District Consumer Disputes Redressal Commission, Hooghly
PETITIONER
VS.
OPPOSITE PARTY
Complaint Case No.CC/170/2022
(Date of Filing:-18.08.2022)
- Sri Asim Sarkar
Village:- Kanaipur, P.O. Dakshin Basudebpur,
P.S. Dhaniakhali
Dist. Hooghly, Pin:-712301
- Star Health & Allied Insurance Company Ltd.
Represented by its Branch Manager,
2nd floor, 7, Post Office Road, Tarakeswar
District:- Hooghly,Pin:- 712401
- Star Health & Allied Insurance Co. Ltd.
Represented by its Manager
No. 15, Sri Balaji Complex, 1st Floor, Whites Lane Avenue, P.O. & P.S. Roy Apettah, Chennai-600014
- M/S Punjab National Bank
Plot No. 4, Sector-10, Dwarka New Delhi
New Delhi-110075
- The Manager,
Oriental Insurance Co. Ltd.
Regd. And Head Office,
A-25/27, Asraf Ali Road, New Delhi-110002
…..Opposite parties
Before:-
Mr. Debasish Bandyopadhyay, President
Mr. Debasis Bhattacharya, Member
Mrs. Babita Chaudhuri, Member.
-
Final Order/Judgment
DEBASIS BHATTACHARYA:- PRESIDING MEMBER
Being aggrieved by and dissatisfied with the service extended mainly by Star Health & Allied Insurance Company Ltd. (hereinafter referred to as OP1 and 2) of the address as mentioned above, in the matter of lodging of a claim for reimbursement of medical expenses related to the medical treatment and surgery of his son, and subsequent repudiation of the said claim for reimbursement of the medical expenses by the insurance company, the instant case has been filed by the complainant, u/s 35 of the Consumer Protection Act 2019.
In the instant case the other OPs viz. Punjab National Bank and Oriental Insurance Company Ltd. appear to have secondary roles in the matter of the dispute.
The fact of the case is as follows.
Reportedly, the complainant, initially being a holder of the medical Insurance Policy of Oriental Insurance Company, through Punjab National Bank (Mandra Branch) which was a continuing one since 25.03.2015 and the last renewal of the same was made for the period from 25.03.2021 to 24.03.2022.
The policy covered himself, his wife and his son.
However when the Complainant approached to the OP bank for renewal of the policy in the first week of January 2022 he was intimated by the Bank that the tie-up between the Bank and Oriental Insurance Company Ltd. was severed and a fresh tie-up was made with Star Health & Insurance Co. Ltd.
At this, the Complainant made a contact with the agent of the OP1 Insurance Company and on enquiry the concerned agent of the Insurance Company assured him that in claim matters, there would be no problem in future as the policy was a continued one.
On 14.02.2022 the Complainant’s son suffered a leg injury while playing cricket. As the treatment of the local physician was of no effect, the Complainant visited AMRI Hospital in Kolkata on 22.02.2022 and the attending doctor suggested an MRI of right knee and the said MRI was done on 25.02.2022.
On receipt of the MRI report the Complainant visited one Tulip Nursing Home Dum Dum for further treatment of his son and the attending doctor on examination of the report advised a surgery.
However the Complainant at that very juncture did not go for the surgery as his son was supposed to be preoccupied with his academic schedule.
By this time the Complainant ported the medical Insurance Policy to OP Insurance Company and the policy certificate was issued on 26.02.2022.
On 27.03.2022 the Complainant got his son admitted in the said Nursing Home.
His son underwent a surgery on 28.03.3022 and was discharged from the nursing home on 30.03.2022.
Subsequently the Complainant submitted the claim form covering a claim amount of Rs.1,07,510/-, through his agent along with all relevant documents related to the treatment, before the OP Insurance Company.
In the result, the claim was repudiated by the OP Insurance Company allegedly on some ‘false and baseless’ ground.
A request for reconsideration of the claim and repeated visits to the office of the OP Insurance Company were futile exercises.
All these developments caused gross mental agony, anxiety, harassment and financial loss for the Complainant.
Considering the stance taken by the OP, as deficiency of service, willful negligence and unfair trade practice, the complainant submits a prayer before this Commission to impose direction upon the OP to reimburse the claim to the extent of Rs.1,07,510/- , Rs.2,00,000/- as compensation for sufferings and mental agony, and to pass any other order or orders as the Commission may deem fit and necessary to meet the ends of justice.
The Complainant along with the Complaint petition has annexed photocopies of certain corroborating documents viz. 1) primary Insurance policy of Oriental Insurance Company, 2) insurance policy ported to Star Health and Insurance Company Ltd., 3) Repudiation letter of OP 2 Insurance Company dtd.30.04.2022, 4) Medical documents and the corresponding medical bills, 5) Communications received from the OP Insurance Company and 6) Letters sent to the OP Insurance Company, postal receipts and postal track reports thereof.
In view of the above discussion and on examination of available records it transpires that the complainant is a consumer as far as the provisions laid down under Section 2(7) (ii) of the Consumer Protection Act 2019 are concerned.
Both the complainant and the opposite party 1 are resident/having their office address within the district of Hooghly.
The claim preferred by the complainant does not exceed the limit of Rs.50,00,000/-Thus, this Commission has territorial as well as pecuniary jurisdiction to proceed in the instant case.
The issues related to the questions whether there was any deficiency of service and whether the complainant is entitled to get any relief, being mutually inter-related, will be taken together for convenient disposal.
Evidence on affidavit and BNA filed by the Complainant are almost replicas of the Complaint petition. However, in the evidence on affidavit, the Complainant claims that the allegations leveled by the OP insurance Company in their written version against the Complainant are totally false
The OP 1 and 2 primarily against whom the grievances are expressed by the Complainant, belong to the same organization.
OP Insurance Company has contested the case by filing written version, evidence on affidavit and brief note of argument. The Commission was compelled to make the case run ex parte against the OP 3 Punjab National Bank and OP 4 Oriental Insurance Company as OP3 and OP 4 did not make their appearance at any stage of hearing.
Defence case:- Now the OP 1 and OP 2 Star Health & Allied Insurance Company contested the case by filing written version and brief notes of argument.
On prayer, the written version was treated as evidence on affidavit.
In the written version the complaint petition is described as baseless allegation and concocted stories. It is further alleged that there are suppression of material facts in the complaint petition.
In fact the OP Insurance Company denies vociferously all the allegations leveled against them.
Besides it is also claimed that that this Commission is devoid of any jurisdiction to try, entertain and adjudicate this instant case and justice will be sub served if and only the Complainant be directed to prefer a suitable application before any competent court of law. However, while placing this proposition, the OP insurance Company does not clarify referring to specific reason that in which sense this Commission is devoid of any jurisdiction to adjudicate the instant case.
However the proposition being absurd, audacious and funny is brushed aside at once.
However, the written version which is treated as evidence on affidavit points out the following issues which deserves mention.
- The proposer/complainant opted for Star-Group Health Insurance Policy-Gold (For Bank Customers) covering self, his spouse and dependant son for sum insured Rs.2,00,000/- for the period 25.03.2022 to 24.03.2023.
- Prior to switching over to this policy, the Complainant initially was covered under the Group Policy of Punjab National Bank with The Oriental Insurance Company Limited for sum insured Rs.1,00,000/- for the period 25.03.2014 to 24.03.2015 which were renewed from time to time.
OP Insurance Company has annexed copies of the policy with terms, conditions and exclusions, proposal form and the claim form filed by the Complainant.
The OP Insurance Company draws attention to the fact that the insured suffered injury in his right knee around mid February for which treatment was received from AMRI Hospital on 22.02.2022. But this development, which is claimed to be material facts pertaining to the issue of the said policy, was not disclosed while switching over to the OP Insurance Company for the first time.
Allegedly this was suppression of material fact at the time of taking the policy with the OP Insurance Company which resulted in the repudiation of the claim.
In this reference the OP insurance Company refers to standard condition no. B (8) of the policy where it is stated that ‘the policy shall be void and all premium paid thereon shall be forfeited to the Company, in the event of misrepresentation, mis- description or non-disclosure of any material fact by the policy holder’.
The OP Insurance Company argues that as per the Contract of Insurance, the Proposer/Insured/Complainant is expected to declare in the proposal about the details of medical history which helps the insurer to evaluate the material facts and to decide whether to accept the proposal or not. In the instant case, it is claimed that the Insured/Complainant who signed the proposal did not declare the pre-existing condition in the proposal form of the insured, which amounts to non-disclosure of material fact.
The OP Insurance Company to substantiate their arguments has annexed copies of the certificate of insurance, terms and conditions thereof, the filled up proposal form, the filled up claim form submitted by the Complainant insured, MRI of right knee report, medical prescriptions and the repudiation letter.
Decision with reason
It transpires from the available records that the Complainant maintained a medical insurance policy with sum insured of Rs.1,00,000/-, uninterruptedly for the period from 25.03.14 to 24.03.2022 with The Oriental Insurance Company Ltd. The policy was in nature was group insurance one mediated by Punjab National Bank.
However as the tie-up between Punjab National Bank and The Oriental Insurance Company was severed, the Complainant shifted to the OP Star Health & Allied Insurance Company Ltd. with effect from 25.03.2022 with sum insured of Rs.2,00,000/-.
On examination of the related documents it is found that on 14.02.2022 the son of the Complainant suffered a knee injury and following the advice of the concerned physician, MRI of the right knee was done on 25.02.2022. The MRI report is dtd.25.02.2022. On 17.03.2022 admission to the nursing home and surgery were suggested by the attending doctor. Accordingly admission was made on 27.03.2022, surgery was done on 28.03.2022 and the patient was discharged on 30.03.2022.
On the other hand the proposal form was filled up by the Complainant on 23.02.2022 and was received by the OP Insurance Company on 24.02.2022
It is apparent from the records and particularly from the communication made by the OP that the only reason assigned to the repudiation of the claim of the Complainant was misrepresentation/non-disclosure of facts.
Opposite parties pointed out that they repudiated the claim of the complainant on the ground of non-disclosure of facts at the time of porting of the policy.
The OP Insurance Company issued ported mediclaim insurance policy in continuation of Mediclaim Insurance Policy issued by OIC in the year 2014 and the ported medical insurance policy was effective from 25.03.2022 and was valid up to 24.03.2023.
Now the question remains that whether there was deliberate suppression /non-disclosure of pre-existing injury by the Complainant or whether there was desperate attempt by the OP Insurance Company to shrug off the burden of reimbursement.
The existing records reflect that prior to filling up of the proposal form, the Complainant had no knowledge that his son had such a severe injury that he would have to undergo a surgery.
In daily life activities, anyone may have a knee injury while negotiating the stairs or in playground or while doing any sort of physical movement.
If this amounts to non-disclosure/misrepresentation of facts, then almost 90% claims lodged with different medical Insurance Companies each day, are to be repudiated for non-disclosure/misrepresentation of facts. Then the question remains that whether these companies are meant for realizations of premiums only and to do brisk business.
Now, as the insurance policy was ported, it is to be construed that the policy was a continued one and not a new one. The insured persons opted for porting of the policy almost under compulsion.
In the policy schedule a ‘Previous Policy No.’ is also mentioned. This clearly indicates that this is a continued policy with a changed issuing Company only.
It appears that IRDA issue a detailed portability guideline on 09.09.2011. According to this guideline, “Portability means the right accorded to an individual health insurance policyholder (including family cover) to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policyholder chooses to switch from one insurer to another insurer or from one plan to another plan of the same insurer, provided the previous policy has been maintained without break”.
Hence question of non-disclosure/misrepresentation of facts in the instant case does not arise.
Common men in our country approach to these insurance companies to get relief from shouldering the burden of huge medical expenses. So far as the documentary evidences filed by the complainant are concerned, the genuineness of the complaint does not appear to be questionable. But the manner in which the complainant’s case has been treated by the OP is thoroughly disappointing. In a desperate attempt to get out of the burden of reimbursement, they have taken shelter under the roof of so-called ‘non-disclosure’.
In the instant case, the opposite parties have failed to produce credible evidence to establish that prior to the date of first inception of the policy or even prior to the date of porting of the policy the insured was suffering from any pre-existing disease/injury and there was anticipated surgery and that fact was within his knowledge and he deliberately concealed the same.
On meticulous scrutiny of all the aspects of the case, this Commission is of the view that there was gross deficiency of service and unfair attitude on the OP’s part.
Hence it is
ORDERED
that the complainant case no.170/2022 be and the same succeeds on contest but in part.
The opposite party 1 and 2 who belonging to the same organisation are directed to reimburse the treatment expenses as claimed, to the extent of Rs.1,07,510/- with interest @9% for the period from the date of lodging the claim for the first time to the date of payment of the principal amount.
Besides, a further amount of Rs. 20,000/- will have to be paid by the OP to the complainant as compensation for his mental agony and harassment.
In the event of failure to comply with this order, the opposite parties will be jointly liable to pay a cost of Rs.30,000/- by depositing the same in the Consumer Legal Aid account.
This order has to be complied within 45 days from the date of this order.
Let a plain copy of this order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgement/sent by ordinary post for information and necessary action.
The final order will be available in the website www.confonet.nic.in.
