BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 631 of 2019
Date of Institution : 29.10.2019
Date of Decision : 16.11.2023
Darshan Kumar Singla aged about 58 years son of Shri Sarna Kumar Singla resident of H. No. 167, RSD Colony, Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
1. Mr. Hemant Kumar, Agent, Star Health and Allied Insurance Company Ltd. Sirsa, C/O Dr. Inderjeet Wali Gali Sirsa.
2. Star Health and Allied Insurance Company Ltd. having its corporate office at 1, New Tank Street, Valluvar Ottam High Road, Nungambakkam, Chennai- 600034 through its Managing Director.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA……….MEMBER
Present: Sh. J.D. Garg, Advocate for the complainant.
Opposite party no.1 already exparte.
Sh. M.K. Saini, Advocate for opposite party no.2.
ORDER:-
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 ( now under Section 35 of C.P. Act, 2019) against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that complainant had purchased a cashless mediclaim policy from op no.2 through op no.1 for himself and his wife and submitted requisite documents and paid Rs.33,700/- as annul premium amount including all taxes and ops issued policy bearing no. P/211119/01/2018/010348 to the complainant and his wife. As per policy, the sum assured was of Rs. five lacs apart from the bonus of Rs. five lacs and policy was valid from 31.03.2018 to 30.03.2019. That prior to said policy, complainant also obtained policy from ops since last two years and kept on paying annual premium regularly. During that period, the complainant did not suffer with any disease and did not get indemnified any claim from ops under the said policy. It is further averred that at the time of issuance of the present fresh policy, the complainant disclosed his existing disease i.e. Prostate and their complications and wife of complainant disclosed disease related to female Genital System and their complications. That complainant is a vigilant person and he used to undergo regular check ups from higher institutes and before taking this policy in the year 2015 the complainant was thoroughly checked up by the Inderprastha Hospital, Delhi. At that time his full body scan and various tests were conducted and all the reports were found negative and he was not having disease relating to his heart. It is further averred that ops due to malafide intention wrongly mentioned in the policy that complainant was having disease relating to cardio vascular system despite the fact that all the reports of Inderprastha Hospital were supplied to the ops at the time of issuance of the policy according to which he was not suffering with any such disease but the ops in order to debar him from his legal right of getting indemnified his claim had wrongly mentioned him to be the patient of said alleged disease.
3. It is further averred that in the month of June, 2018 the complainant suffered heart attack and he was immediately shifted to Fortis Hospital, Mohali where he was operated upon and coronary angioplasty was done and he remained admitted there from 20.06.2018 to 22.06.2018. The hospital authorities charged an amount of Rs.3,43,087/- from complainant against the hospitalization and treatment and his family members contacted the ops for reimbursement of bills of the hospital but they denied to make the payment and as such his family members had to make the payment of the said amount after arranging the same from nears and dears. That after discharge from hospital the complainant lodged his claim with all requisite documents and his claim was registered with op no.2 but despite that same has been declined by them and the act and conduct of the ops clearly amounts to deficiency in service and unfair trade practice due to which complainant has suffered unnecessary harassment and mental agony. Hence, this complaint.
4. On notice, none appeared on behalf of op no.1 despite service and as such op no.1 was proceeded against exparte.
5. OP no.2 appeared and filed written statement taking certain preliminary objections. It is submitted that policy is contractual in nature and claims arising therein are subject to the terms and conditions forming part of the policy. Only based on the Pre Medical Examination and consent of the insured, the Cardiovascular disease was endorsed as Pre Existing Disease. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. It is further submitted that insured patient Mr. Darshan Kumar Singla was hospitalized at Fortis Hospital, Mohali on 20.06.2018 for the treatment of ACS. The insured has submitted claim for reimbursement of medical expenses towards the treatment of heart disease in the 4th year of the policy which is not payable as per terms and conditions of the policy. Hence, the pre authorization was rejected. Subsequently the insured has submitted claim for reimbursement of ACS for Rs.3,33,087/-. As per discharge summary dated 20.06.2018 he was diagnosed with CAD- USA- DVD- PTCA with stent to RI and RCA. As per waiting period 3(iii) of the policy, the company is not liable to make any payment in respect of expenses for treatment of the pre existing disease/ condition until 48 months of continuous coverage has elapsed since the date of commencement of the first year policy. Hence, the claim was repudiated and same was communicated to the insured vide letter dated 14.07.2018. It is further submitted that answering op is acting as per the terms and conditions of the policy and legally rejected the claim of complainant. It is also submitted that in case it is found that company is liable to pay the claim, the maximum quantuam of liability under the terms of the policy shall be Rs.3,29,775/- on submission of original discharge summary but no original final bill and original payment receipt have been provided and only copy of documents have been submitted. With these averments, dismissal of complaint prayed for.
6. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex. C1 to Ex.C36.
7. On the other hand, op no.2 has tendered affidavit of Sh. Rajiv Jain, Chief Manager as Ex.R1 and documents Ex.R2 to Ex.R22.
8. We have heard learned counsel for the parties and have gone through the case file carefully.
9. There is no dispute of the fact that complainant had availed health insurance policy from op no.2 for sum insured amount of Rs.5,00,000/- for himself and his wife Smt. Savita which was effective from 31.03.2018 to 30.03.2019 and said fact is also proved from the policy schedule placed on file by complainant as Ex.C2. It is also proved on record that complainant had been purchasing health insurance policy from op no.2 since 2015 and complainant has already disclosed to the op no.2 that he is suffering from existing disease of prostate and its complications as is evident from the copies of policy schedule Ex.C2, Ex.C4, Ex.C5 and Ex.C6. However, in the present policy schedule in question Ex.C2 (effective from 31.03.2018 to 30.03.2019) besides disease of prostate and their complications it is also mentioned by op no.2 that complainant is taking treatment of diseases related to Cardio Vascular System. However, the op no.2 has failed to prove on record that how they mentioned the fact in the policy document Ex.C2 that complainant is also suffering from disease related to Cardio Vascular System and is taking treatment of said disease because the complainant suffered from the said disease of heart only in the month of June, 2018 i.e. after about three months of the purchase of policy in question. Prior to purchase of policy in question in the year 2015 the complainant underwent all necessary tests of heart in Indraprastha Apollo Hospital and all his tests regarding heart were found normal and no any kind of abnormality was seen and said fact is proved from the reports placed on file by complainant as Ex.C12 and Ex.C15 to Ex.C36. It is proved on record that op no.2 at its own mentioned in the present policy document that complainant is taking treatment of diseases related to Cardio Vascular System which is wrong and illegal because prior to purchase of policy in question the complainant was not suffering from such type of disease and was only having disease of prostate which fact was already disclosed by the complainant to the ops. So the op no.2 has wrongly and illegally repudiated the genuine claim of complainant on false and frivolous ground that company is not liable to make any payment in respect of expenses for treatment of the pre existing disease/ condition until 48 months of continuous coverage has elapsed since inception of the policy i.e. from 29.03.2015. The said disease suffered by complainant only in the month of June, 2018 cannot be said to be a pre existing disease and as such repudiation of the claim of complainant by the op no.2 is set aside. The complainant has claimed reimbursement of the amount of Rs.3,43,087/- and it is proved on record by complainant through various bills/ receipts and detailed bill Ex. C10/A that he has spent an amount of Rs.3,43,087/- on his above said treatment whereas op no.2 has asserted that maximum quantum of liability of op no.2 under the terms of the policy shall be Rs.3,29,775/-. As such in our considered opinion the complainant is entitled to the said amount of Rs.3,29,775/- after some deductions as per document Ex.R22 of the op no.2. Non payment of this amount clearly amounts to deficiency in service as well as unfair trade practice on the part of op no.2. However, op no.1 is mere an agent of op no.2 and as such complainant is entitled to the above said amount from op no.2 insurance company.
10. In view of our above discussion, we allow the present complaint and direct the opposite party no.2 to pay the claim amount of Rs.3,29,775/- to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to receive the said amount of Rs.3,29,775/- from op no.2 alongwith interest at the rate of @6% per annum from the date of this order till actual payment. We also direct the ops to further pay a sum of Rs.10,000/- as compensation for harassment and Rs.5000/- as litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 16.11.2023. District Consumer Disputes
Redressal Commission, Sirsa.
