Punjab

StateCommission

A/25/2018

Star Health and Allied Insurance Co. Ltd. - Complainant(s)

Versus

Gurinder Singh - Opp.Party(s)

Punit Jain

21 May 2018

ORDER

                                                               FIRST ADDITIONAL BENCH

 

STATE  CONSUMER DISPUTES  REDRESSAL COMMISSION,    PUNJAB

          SECTOR 37-A, DAKSHIN MARG, CHANDIGARH

 

                   First Appeal No.25 of 2018

 

                                                          Date of Institution:  15.01.2018

                                                          Order Reserved on : 17.05.2018

                                                          Date of Decision  :  21.05.2018

 

Star Health and Allied Insurance Company Limited, through its Chairman/Managing Director/Principal Officer, through its Branch Office at District Shopping Complex, Ranjit Avenue, Amritsar through its Branch Manager.

 

                                                                         Appellant/Opposite party                  

          Versus

 

Mr. Gurinder Singh son of Sh. Harbans Singh, Resident of Care of Raja Ram & Sons  O/s Hall Gate, Amritsar.

 

                                                                    Respondent/Complainant

 

First Appeal against order dated 24.11.2017 passed by the District Consumer Disputes Redressal Forum,  Amritsar.

 

Quorum:-

          Shri J. S. Klar, Presiding Judicial Member.

            Smt. Surinder Pal Kaur, Member

Present:-

          For appellant                :  Sh. Amit Gupta, Advocate.

          For respondent            :  Sh. Sukhandeep Singh, Advocate

. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

 

J.S KLAR, PRESIDING JUDICIAL MEMBER :-

         

                    The appellant has directed this appeal against order dated 24.11.2017 of District Consumer Disputes Redressal Forum Amritsar, directing the appellant to pay the amount of Rs.3 lac on account of medical expenses to respondent of this appeal within one month from the date of receipt of the order, failing which to pay interest @ 6% p.a. from the date of filing the complaint till actual payment and further awarding Rs.2000/- as costs of litigation to him. The respondent Gurinder Singh of this appeal is complainant in the complainant and respondent Star Health is opposite party therein and they be referred as such hereinafter for the sake of convenience.

2.                The complainant has filed the complaint U/s 12 of The Consumer Protection Act, 1986 (in short, "the Act") against OP on the averments that the he got Health Benefit medi-claim insurance policy for himself and his family from OP, covering risk period from 10.01.2017 to 09.01.2018 and as such he is consumer of OP. He fell ill and was hospitalized at Nayyar Hospital Amritsar from 11.01.2017 till 16.01.2017 and 23.01.2017 till 24.01.2017 and incurred the expenses of Rs.5 lac on his treatment. He intimated OP about his hospitalization and treatment to be taken thereof as the policy was cashless one and insured sum for medical benefit was of Rs. 3 lac. OP repudiated the claim of the complainant, vide repudiation letter dated 16.03.2017 on the ground that he was afflicted with pre-existing disease.  He made representation to OP in this regard, but to no effect. The act of OP has been termed as baseless and deficient in service by him and he sought compensation of Rs.50,000/- for undue harassment. He has prayed that OP be directed to pay the amount of Rs. 3 lac along with interest @ 12% from 16.03.2017 till its realization. It was further prayed that OP be directed to pay Rs.5000/- as compensation  and cost of litigation.

3.                Upon notice, OP appeared and filed written reply and contested the complaint of the complainant vehemently by raising preliminary objections that complaint is not maintainable. The. complainant has suppressed the material facts from the Forum. The complainant is estopped by his act and conduct from filing the complaint. The complaint is without cause of action. It was further averred that the terms and conditions of the policy were explained to complainant at the time of proposing the policy and same were served to him along with the policy schedule. The insurance policy was subject to conditions, clauses, warranties, exclusion etc.  The complainant was admitted in Nayyar Hospital at Amritsar on 11.01.2017 for the treatment of CVA/CAD-DVD/inferior wall MI /LVDF , vide claim no. CLI/2017/211111/0438926 and submitted the authorization request for cashless treatment and same was denied on the ground that the claim fell during the breaking period. The insured was also requested to submit the claim records for reimbursement of claim records and the same was communicated to the insured, vide letter dated 12.01.2017. The insured was admitted on 11.01.2017 at 9.42 am and was discharged on 16.01.2017 at 4.56 pm and diagnosed as CVA, CAD and AWMI.  The consultation report dated 10.01.2017 of Dr. Kewal Krishan  stated that insured patient had consulted the doctor at 9.00 am, which was during the break in policy period, as above policy was renewed only at 15.20 hrs on 0.01.2017. As per condition no.9 of the above policy, the company is not liable to protect the insured person between policy expiry date and date of payment of renewal premium. OP asserted the legality of the repudiation of the claim. The complainant was admitted in the hospital during the currency period of policy on 11.01.2017. OPs controverted the other averments of the complainant and prayed for dismissal of the complaint.

4.                The complainant tendered in evidence his affidavit Ex.C-1 along with copies of other documents Ex.C-2 to Ex.C-8 and closed the evidence. As against it; OP tendered in evidence affidavit of P.C Tripathy Zonal Manager of OP as Ex.OP-1 along with copies of documents Ex.OP-2 to Ex.OP-22 and closed the evidence. On conclusion of evidence and arguments, the District Consumer Forum Amritsar accepted the complaint of the complainant by virtue of order dated 24.11.2017. Aggrieved by above order of the District Forum Amritsar, opposite party now appellant, has carried this appeal against the same.

5.                We have heard learned counsel for the parties and have also examined the record of the case. Affidavit of Gurinder Singbh complainant Ex.C-1 has been perused by us on the record. Ex.C-2 is repudiation letter of claim dated 16.03.2017, conveyed to complainant by OP. It is evident from perusal of this repudiation letter observing that above policy was renewed after break in period of 12 days from 29.12.2016 to 09.01.2017. It is observed from consultation report dated 10.01.2017 of Dr. Kewal Krishan as submitted, vide claim no. 0374000 that insured patient had consulted the doctor at 9.00 am , which was during the break in policy period. The above policy was renewed only at 15.30 hours on 10.01.2017, whereas it expired on 09.01.2017. OP repudiated the claim of the complainant not on account of suppression of fact of pre existing ailment, but on the point of lapsation of the previous policy and complainant falling ill during the break in period of the policy. Ex.C-3 is cover note of the policy.  Patient discharge summary is Ex.C-4 to the effect that Gurinder Singh complainant was admitted on 11.01.2017 at 9.42 am at Nayyar Hospital Amritsar and was discharged on 16.01.2017 at 4.56 pm. Diagnose is CVA CAD-DVD/INF WALL MI/LVDF/TROP-T +VE  procedure PTCA + STENT TO RCA (3.0X28MM) XIENCE XPEDITION (11.01.2017). The complainant presented with chest pain radiating to left arm and A/W Cold sweating and inability to speak. Ex.C-5 is prescription slip of Dr. Bajaj dated 11.01.2017. Ex.C-6 is Heart Care Solutions of Nayyar Hospital of complainant. Ex.C-7 is patient discharge bill. Ex.C-8 is Heart Care Solution. The complainant heavily relied upon above documents.

6.                To refute this evidence, OP tendered in evidence affidavit of P.C Tripathy Zonal Manager of Start Health and Allied Insurance Co. Ltd /OP is Ex.OP-1, who stated that complainant suppressed the material facts from the Forum. The complainant is estopped by his act and conduct from filing the complaint. He further stated that policy was subject to exclusion clauses. The complainant was admitted at the Nayyar Hospital at Amritsar on 11.01.2017 for the treatment of CVA/CAD-DVD/inferior wall MI/LVDF and submitted his pre-authorization request for cashless treatment, which was not accepted by OP. He further stated that the complainant was admitted in the hospital during the currency period of second policy for the treatment of CVA/CAD/DVD/Inferior wall MI/VDF and submitted pre-authorization request for cashless treatment, which was denied. He stated that policy was not in operation on 11.01.2017, as second policy had expired before 11.01.2017 i.e. date of admission of complainant at Nayyar Hospital. Ex.OP-2 is Family Health Optima Insurance Plan. Ex.OP-3 is Star Health and Allied Insurance Company Limited. Ex.OP-4 is Family Health Optima Insurance Plan. Ex.OP-5 is Family Health Optima Insurance Plan. Ex.OP-6 is request for cashless hospitalization for medical insurance policy. Ex.OP-7 is letter addressed to Nayyar Hospital regarding treatment of the insured patient. Ex.OP-8 is pre authorization for cashless treatment. Ex.OP-9 and Ex.OP-10 are claim forms no. A & B. Ex.OP-14 is repudiation of the claim of the complainant. Ex.OP-15 is patient discharge summary. Ex.OP-16 is MRI Report dated 14.01.2017. Ex.OP-17 is Department of Interventional Cardiology Coronary Angiography Report.

7.                From hearing respective submissions of counsel for the parties at length and from perusal of the record, we conclude that OP has not repudiated the claim of the complainant on the ground of concealment of material facts of his previous ailment. We cannot travel beyond the repudiation letter and grounds on which is is passed. The repudiation letter sent by OP to complainant is Ex.C-2 dated 16.03.2017 and OPs also placed on record repudiation letter Ex.OP-14 dated16.03.2017. It is evident from perusal of repudiation letter Ex.OP-14 of this claim, as brought on record by OP, that OP has not repudiated the claim of the complainant on the ground of concealment of material facts of his pre-existing ailment, if any. OP only repudiated the claim of the complainant on the ground that policy had already expired on 09.01.2017 and complainant was struck with the illness on 10.01.2017 only and hence there was no policy in operation at that time. Since OP has not repudiated the claim of the complainant on the ground of concealment of material facts of previous ailment, hence, we need not touch this point in this case, which is not germane to this controversy before us.

8.                Now, we restrict ourselves to decide this point, as to whether OP is justified in repudiating the claim of the complainant on account of non-operation of any policy after 09.01.2017. The complainant was struck with illness on 10.01.2017 and was admitted in Nayyar Hospital Amritsar on 11.01.2017. There is ample evidence on the record to prove this fact nor it has been disputed by either of the parties that the policy was taken by the complainant covering the risk from 10.01.2017 to 09.01.2018 and complainant was admitted in the Nayyar hospital at Amritsar on 11.01.2017 till 16.01.2017 and 23.01.2017 till 24.01.2017. OP has alleged that policy has already expired and complainant fell ill during the break in period of the policy. Ex.C-3 is Family Health Optima Insurance Plan showing that period of previous insurance policy was from 29.12.2015 to 28.12.2016. The contention of OP is that previous policy expired on 28.12.2016 and complainant took this policy, which was to commence from 10.01.2017 to 09.1.2018. The complainant was admitted in the Nayyar Hospital at Amritsar on 11.01.2017. This policy commenced from 10.01.2017. We, thus, found that admission of the complainant at Nayyar Hospital Amritsar on 11.01.2017 and policy commenced on 10.01.2017 and hence the contention of OP is that insured fell ill within the break in period is without consequence. The point of previous existing ailment and suppression of this material point by complainant need not to be discussed, because it is not a part of the cause of action, as OP repudiated the claim of the complainant on the ground of break in period of only.

9.                As a result of our discussion, we find no illegality or material infirmity in the order of the District Consumer Forum Amritsar dated 24.11.2017 under challenge in this case and same is affirmed. Sequentially, the appeal of the appellant is hereby dismissed.

10.              The appellant had deposited the amount of Rs.25,000/-with this Commission at the time of filing  the appeal and further deposited Rs.214149.50, vide receipt dated 07.02.2018 as per compliance with the order of this Commission. Both these amounts  with interest, which accrued thereon, if any, be remitted by the registry to the respondent/complainant  by way of a crossed cheque / demand draft after the expiry of 45 days, subject to stay order if any. Remaining amount, if any, due shall also be paid to complainant by the appellants within 45 days from receipt of the copy of this order

11.              Arguments in this appeal were heard on 17.05.2018 and the order was reserved. Certified copies of the order be communicated to the parties as per rules.

12.              The appeal could not be decided within the statutory period due to heavy pendency of court cases.

 

                                                                          (J. S. KLAR)

                                                          PRESIDING JUDICIAL MEMBER

                    

 

                                                                   (SURINDER PAL KAUR)           

                                                                            MEMBER

May 21,   2018                                                            

(ravi)