State Consumer Disputes Redressal Commission
Reliance Gen. Insu.Co. vs Sanovar Khan on 15 June, 2023
M.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION
PLOT NO. 76, ARERA HILLS, BHOPAL (M.P.)
APPEAL NO. 827/2020
1. Manager
Reliance General Insurance Company Ltd.
3rd floor, Krishe block, Krishe Sapphire
Madhapr, Hyderabad,
Telangana -500 081.
2. Manager,
Reliance Insurance Company Ltd.
Reliance Centre, Souht Wing 4th floor,
Off. Western Express Highway,
Santa Cruz (East),
Mumbai- 400 055.
3. Shri Pankaj Goyal,
Agent,
Reliance General Insurance Co.
Sharda Sadan, Shriram Colony,
Shivpuri (M.P.) ... Appellants
VERSUS.
Sanovar Khan,
D/o Israr Ahmad Khan ,
R/o 64, Near Police Station,
Circuit House Road,
Shivpuri (M.P.) 473 551. ... Respondent
BEFORE;
HON'BLE SHRI A.K. TIWARI, PRESIDING MEMBER
HON'BLE SHRI DR. SRIKANT PANDEY.
COUNSEL FOR THE PARTIES:
MS. PREETIMA SHRIVASTAVA, LEARNED COUNSEL FOR APPELLANTS.
RESPONDENT IS PRESENT IN PERSON.
: 2 :
ORDER
( 15.06.2023 ) The following order of the Bench was delivered by Shri A.K. Tiwari, Member.
This appeal by the appellants/opposite parties is directed against the order dated 25.9.2020, passed by the District Consumer Disputes Redressal Commission, Shivpuri (for short 'District Commission'), in complaint case No. 132/2019, whereby the District Commission has allowed the complaint filed by the complainant/respondent.
2. Briefly put, the facts of the case are that the respondent/compliant had obtained a Health Insurance Policy from appellants-Insurance Company in the year 2008. The Insurance Company assured that the respondent-complainant will get the facility of treatment from any hospital and the Insurance Company will indemnify the expenses incurred by the respondent within 15 days of discharge from the hospital, in some selected hospitals, benefit cashless policy was also available. In the year 2014, the respondent/complainant underwent a surgery for implant of artificial heart valve in Apollo Hospital, Delhi. The appellants-Insurance Company accepted the claim for the said surgery and by extending facility of cashless policy, paid Rs.1,00.000/- to the her. The respondent developed some complications after surgery of artificial heart valve implantation and she visited the doctors at Indore and Delhi, who referred her to M.N. Hospital Chennai, for expert opinion and further treatment, where she got admitted on 22nd : 3 : November, 2016 from where she informed the appellants/Insurance Company about her health condition and sought cashless approval for her treatment. The appellants/Insurance Company refused cashless approval on the ground that the treatment sought by the respondent was of a disease of congenital in nature, which is not covered under the policy and rejected her claim for cashless approval.
Aggrieved by the refusal of her claim, the respondent/complainant approached the District Commission by filing the aforesaid complaint which was allowed.
3. The appellants/opposite parties have filed reply before the District Commission and submitted that the complainant took treatment and underwent a surgery for heart ailments from G.B. Pant Hospital, New Delhi in the year 1993. According to the discharge summary issued by the said Hospital the disease with which the complainant was suffering, was congenital in nature. Therefore, when complainant informed about treatment at Madras Medical Mission Hospital she was informed vide letter dated 27.11.2018 that her ailment is not covered as per policy's permanent exclusion clause 3.3.11 and rejected her request. The opposite parties, therefore, sought dismissal of the complaint.
4. The District Commission allowed the complaint with compensation cost.
5. Learned counsel for appellants submits that it is undisputed that the respondent/complainant took treatment from G.B. Pant Hospital, New Delhi, in the year 1993 and it is also clear from the discharge summary issued by this hospital : 4 : that the respondent was suffering with congenital disease. She further submits that the pre-approval sought by the respondent/ complainant for treatment at Medical Mission Hospital was rejected on this ground. Learned counsel for appellants, therefore, submits that there in no deficiency in service on the part of appellants/Insurance Company. The order passed by the District Commission is erroneous and liable to be set aside and the appeal filed by the appellants may be allowed.
6. Respondent, who is present in person, submits that she had obtained the health insurance policy in the year 2008 and the appellants/Insurance Company renewed the policy regularly, on payment of annual premiums by her. She further submits that while obtaining the policy she has informed the Insurance Company about her health issues and about her open heart surgery in the year 1993, therefore, the appellants/ Insurance Company, while issuing the health insurance policy, put her under the category of pre-existing disease and it has been mentioned in the policy 'pre-existing disease - open heart surgery in 1993 for hole in the heart'. She further submits that in the year 2014 the appellants/Insurance Company paid Rs.1,00,000/- for surgery of implant of artificial valve. Due to ring of artificial/new valve, the respondent developed some complications for which she visited doctors at Indore and Delhi and they referred her to Madras Medical Mission Hospital for expert opinion and treatment. The doctors of Madras Medical Mission Hospital advised her to go for Cardiac Cath Plus Alcohol Ablation and in this regard when respondent sought : 5 : cashless approval from appellants/Insurance Company they refused the same on the ground of congenital disease.
7. Respondent further submits that a certificate of the Madras Medical Mission Hospital has also been sent to the Insurance Company, in which it has been clearly mentioned that the disease with which the respondent is suffering viz. Left Ventricular Outflow Tract (hereinafter referred to as 'LVOT') was not present during the surgery, she underwent in the year 2014, hence it is an acquired defect. She submits that the appellants/Insurance Company without any valid ground rejected pre-approval for her. Respondent submits that the District Commission after considering all the aspects of case and due consideration of all the evidence placed before it has passed a well reasoned order. She, therefore, submits that the appeal must be dismissed and the impugned order be upheld.
8. Heard learned counsel for the parties and perused the record.
9. The appellants/Insurance Company has rejected the cashless approval for treatment of respondent/complainant on the ground that it is a known case of congenital heart ailment and as per exclusion clause 3.3.11 of the policy, congenital anomaly/illness are not covered. For this rejection, the Insurance Company placed reliance on the discharge summary/operation record of the G.B. Pant Hospital, where the respondent underwent an open heart surgery in the year 1993. At the very out set it is to be noted that from the record it is not clear that how the appellants got this document/operation record of G.B. Pant Hospital. They have not filed any affidavit : 6 : in support of this document. It is also pertinent to note that in the complaint it has been categorically stated by the respondent/complainant that while obtaining the health insurance policy in the year 2008, she informed the Insurance Company about her health condition and specifically about her open heart surgery in the year 1993 at this very hospital and therefore, the Insurance Company put her under the category of pre-existing disease and it has been mentioned in the policy as 'pre-existing disease - open heart surgery in 1993 for hole in the heart', issued to her also. When the Insurance Company was well aware of her heart disease they ought to have thoroughly investigated the health condition of the respondent before issuing a health insurance policy to her. After issuing the policy in the year 2008, they renewed it regularly for about 10 years, on payment of annual premiums, now the Insurance Company cannot take a stand that the respondent is suffering with congenital disease, therefore, preapproval/insurance amount is not payable under the said exclusion clause. More so, when they paid Rs.1,00,000/- to the complainant for her surgery in the year 2014 for implant of artificial heart valve by extending cashless benefit.
10. On rejection of pre-approval, the appellant wrote a letter to the Insurance Company, clearly stating therein that her illness is not congenital, as there was no past history of LVOT. It was only started after valve replacement surgery in the year 2014. This contention of the respondent finds support from the certificate dated 23.11.2018 issued by the Madras Medical : 7 : Mission Hospital addressed to the Insurance Company, which reads as under:-
"Ms. Sanober Khan UHID No. 20181120372 has been identified to have progressive left ventricular outflow tract (LVOT) obstruction since 2015, This LVOT obstruction was not present during the Mitral Valve replacement surgery that she underwent in 2014, or during any of the prior cardiac evaluations and hence it is an acquired defect. She requires early valuation by Cardiac Catheterisation to assess the severity of LVOT obstruction to plan further management"
11. In this view of the matter the refusal on part appellants/Insurance Company for cashless approval for treatment of some serious complications developed after surgery in the year 2014 (for this surgery the appellants have paid Rs.1,00,000/-), on the ground that the appellant was suffering with congenital disease, which not covered under the policy in view of clause 3.3.11 of the policy, cannot be appreciated. Specially, when there is a certificate issued by the Madras Medical Mission Hospital, clearly stating that the LVOT obstruction was not present during the Mitral Valve replacement surgery that she underwent in 2014, or during any of the prior cardiac evaluations and hence it is an acquired defect. The respondent/complainant had never suppressed her health conditions. The appellants/Insurance Company were well aware of her heart problems and the treatment taken by : 8 : her for it and issued a policy by mentioning that 'pre-existing disease - open heart surgery in 1993 for hole in the heart', now the refusal for pre-approval for further treatment, amounts to deficiency on their part.
12. In view of the foregoing discussion, we find that the order passed by the District Commission does not suffer from any infirmity or illegality. It is accordingly affirmed. The appeal filed by the Insurance Company is dismissed. Parties to bear their own cost.
(A.K. TIWARI) (DR. SRIKANT PANDEY)
PRESIDING MEMBER MEMBER
Mercy