BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.468 of 2015
Date of Instt. 03.11.2015
Date of Decision :26.07.2016
Ram Krishan Chadha son of Kishori Lal Chadha aged about 62 years R/o House No.147, Adarsh Nagar, Jalandhar City-144001.
..........Complainant
Versus
1.M/s Star Health and Allied Insurance Co.Ltd., KRM Centre, VI Floor No.2, Harrington Road, Chetpet, Chennai-600031, through its Managing Director.
2.M/s Star Health and Allied Insurance Co.Ltd., Branch Office, EH 198, 2nd Floor, Nirmal Complex, GT Road, Jalandhar-144001.
.........Opposite parties
Complaint Under Section 12 of the Consumer Protection Act.
Before: S. Bhupinder Singh (President)
Sh.Parminder Sharma (Member)
Present: Sh.ON Wahi Adv., counsel for the complainant.
Sh.AK Arora Adv., and Sh.Nitish Arora Adv., counsels for the OPs.
Order
Bhupinder Singh (President)
1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act against the opposite parties (hereinafter called as OPs), on the averments that complainant purchased mediclaim insurance policy namely Family Health Optima Insurance Policy bearing No.P/161125/01/01/2013/000883 effective from 10.11.2011. Complainant submitted that before the sale of the policy by the OP No.2, at Jalandhar, he was got medically checked-up by the OPs i.e. Pathology tests were conducted and then the OPs sold the insurance policy to the complainant after being satisfied by the medical test by the doctors appointed by the OPs. Thereafter, complainant got renewed the aforesaid policy, upto the year 2014, every year. The last policy for the year 2014-15. The complainant felt trouble in the heart and got checked-up from Shriram Cardiac Centre, Joshi Hospital, Jalandhar on 4.1.2015 where the complainant was admitted and got treatment from the said hospital and was discharged on 15.1.2015 and complainant spent Rs.2 Lakhs towards his treatment at the aforesaid hospital. The complainant lodged claim of Rs.2 Lakhs towards reimbursement of the hospitalization expenses and furnished all the necessary documents to the OPs. But the OPs repudiated the claim of the complainant on the ground of past history of the complainant in the year 1998. On such averments, the complainant has prayed for directing the OPs to pay a sum of Rs.2 Lakhs as claim amount, Rs.50,000/- as mental tension, torture and litigation expenses alongwith interest @ 18% per annum.
2. Upon notice, OPs appeared through counsel and filed written reply pleading that in order to obtain the aforesaid policy, the complainant filled in and signed proposal/application form and he declared in that application that he does not have any medical history. He did not suffer any ailment nor he was admitted in any hospital. Resultantly, on the application and the declaration made by the complainant, policy bearing No.P/161125/01/2014/00107 for the period from 10.11.2013 to 9.11.2014 was issued to the complainant. Complainant was admitted in Shriram Cardiac Centre, Jalandhar on 4.1.2015 for undergoing the treatment of hypertension, CAD (coronary artery disease) and unstable angina and thereafter approached the OPs for reimbursement of the medical expenses by submitting medical record. On scrutiny of the claim records, it was observed from the discharge summary of the complainant from Sikka Hospital for the admission on 28.10.2014 vide claim No.173592, states that the insured/complainant has a past history of CAD (Coronary Artery Disease)/MI (Myocardial Infarction) in 1998 which is prior to inception of the medical insurance policy and the complainant did not disclose these facts in his application/proposal form for obtaining the policy from the OPs. It was also observed that hypertension is incorporated in the above policy as pre-existing disease for the above insured person at the time of inception of the policy. Therefore, the present admission and treatment is for pre-existing i.e. hypertension and coronary heart disease, the claim was repudiated and the same was communicated to the insured vide letter dated 31.3.2015. As per exclusion clause No.1 of the policy, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease, until 48 months of the continuous coverage has elapsed, since inception of the policy. Pre-existing disease means any ailment, injury or related condition for which the insured person had signs or symptoms and/or was diagnosed and/or was diagnosed and/or received medical advise/ treatment within 48 months prior to insured person's first policy with the company. The present claim of the insured was in the fourth year of the policy i.e. after 38 months of the policy inception. Therefore, the expenses relating to pre-existing disease are payable only after 48 months of continuous coverage of policy. Moreover, the insured had not disclosed history of CAD/MI in the year 1998, in the proposal form at the time of inception of the policy despite the fact that it was in the knowledge of the complainant but the complainant had filled the wrong answers in that proposal form just to commit fraud upon the insurance company.
3. In support of his complaint, complainant has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C9 and closed his evidence.
4. On the other hand, learned counsel for opposite parties has tendered into evidence affidavits Ex.OP1/A and Ex.OP1/B alongwith copies of documents Ex.OP1 to Ex.OP13 and closed evidence.
5. We have heard the Ld. counsel for the parties, minutely gone through the record and have appreciated the evidence produced on record by both the parties with the valuable assistance of Ld. counsels for the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that complainant purchased mediclaim insurance policy namely Family Health Optima Insurance Policy bearing No.P/161125/01/01/2013/ 000883 effective from 10.11.2011. Complainant submitted that before the policy, he was got medically checked-up by the OPs. Thereafter, complainant got renewed the aforesaid policy, upto the year 2014, every year. The last policy for the year 2014-15. On 4.1.2015 complainant suffered heart ailment and got checked himself from Shriram Cardiac Centre, Joshi Hospital, Jalandhar where he was admitted on 4.1.2015 and was discharged on 15.1.2015 and complainant spent Rs.2 Lakhs towards his treatment at the aforesaid hospital. The complainant lodged claim of Rs.2 Lakhs towards reimbursement of the hospitalization expenses and furnished all the necessary documents to the OPs. But the OPs repudiated the claim of the complainant vide letter dated 31.3.2015 Ex.C6 on the ground of past history of the complainant. Complainant also served legal notice dated NIL upon the OPs Ex.C8 and the OP submitted reply dated 23.9.2015 Ex.C9 and they submitted that OP has rightly repudiated the claim of the complainant. Learned counsel for the complainant submitted that the OP has wrongly repudiated the claim of the complainant and all this amounts to deficiency of service on the part of the OP.
7. Whereas the case of the OPs is that in order to obtain the aforesaid policy, the complainant filled in and signed proposal/ application form and he declared in that application that he does not have any medical history. He did not suffer any ailment nor he was admitted in any hospital. Resultantly, on the application and the declaration made by the complainant, policy bearing No.P/161125/01/ 2014/00107 for the period from 10.11.2013 to 9.11.2014 Ex.C2 was issued to the complainant. Complainant was admitted in Shriram Cardiac Centre, Jalandhar on 4.1.2015 for undergoing the treatment of hypertension, CAD (coronary artery disease) and unstable angina and thereafter approached the OPs for reimbursement of the medical expenses by submitting medical record. On scrutiny of the claim records, it was observed from the discharge summary of the complainant from Sikka Hospital for the admission on 28.10.2014 vide claim No.173592, it came to light that insured/complainant has past history of CAD (Coronary Artery Disease)/MI (Myocardial Infarction) in 1998 which is prior to inception of the medical insurance policy and the complainant did not disclose these facts in his application/proposal form for obtaining the policy in question from the OPs. It was also observed that hypertension is incorporated in the above policy as pre-existing disease for the above insured person at the time of inception of the policy. Therefore, the present admission and treatment is for pre-existing i.e. hypertension and coronary heart disease, the claim was repudiated and the same was communicated to the insured vide letter dated 31.3.2015 Ex.C6. As per exclusion class No.1 of the policy, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease, until 48 months of the continuous coverage has elapsed, since inception of the policy. Pre-existing disease means any ailment, injury or related condition for which the insured person had signs or symptoms and/or was diagnosed and/or was diagnosed and/or received medical advise/ treatment within 48 months prior to insured person's first policy with the company. The present claim of the insured was in the fourth year of the policy i.e. after 48 months of the policy inception. Therefore, the expenses relating to pre-existing disease are payable only after 48 months of continuous coverage of policy. Moreover, the insured had not disclosed history of CAD/MI in the year 1998, in the proposal form at the time of inception of the policy despite the fact that it was in the knowledge of the complainant. Thereby, complainant has obtained the insurance policy in question by concealment of facts. Learned counsel for the OPs submitted that earlier also complainant filed claim for his similar disease for his admission in the hospital on 28.10.2014 in Sikka Hospital, Jalandhar which was repudiated by the OP vide repudiation letter dated 31.12.2014 Ex.OP5 on the same ground and the complainant had concealed all these facts from this Forum. Learned counsel for the OP submitted that present claim has also been repudiated by the OP as per terms and conditions of the policy vide repudiation letter dated 31.3.2015 Ex.C6. So, there is no deficiency of service on the part of the OPs qua the complainant.
8. From the entire above discussion, we have come to the conclusion that in order to obtain medical claim insurance policy namely Family Health Optima Insurance Policy for himself. Complainant filled in and signed the proposal/application form. Resultantly, mediclaim insurance policy was issued to the complainant bearing No.P/161125/01/01/2013/000883 effective from 10.11.2011 Ex.C1 which was continuously renewed by the complainant and the present policy was for the period from 10.11.2014 to 9.11.2015 Ex.OP10/Ex.C1. On 4.1.2015, the complainant suffered heart ailment and he was admitted in Shriram Cardiac Centre, Joshi Hospital, Jalandhar on 4.1.2015 and was discharged on 15.1.2015 and he spent about Rs.2 Lakhs towards his treatment at the aforesaid hospital with the OP. The OP investigated the claim of the complainant and during investigation it came to light that earlier also the complainant filed claim regarding similar medical treatment. The said claim form is Ex.OP2 for his admission from 28.10.2014 to 31.10.2014 and that claim was repudiated by the OP under the same policy on the ground that complainant remained under treatment in Sikka Hospital, Jalandhar City and he was diagnosed as CAD/IM in 1998. The complainant was admitted in Sikka Hopital and was diagnosed unstable angina. The said record of Sikka Hospital, is Ex.OP4. Complainant never raised any protest against that repudiation of claim by the OP vide letter dated 31.12.2014 Ex.OP5. Similarly, now the complainant has lodged another claim for his admission in Joshi Hospital, Jalandhar for admission from 4.1.2015 to 15.1.2015 Ex.OP6. As per exclusion clause 1 of the policy, the company is not liable to make any payment in respect of expenses for the treatment of the pre-existing disease, until 48 months of the continuous coverage has elapsed, since inception of the policy. The complainant obtained the first policy from the OP for the period from 10.11.2011 to 9.11.2012 and the present claim relates to 4.1.2015 to 15.1.2015 i.e. in the fourth continuous policy of the complainant. Whereas the complainant shall be entitled to reimbursement of medical expenses for pre-existing disease after 48 months continuous policy i.e. in the fifth policy. So, OP was justified in repudiating the claim of the complainant vide letter dated 31.3.2015 Ex.C6.
9. Apart from this, the complainant has concealed the material facts while obtaining the first policy for the year 2011-12 from OP, that he has suffered and undergone treatment for CAD in the year 1998 which also proves that complainant obtained the present policy from the OP in the year 2011 by concealment of facts.
10. In the light of aforesaid facts, this Forum is of the opinion that the OP was justified in repudiating the present claim of the complainant vide letter dated 31.3.2015 Ex.C6. As such, we do not find any merit in this complaint and the same is hereby dismissed with no order as to cost. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.
Dated Parminder Sharma Bhupinder Singh
26.07.2016 Member President
