identification but in accordance with rules subject to appeal/revision, if any.
Announced (Manjula) (T.P.S. Mann) 05.07.2022 Member President DR