Orissa

Cuttak

CC/63/2015

Partha Sarathi Samantry - Complainant(s)

Versus

Branch Manager,Star Health & Allied Insurance co Ltd - Opp.Party(s)

30 Aug 2016

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL FORUM,CUTTACK.

C.C No.63/2015

 

Parth Sarathi Samantray,

C/O:Harekrushna Nayak,

At:Aparna Nagar,Chauliaganj,

Cuttack.                                                                                            … Complainant.

 

                Vrs.

 

1. Branch Manager,

Star Health and Allied Insurance Co. Ltd.,

Ground Floor Gajanan Compled,

Dolamundai,Cuttack.

 

2. Chief Executive of Star Health & Allied Insurance Co. Ltd.,

Corporate Office:New Tank Street Valluvarkokottem.

High Road Chennai-600034.                                                   … Opp. Parties.

 

Present:               Sri Dhruba Charan Barik,Preswident.

Sri Bichitra Nanda Tripathy, Member.

Smt. Sarmistha Nath, Member.

 

Date of filing:   24.06.2015

Date of Order: 30.08.2016

Sri Bichitra Nanda Tripathy, Member.

This is a dispute wherein the complainant has alleged deficiency in service on the part of the O.Ps.

The complaint in nutshell is as follows:-

1. The complainant Sri Partha Sarathi Samantaray made a mediclaim policy with M/s. Star Health & Allied Insurance Company vide policy No.P/191212/01/2012/000289 on 8.6.2011.  The policy was taken for himself, his wife and his son Isan Samantaray whose date of birth was 12.10.2010. As such the child was about eight months old when the policy was taken and the policy was valid from 8.6.2011 to 7.6.2012 as per the Annedure-I submitted by the complainant regarding details of policy which also indicates that a sum of Rs.9966/- was paid towards premium and the sum assured was Rs.10,00,000/-.
2. On 6.7.2012 it was detected that Isan Samantaray the son of the complainant was suffering from “Beta thalassemia Major”.(marked as Annexure-9).
3. On 10.6.2013 the O.,P,Insurance Company was intimated regarding the disease of the child by the complainant and the complainant also wanted to know from the O.P,Insurance Company that whether such disease was included in the insurance policy made for the family(marked as Annexure-3).
4. Vide letter dt.19.6.2013 the O.P, Insurance Company intimated Sri Parth Sarathi Samantaray, the complainant that the claim department at Head Office has advised to submit all treatment papers of the child, consultation history regarding the child from birth till detection of the disease. (Marked as Annexure-4).
5. The complainant vide his letter dt.29.6.13 submitted the treatment documents (5 nos.) of his child to the O.P., Insurance Company. (Marked as annexure-5).
6. On 29.6.2013 the complainant paid a sum of Rs.14,466/- towards insurance premium at the Cuttack office of the said insurance company i.e. O.P.1 (Marked as Annexure-2).
7. Vide letter dt.29.8.2013 the O.P, Insurance Company intimated the complainant that as per prevailing guidelines if Beta thalassemmia major is a PED it is not covered as per terms and conditions of policy. It is also stated in the said letter that if there has been non-disclosure of thalassemmia major it is willful non-disclosure with ensuing rejection of the claim and grounds for cancellation of the policy.  (Marked as Annexure-7).
8. Vide his letter dt.5.11.2013, the complainant intimated the O.P, Insurance Company (O.P.2) that as per terms and conditions of the policy Para-3(1 & 4) Bita thalassemia major being a  congenital internal disease is included in policy.  But illegally the O.Ps have cancelled the policy.  The complainant requested the O.Ps to continue the policy or to refund the entire premium paid with 15% quarterly compounded interest and Rs.50,000/- for mental tension and Rs.50,000/- for harassment.  But it yielded no result.  Finding no other way the complainant filed a case with this Hon’ble Forum under C.P.Act.1986.
9. He has prayed to direct the O.Ps for refund of the premium paid by him amounting to  Rs.24,432/- i.e. Rs.9966/- paid on 8.6.11 and Rs.14,466/- paid on 29.6.2013 along with interest @ 15% (quarterly compounded) till date of payment, to direct the O.Ps to return the original medical certificate of the child which was taken by the O.Ps and to pay Rs.10,000/- towards mental tension and also to pay Rs.2000/- towards court expenses.
10. Advocate Sri N.C.Mishra has briefed the matter on behalf of the O.Ps and has also filed the written version dt. 15.10.15. We have gone through the case carefully and perused all the  documents/papers filed by the complainant and also as filed by the O.Ps.  We have observed as follows:-

1. Vide page 1 & 2 para-3 of the written version dt.15.10.15 filed by O.Ps, it is stated that the complainant at the time of taking the policy has not disclosed regarding the disease of his son who suffered from Bita Thalassemia Major which can be said as suppression of material facts that while the child was born on 12.10.2010, the date of inception of the policy is 8.6.2011 and thereby violates the condition of the policy.
2. The details of terms and conditions of the policy of the O.P,Insurance Company marked as “Family Health Optima-Insurance Plan” wherein vide sl. No.3  (Exclusions) point No.1 it is stated that “Pre existing diseases as defined in the policy until 48 consecutive months of continuous coverage has elapsed since inception of the first policy with any Indian Insurer.  However, the limit of the company’s liability in respect of claim for pre-existing diseases under such portability shall be limited to the sum insured under the first policy with any Indian Insurance Company”.(Marked as Annexure-10B of the plaint).
3. But vide letter dt.29.8.2013 the O.P Insurance Company has intimated the complainant that as per prevailing guidelines if Beta Thalassemia major is a PED it is not covered as per terms and conditions of the policy.  It was also stated in the said letter that if there has been non-disclosure of thalessemia major, it is willful non-disclosure with ensuing rejection of claim and grounds for cancellation of policy.  It is pertinent to mention it here that the details of treatment papers of the child and history of the child’s disease was communicated to O.Ps vide letter dt.29.6.2013 and basing on the clarification received from the corporate office, Chennai(O.P.2) the above replay was drafted by O.P.1 to the complainant
4. The letter dt.29.8.2013 of the O.P.1 indicates that O.Ps were not sure whether the disease was PED or not and therefore they have quoted “if Beta Thalassemia is a PED it is not covered as per terms and conditions of the policy.”   It is also stated in the written version dt.15.10.15 of the O.Ps at page-3 vide sl.no.6 that children born with Thalassemia major usually develop the symptoms of severe anemia within 1^st year of life.  Since the policy was taken when the child was only 8 months old.  We cannot conclude that the child was suffering from thalassemia and the same was detected prior to the time of taking the policy.  So it is held that the complainant has not suppressed anything about thallassemia of the child at the time taking the policy.
5.  The O.Ps vide the said written version (page-4 sl.no.8-para-1) has submitted that the 1st policy No.P/191212/01/2012/000289 was issued for the period from 8.6.2011 to 7.6.2012 against a premium of Rs.9966/- and was further renewed from 11.6.2012 to 10.6.2013 vide policy No.P/191212/01/2013/000308 for a premium of Rs.14,466/.  It is stated in the said written brief that the policy had expired on 10.6.2013 and was never renewed(page-5) but the said written brief is silent regarding the fact that the O.P,Insurance Company has accepted the premium amounting to Rs.14,466/- on 29.6.13 when the policy had already expired.
6. In the written evidence and additional prayer submitted by the complainant dt.17.8.16 it is stated that symptoms of Thalassemia do not develop in the 1^st year of newly born child.  His child was suffering from cold.   On 6.7.2012 it was detected that the child was suffering from Beta Thalassemia major and the O.Ps were intimated about the disease of the child on 10.6.2013.
7. Although the O.Ps have stated that the policy was not cancelled by O.Ps but it was automatically cancelled for non-payment of premium on 10.6.2013 but vide their letter dt.29.813 the O.Ps have clearly indicated that if there has been non-disclosure of Thalassemmia Major it is willfull non-disclosure with ensuing rejection of claim and grounds for cancellation of policy (copy of this letter is also enclosed by the O.Ps vide Sl.No.5).
8.   Annexure-2 filed by the complainant indicates that a sum of Rs.14,466/- was paid by the complainant on 29.6.2013.  The complainant vide his letter dt.17.8.2016 has indicated that he has paid a total premium of Rs.38,898/- which was not shown in the original plaint  wherein it was shown as 24,432/-.  Hence he was prayed for the refund of total premium i.e. Rs.38,898/-/
9. Regarding return of the medical certificate of the child, the O.Ps have indicated vide their written brief dt.22.8.16 that no original documents of the child were submitted by the complainant as stated in his letter dt.29.6.2013.
10. After going through the documents and papers as submitted by the complainant as well as by the O.P we conclude  that:

 

1.  Thalassemia major was not detected earlier i.e. prior to taking the policy on 8.6.2011.
2. The O.Ps have not cancelled the policy but the policy was automatically cancelled due to non-payment of premium on 10.6.2013.
3. O.Ps have accepted a sum of Rs.14,466/- as premium from the complainant on 29.6.2013 when the policy was not valid.(Annexure-2)

11. Basing on the facts and circumstances, as stated above and to meet the ends of justice we observe that the O.P insurance company has accepted a sum of Rs.14,466/-as premium  from the complainant vide receipt  dt.29.6.2013 even if such policy has already expired since 10.6.13.   As such we allow the case against O.Ps for accepting such premium on 29.6.2013.

                      ORDER

The O.Ps will refund the last insurance premium paid by the complainant on 29.6.13 amounting to Rs.14,466/- with interest @ 15% P.A till the date of payment.  O.Ps will also pay a sum of ‘Rs.2000/- towards cost of the suit. 

O.Ps will pay the above dues as payable to the complainant within a period of 45 days from the date of receipt this order, failing which the complainant is at liberty to take shelter of this Hon’ble Court as per C.P.Act,1986.

Typed to dictation, corrected and pronounced by the Hon’ble Member in the Open Court on this the 30^th day of August, 2016 under the seal and signature of this Forum.

 

                                                                                                                                (Sri B.N.Tripathy)

                                                                                                                                     Member.

 

                                                                                                                                    (Sri D.C.Barik )

                                                                                                                                        President.

 

                                      Smt. Sarmistha Nath)

                                                                                                                                          Member(W)