Chandigarh

DF-I

CC/45/2019

Daljeet Singh Sidhu - Complainant(s)

Versus

M/s Star Health and Allied Insurance Co. Ltd. - Opp.Party(s)

Vikrant Sharma

04 Jun 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

============

Consumer Complaint  No	:	CC/45/2019
Date  of  Institution	:	29/01/2019
Date   of   Decision	:	04/06/2020

 

 

 

 

 

Daljeet Singh Sidhu S/o Sh. Zora Singh, R/o House No.98, AKS Colony Zirakpur, District Mohali, Punjab (father & natural guardian of Ms.Keerat Sidhu D/o Daljeet Singh Sidhu).

……… Complainant

 

Versus

 

1]   M/s Star Health and Allied Insurance Co. Limited, IRDA Registration No.129, SCO 130-131, 4^th Floor, Sector 34-A, Chandigarh – 160022, through its Branch Manager.

 

2]   M/s Star Health and Allied Insurance Co. Limited, having Regd. Office at 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai – 600034 through its Managing Director.

……. Opposite Parties

 

BEFORE:   RATTAN SINGH THAKUR     PRESIDENT

SMT.SURJEET KAUR             MEMBER

DR.S.K. SARDANA              MEMBER

                               

 

For Complainant	:	Sh. Vikrant Sharma, Advocate.
For Opposite Parties	:	Sh. Gaurav Bhardwaj, Advocate.

 

PER SURJEET KAUR, MEMBER

 

 

          Adumbrated in brief, the facts necessary for the disposal of the instant Consumer Complaint are, the Complainant ported his Health Insurance Policy from ICICI Bank to the Star Health & Allied Insurance Co. Limited (for brevity hereinafter to be referred as the Opposite Parties), covering himself, his wife Kuldeep Sidhu and two minor children namely Keerat Sidhu and Tanay Sidhu. It has been alleged that during the currency of the said policy, the minor daughter of the Complainant namely Ms. Keerat Sidhu slipped from the stairs at her home and suffered fracture at the Elbow. By virtue of having the aforesaid policy, the Complainant requested for cashless treatment. Both the Hospital and the Complainant immediately informed the Opposite Parties regarding the same. The daughter of the Complainant admitted to the Hospital on 01.11.2018 and was operated upon and was discharged on 02.11.2018. However, the Opposite Parties vide letters dated 17.10.2018 (Annexure C-4 & C-5) rejected the claim of the Complainant on the ground that the patient is a known case of recurrent seizure since 2013 and was hospitalized in 2014, which facts were not disclosed by him at the time of porting of Health Policy. The Complainant was thus forced to incur a sum of Rs.79,750/- on the treatment of his daughter for which she was insured with the Opposite Parties. Eventually, the Complainant got served a legal notice dated 12.01.2019 upon the Opposite Parties, but the same did not fructify. With the cup of woes brimming, the Complainant has filed the instant Consumer Complaint, alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties.

 

2.      Notice of the complaint was sent to Opposite Parties seeking their version of the case.

 

3.      Opposite Parties contested the claim of the Complainant and filed their joint written statement, inter alia, admitting the basic facts of the case. It has been pleaded that at the time of porting of the Policy, the medical history/ health details of the insured person (daughter of the Complainant) were not disclosed in the proposal form which amounts to misrepresentation/ non-disclosure of material facts, due to which the pre- authorization was rejected and the same was informed to the insured vide letter dated 17.10.2018. Thus, denying all other allegations and stating that there is no deficiency in service or unfair trade practice on their part, Opposite Parties have prayed for dismissal of the complaint.

 

4.      Rejoinder was filed and averments made in the consumer complaint were reiterated.

 

5.      Parties were permitted to place their respective evidence on record in support of their contentions.

 

6.      We have heard the learned counsel for the Parties and also perused the record with utmost care and circumspection.

 

7.      It is evident from the copy of the Health Insurance Policy (Annexure C-2) that the Complainant paid the premium of Rs.15,287/- for the said Policy, which covers the Complainant, his wife and two minor children. Over this Policy document the mention of the Basic Floater Sum Insured is Rs.5,00,000/- with Recharge Benefit of Rs.1,50,000/-. The period of insurance is from 19.10.2017 to 18.10.2018.

 

8.      The sole grouse of the Complainant is that when on 15.10.2018 his minor daughter namely Keerat Sidhu slipped from the stairs and suffered fracture at the elbow, the Complainant spent an amount of Rs.79,750/- for the treatment of the same. The said incident was duly conveyed to the Opposite Parties with a request for cashless treatment. However, the Opposite Parties vide letters (Annexures C-4 & C-5) rejected the claim of the Complainant on the ground that the patient (daughter of the Complainant) is a known case of recurrent seizure since 2013 and was hospitalized in 2014 and these facts were not disclosed by the Complainant at the time of porting of the Health Insurance Policy in question.

 

9.      The stand taken by the Opposite Parties is that it is the fault of the Complainant himself who did not disclose the health status of his daughter who is suffering since 2013, hence the rejection is genuine.

 

10.      It is pertinent to note that the Complainant paid a premium of Rs.15,287/- for the purpose of safety of his own health along with his family members. Moreover, the treatment for which the Complainant has been pressing his claim is nowhere associated with the seizure for which the daughter of the Complainant took treatment 3-4 years prior to the incident. In other words, the said disease has nothing to do with the present incident of fracture in the elbow. At any rate, it was the duty of the Opposite Parties to confirm the health details of the Complainant as well as his family members before issuing the policy and thereafter at the time of its renewal. 

 

11.      Notably, perusal of the legal notice dated 12.01.2019 (Annexure C-7) to which the Opposite Parties relied as Annexure C-10 on 07.02.2019, shows that the Opposite Parties in a very unprofessional manner replied to the said legal notice of the Complainant that they are unable to trace any details of the Complainant despite having the complete contents with them, as they have filed a detailed written statement perusing the same documents. This conduct of the Opposite Parties itself shows the deficiency in service on their part.

 

12.      It is thus legitimately proved that the Opposite Parties caused great harassment, inconvenience and mental torture agony and suffering to the Complainant, despite getting the requisite premiums for the policy and thereafter for the renewal of the policy and later denying the benefit of cashless treatment to the Complainant in case of emergency, proves deficiency in service and their indulgence into unfair trade practice. 

 

13.      In the light of above observations, we are of the concerted view that the Opposite Parties are found deficient in giving proper service to the complainant. Hence, the present complaint of the Complainant deserves to succeed against the Opposite Parties, and the same is allowed, qua them. The Opposite Parties are, jointly and severally, directed to:-

 

[a]  To refund Rs.79,750/- along with interest @9% per annum from the date of repudiation i.e. 17.10.2018, till its realization;

 

[b]  To pay Rs.15,000/-on account of deficiency in service and causing mental and physical harassment to the Complainant; 

 

[C] To pay Rs.10,000/- as cost of litigation;

 

14.      The above said order shall be complied within 30 days of its receipt by the Opposite Parties; thereafter, Opposite Parties shall be liable for an interest @12% p.a. on the amount mentioned in sub-para [a] above from the date of repudiation i.e. 17.10.2018, till it is paid. The compensation amount as per sub-para [b] above, shall carry interest @12% p.a. from the date of institution of this complaint, till it is paid, apart from costs of litigation of Rs.10,000/-.  

 

15.      Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.
16.  

04^th June, 2020                                                           

Sd/-

(RATTAN SINGH THAKUR)

PRESIDENT

 

Sd/-

 (SURJEET KAUR)

       MEMBER

 

Sd/-

 (DR.S.K. SARDANA)

       MEMBER