PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

Consumer Complaint No.- 28/2024

Present-Dr. Ramakanta Satapathy, President,

  Sri. SadanandaTripathy, Member

Binod Kumar Agrawal, Aged about 77 years

S/O-Late Laxmi Narayan Agrawal,

R/O- SreeKunj, BohidarNuapali, PO-Bhalupali, Ps-Ainthapali,

Dist-Sambalpur, Odisha-768006.                          .……….......Complainant.

Vrs.

1. Star Health And Allied Insurance Co. Ltd.

New Tank SteetValluvarKottam High Road, Nungambakkam,

Chennai-600034, Tamilnadu, Ph; 044-28302700/28288800.

2. Star Health And Allied Insurance Co. Ltd.

2nd Floor, Quality Mansion, Nayapara,

PO/Dist-Sambalpur-768001.                                 …...……….Opp. Parties

Counsels:-

1. For the Complainant         :- Sri. P.C.Hota & Associates
2. For the O.P.s                       :- Sri. B.K. Purohit, Adv.

Date of Filing:30.01.2024,  Date of Hearing :15.07.2024  Date of Judgement : 27.08.2024

Presented by Sri SadanandaTripathy, Member.

1. The Brief fact of the Complainant is that the Complainant availed one Health Insurance Policy from the OP vide product name Senior Citizens Red Carpet Health Insurance Policy vide Renewal Endorsement Policy No. P/161130/01/2023/165125, with starting date of policy on 01.02.2020, which is renewed yearly upon payment of yearly premium. The Policy of Insurance has been renewed for the period 1^st Feb, 2023 to 31^st  Jan, 2024 issued on 14^th  Jan, 2023 on payment of premium vide Invoice dated. 14.01.2023 for Rs. 25,223/- to the OPs. Upon receipt of premium from the Complainant the OP has issued the policy and premium certificate to the Complainant. Since the date of commencement of the policy on 01.02.2020, the Complainant had no any disease like, diabetes, hypertension, prostrate etc. However the policy has been renewed thrice from 01.02.2020 to 31.01.2021, from 01.02.2021 to 31.01.2022, from 01.02.2022 to 31.01.2023 and from 01.02.2023 to 31.01.2024 and in all the previous policies there is mentioned of non existence of pre existing decease. During the subsistence of the current policy, the Complainant received a letter from the OPs dtd. 17.04.2023 wherein the OP has alleged the Complainant suffered from pre existing disease which amounts to non disclosure of material facts. Accordingly the OPs intended to cancel the policy w.e.f 27.05.2023. The Complainant was admitted in Vikas Hospital Pvt. Ltd., Sambalpur on 06.04.2022 for treatment of Gastro Intestinal Infection as per the advice of doctor of said hospital. It is the opinion of the doctor that the Gastrointestinal infection is not an underlying disease or pre existing disease. Prior to this treatment, the Complainant never suffered from any disease at any point of time. The Complainant was not aware of cancellation of the policy by the OP and in order to renew the policy like previous years, the Complainant made contact through Emails on 11.01.2024 with the OP in advance before completion of the policy on 31.01.2024 requesting to  take steps for the period from 01.02.2024 to 31.01.2025. But the OP on 11.01.2024 informed by email that the policy  has been cancelled without explaining the reason of cancellation unilaterally and advised to collect copy of endorsement. However the Complainant downloaded the copy of endorsement of the OP and came to know that his policy of health Insurance had been cancelled on 27.05.2023 by the Insurer on a fake and baseless ground of non disclosure of pre existing disease although the said detection doesn’t come within the purview of pre existing disease within the period of 48 months prior to the effective date of policy. The OP has not refunded the premium amount which clearly mandates that the policy is in force. The Complainant being a bonafide consumer of the OP since last 34 years has been deprived from the genuine benefit and as such the OP is negligent in rendering service. For the fault of the OP the Complainant is suffering from mental agony, financial loss along with other botherations for which is liable to pay the premium amount along with interest and adequate compensation.
2. The written version of O.Ps  is that the Insured-Complainant had availed the Star Senior Citizen Red Carpet Insurance Policy covering himself for sum insured Rs. 10,00,000/- for the period from 01.02.2022 to 31.01.2023. In the said policy, the Complainant declared that there was no any pre-existing disease from its inception from 01.02.2020. The terms and conditions of the policy were explained to the Complainant at the time of proposing policy and the same was served to the Complainant along with the Poicy Schedule. It is evident from the discharge summary of Gleneagles Global Hospital for the period of hospitalization from 31.03.2019 to 04.04.2019 that the insured patient was already diagnosed of Acute Calculus Cholecystitis along with gall bladder removal and enlarged prostate since 2019. Despite being aware of the above aliments prior to policy inception, the insured did not disclose the ailments in the proposal form. From Sigmoidoscopy report dt. 01.04.2019 it was found that, the insured patient already had multiple diverticula (a blind tube leading from a cavity or passage) prior to policy inception. These following amounts to major non-disclosure. Policy commenced from 01.02.2020 and the renewal proposal was submitted by the Complainant for the period 2022-23 but the Insurance Company intended to cancel the policy as there was non-disclosure of material facts, i.e. pre-existing disease, which is very much required for a prudent insurer either to take the Policy or reject the proposal when the insured did not disclose the pre-existing disease but made a claim and submitted the documents, it came to the light that he was diagnosed for Acute Calculus Cholecystitis and was hospitalized from 31.03. 2019 to 04.04.2019 at Global Hospital for removal of the gall bladder and enlarged since which the insured suffering since 2019. It was also observed from the SIGMOIDOSCOPY Report dtd. 01.04.2019 that the insured already had multiple diverticula prior to the inception of the policy. Since this is a major non-disclosure of material facts, the policy was cancelled by the Insurance Company. The Complainant has made a frivolous complain against the OP for which he is liable to be dealt with as per law.

ISSUES

1. Is the Complainant a Consumer of the O.Ps?
2. Is there any defficiency of service/unfair Trade practice in part of O.Ps?
3. Whether the Complainant is entitled for getting any relief from the OPs?

Issue No. 1Is the Complainant a consumer of the O.Ps?

The Complainant has availed one Health Insurance Policy from the OP vide product name Senior Citizens Red Carpet Health Insurance Policy vide Renewal Endorsement Policy No. P/161130/01/2023/165125, with starting date of policy on 01.02.2020, which is renewed yearly upon payment of yearly premium. The Policy of Insurance has been renewed for the period 1^st Feb, 2023 to 31^stJan, 2024 issued on 14^thJan, 2023 on payment of premium vide Invoice date. 14.01.2023 for Rs. 25,223/- to the OPs. Hence he is a consumer of the OPs.

Issue No. 2Is there any deficiency in service/ unfair Trade practice in part of O.Ps?

The OPs mentioned in their version that the Complainant was diagnosed for Acute Calculus Cholecystitis and was hospitalized from 31.03. 2019 to 04.04.2019 at Global Hospital for removal of the gall bladder and enlarged since which the insured suffering since 2019. The OPs not produced/submitted in the Commission any report of said Medical treatment in which it is reflected that the Complainant has pre-existing disease prior to the policy. In the other hand after completion of three years of a policy almost all pre-existing diseases are also covered.   Here the Complainant has paid already four number of premium to the OPs. The OPs have a duty to properly verify and check up the Insured before acceptance the premium.  So deficiency in service/ unfair Trade practice of the O.Ps established against the O.Ps.

Issue No. 3Whether the Complainant is entitled for getting any relief from the OPs?

From all the facts discussed supra it is clear that, the Complainant is entitled for getting reliefs what he claims in his complaint petition from the O.Ps. However, on dtd. 15.07.2024, the OPs submitted that as per prayer of Complainant Rs. 25,223/- has already been refunded and the Complainant has no any case. In the other hand, in his written argument on 06.08.2024, the Complainant mentioned that “during course of hearing, the OPs have submitted before this Hon’ble Commission to pay the premium amount but till date the same has not yet been credited to the Complainant”.

          Basing on the circumstances it is ordered:

                             ORDER

The O.Ps are directed to refund the premium amount of Rs. 25, 223/- or revive the policy and adjust the amount as the next year premium if not refunded earlier and Rs. 45,000/- towards suffering and mental agony as compensation to the Complainant within 30 days from the date of order,failing which all the amount will further carry with 9% interest per annum till realization to the complainant.

Order pronounced in the open Court today on 27^th day of Aug, 2024.

Free copies of this order to the parties are supplied.