PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

                             CONSUMER COMPLAINT NO.52/2021

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member,

Sanjaya Kumar agrawal,

S/o- Mahendra Kumar Agrawal

R/o- Panchagochhia, PO-Baraipali

Ps-Ainthapali, Dist-Sambalpur-768006               ...………..Complainant

                                                Versus

1. Directror, Star Health and Allied Insurance Company Ltd.

At-No.15, SRI BALAJI COMPLEX,

1^st Floor, The case of the Complainant is that the Complainant took a policy of the O.P. bearing No. P/191200/01/2019/012496 for the period 31.03.2019 to 30.03.2020 for his family members after payment of Rs. 26,001/-. Uma Agrawal wife of the Complainant admitted in Sushrusa Nursing Home Burla on 09.08.2019 and diagnosed kidney problem. As per advice of Dr. Sanjay Kumar Mahapatra an operation was conducted on 10.08.2019 and the patient discharged from Nursing Home on 13.08.2019. The Complainant spent Rs. 64,000/- to-wards operation and Rs. 20,000/- to-wards pathological test. After discharge claim No. CLMG/2020/191200/0600-701 was lodged before O.P. No.1 but it was rejected on the ground of non-disclosure of pre-existing disease of Complainant’s wife. The Complainant requested O.Ps several time and on 31.12.2020 and 15.03.2021 issued legal notices but the O.Ps remained silent. The Complainant is policy holder since 2018 of the O.Ps.

Being aggrieved this complaint was filed.

2. The O.Ps in their version admitted the family Health optima Insurance plan covered by Sanjay Kumar Agrawal, Mrs Uma Agrawal (wife) Prabesh Agrawal(Dependant Child) and Lokesh Agrawal (Dependent Child) for a floater sum insured Rs. 10.00 lakhs vide policy No. P/191200/01/2018/010492 for the period 01.03.2018 to 30.03.2019. Renewal was made vide Endorsement No. P/191200/01/2019/012496 for the period 31.03.2019 to 30.03.2020. Likewise Renewal made vide endorsement P/191200/01/2020/015281 without covering Mrs. Uma Agrawal(Wife). Uma Agrawal was deleted from the coverage from 25.01.2020 under endorsement No. P/191200/01/2019/012496/001 dated 22.01.2020 due to non disclosure of pre-existing disease. Uma Agrawal was hospitalised on 09.08.2019 and for non-disclosure of pre-existing disease deleted from coverage w.e.f. 25.01.2020.

 The claim of Complainant was acknowledged on 05.11.2019. The claims deptt. rejected the claim vide letter dated 06.12.2019 followed by letter dated 17.12.2019. In prescription dated 04.08.2019. Dr. Sanjay reflected that the patient suffered from GENNITOURINARYTUBERCULOSIS for part 8 years which is prior to the first insurance policy. In 2018-19 policy it has not been disclosed although insured suffering from GUTB. Further Sushruta Nurshing Home, Burla in prescription dated 09.08.2019 mentioned insured was K/O/C/HTN and on medication and suffering from DM.CAD. and Asthma.

The insured on the advice of Dr. T.K. Sahu done the USG of abdomen and pelvis at Life Line Diagnostics and Day Care Centre, Sambalpur on 24.02.2019 and suffering from HYDRONEPHROSIS OF LEFT SIDE and renewed the policy concealing facts of GUTB and Diabetes Mellitus type 2. For the said reasons the claim was repudiated.

The O.Ps cited Life Insurance Corporation of India Vs. Smt. G.M. Channabasemma, AIR 1991 SC 392 case and submitted that the insurance contract is void as the policy obtained on misrepresentation. The Complainant has not complied the protection of policy holders Interests Regulations, 2017. The liability of the O.P. shall be maximum Rs. 92,428/- less the deductions to-wards consumables and non-payable items as per policy conditions and I.R.D.A. guidelines. There is no deficiency on the part of the O.P. and the complaint is liable to dismissed.

3. Perused the documents filed by the Complainant. It is the admission of both the parties that Smt. Uma Agrawal was admitted in Sushrusa Nurshing Home, Burla from 09.08.2019 to 13.08.2019 and operation was conducted under the advise of Dr. Sanjay Kumar Mahapatra. During that period policy No. P/191200/01/2019/012496 was valid covering Smt. Uma Agrawal later on the O.P. deleted the scope of policy benefits of Smt. Uma Agrawal on 25.01.2020 under endorsement No.P/191200/01/2019/012496/011 dated 22.01.2020 claim application No. CLMG/2020/191200/0600-701 was made before the O.P. No.1 and vide letter dated 16.10.2019 the O.Ps informed the Complainant that during previous policy 31.03.2018 to 30.03.2019 GENITO URINARYTUBERCULOSIS of Smt. Uma Agrawal was not disclosed. For non-disclosure of facts it violated policy condition No.15 and the O.Ps may cancel the policy on the ground of misrepresentation, fraud, moral hazard by sending 30 days notice by registered post at insured person’s last known address. After cancellation of the policy the Complainant has made several correspondences and pleader notices to the O.Ps.
4. In the present case O.Ps established that Smt. Uma Agrawal was having pre-existing disease (PED) KI c/o GUTB for 8-10 years referring the prescription of Dr. Sanjay Kumar Mahapatra dated 04.08.2019. Further prescription dated 09.08.2019 discloses the PED of K/C/O HTN. At the time of renewal of the policy of Uma Agrawal applying clause 15 of the policy condition repudiating the claim. Here question arises at the time of renewal of the policy why the O.Ps allowed the insured Smt. Uma Agrawal and received the premium to continue the policy. It was the duty of O.Ps to examine all insured person to continue the policy. The O.Ps failed to do so and after receiving the claim became active repudiating the claim and cancellation of policy. The action on the policy by O.Ps is unilateral. As the policy was inforce, the Complainant had undergone surgery operation, as policy terms, the Complainant is entitled for the claim. The afterword action of the O.Ps i.e. cancellation of policy and repudiation are not proper. It is totally an unilateral change. The renewal for the year 2020-21 deleting name of Smt. Uma Agrawal is proper as it is bi-lateral

During 2018-19 the insured had no any PED whereas in 2019-20 dated 04.08.2019. As the policy was in force the Complainant is entitled for the claim.

In the aforesaid background it is ordered:

                                                    ORDER

The Complainant is partly allowed on contest. The O.Ps are directed to pay Rs. 64,000/- along with 4% interest P.A. w.e.f. 10.08.2019 within one month of this order and litigation expenses of Rs. 5000/-. In case of non payment the entire amount will carry 7% interest P.A. till realisation.

Order pronounced in the open court on 5^th day of June, 2023

Supply free copies to the parties.