Chandigarh

DF-II

CC/202/2017

Sh. Kulbhushan Aggarwal - Complainant(s)

Versus

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

S S Pathania Adv. & Mrs Neeta Pathania Adv.

31 Jul 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II,

 U.T. CHANDIGARH

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Consumer Complaint  No	:	202 of 2017
Date  of  Institution	:	28.02.2017
Date   of   Decision	:	31.07.2017

 

 

 

 

Sh.Kulbhushan Aggarwal, H.No.5120/2, Modern Housing Complex, Manimajra, Chandigarh (UT)  

             …..Complainant

Versus

1]  M/s Star Health and Allied Insurance Co. Ltd., KRM Centre, VI Floor, No.2 Harrigton Road, Chetpet, Chennai 600031

2]  M/s Star Health and Allied Insurance Co. Ltd., SCO No.130-131, IV Floor, Sector 34-A, Chandigarh (UT) 160022

                               ….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN        PRESIDENT

MRS.PRITI MALHOTRA    MEMBER

                                SH.RAVINDER SINGH     MEMBER 

 

Argued by: Sh.S.S.Pathania, Adv. for complainant

 Sh.Gaurav Bhardwaj, Adv. for OPs.

 

 

PER RAVINDER SINGH, MEMBER

 

 

          The facts in issue are that the complainant purchased a Family Health Optima Insurance Plan Policy No.P/161113/01/2016/001371 from Opposite Party effective from 23.8.2015 to 22.08.2016 after making payment of premium of Rs.18,970/- thereby covering the complainant and his wife Mrs.Rosy Aggarwal for basic floater sum of Rs.5.00 lacs. The complainant was also given recharge benefit of Rs.1.50 lacs on account of no claims during the previous policy period with ICICI Lombard since 2010 (Ann.C-2).  It is averred that earlier while complainant was working with Reliance Industries since 2004, he was having medical insurance policy under Group Medical Policy of Employer. Thereafter from Aug., 2010 till Aug., 2015, the complainant was having insurance policy from ICICI Lombard and never claimed any reimbursement of medical expenses.  It is averred that after having gone through medical examination on 20.8.2015 (Ann.A-I), the policy with previous insurer-ICICI Lombard was ported to Opposite Party Company with no claim bonus (Ann.C-1).

 

         It is submitted that in Sept., 2012, the complainant was diagnosed as Prostate Cancer at PGIMER, Chandigarh, which was treated there with IMRT (Radio Therapy) in May, 2013 and the complainant was fully cured as per Petitioner Scan thereafter.  However, the complainant did not claim any medical reimbursement from OPs.  It is also submitted that in Feb., 2016, the complainant was diagnosed for PIRADS category-2 and the complainant took treatment for the same at PGIMER, Chandigarh on which an expenditure of Rs.1,38,534/- was incurred.  The complainant filed claim for that amount, but it was repudiated on false and flimsy grounds of concealment (Ann.C-3 & C-4).  However, the previous policy was renewed by the OPs from 23.8.2016 to 22.8.2017 (Ann.C-5). It is also submitted that the complainant took the matter of repudiation of claim before Bima Lokpal, Chandigarh, but nothing was done.  It is further submitted that the renewed policy was received by the complainant, but the requested amendment was not done till date even despite sending of legal notice. It is stated that the claim of the complainant was rejected on the ground that at the time of portability of the policy from ICICI Lombard, the complainant had not disclosed the medical history in the proposal form which amounts to non-disclosure of material facts and concealments. It is also stated that the complainant has not furnished any incorrect or false information nor material facts were hidden/concealed at the time of portability.  It is further stated that the complainant had undergone extensive medical examination before the portability and that too by the Doctor assigned at the choosing of the OPs.  Alleging the said repudiation and illegal and deficiency in service, hence this complaint has been filed.

 

2]       The OPs have filed joint reply and while admitting the factual matrix of the case, stated that the policy was issued subject to terms & conditions of the policy.  It is submitted that the complainant was suffering from prostate cancer since 2012 and not intimated the claim in ICICI Lombard.  It is also submitted that the complainant has not disclosed said fact in his proposal form, whereas there was a specific question with regard to cancer but the complainant mentioned ‘no’ in the answer to the said question. It is further submitted that the complainant was suffering from prostate cancer and present claim is also with regard to the chemotherapy of the same region, which is done upon the cancer patients.  It is stated that the complainant has failed to disclose his ailment in the proposal form and he concealed the material information and misrepresented the facts by mentioning ‘no’ against the specific question regarding cancer.  It is also stated that the claim of the complainant was rightly repudiated as per condition NO.8 of the policy (Annexure R-1/2 & R-1/3).  Pleading no deficiency in service and denying rest of the allegations, the OPs have prayed for dismissal of the complaint. 

 

3]       The complainant has also filed replication reiterating the contentions as raised in the complaint.

 

4]       Parties led evidence in support of their contentions.

5]       We have heard the ld.Counsel for the parties and have carefully examined the facts and pleadings along with entire evidence on record.

 

6]       Sh.Kulbhushan Aggarwal, complainant had medical insurance policy from ICICI Lombard with effect from August, 2010 to August, 2015.  The complainant switched over the medical insurance policy and the same was ported to M/s Star Health and Allied Insurance Company Ltd. with effect from 23.8.2015 to 22.8.2016.  The complainant had not availed any financial benefit/reimbursement from any insurance company prior to 23.8.2015 and as such, he was offered recharge benefit of Rs.1.50 lacs in addition to Rs.5.00 lacs basic floater sum insured under the Family Health Optima Insurance Plan by the Opposite Parties.  It is pertinent to mention that OPs i.e. M/s Star Health and Allied Insurance Company Ltd. had accepted the portability of medical insurance policy after thorough medical examination of complainant on 20.8.2015 (Ann.A-1).

 

7]       In the medical examination, nothing adverse to the health of the complainant has come out, meaning thereby, the complainant was perfectly in health at that appropriate period. 

 

8]       The complainant fell ill in Feb., 2016 and diagnosed for PIRADS category-2 and he took necessary treatment from PGIMER, Chandigarh and incurred an expenditure of Rs.1,38,534/-. 

 

9]       The OPs have extended the benefit of Family Health Optima Insurance Plan by issuing of policy with effect from 23.8.2015 to 22.8.2016 on receipt of premium of Rs.18,970/- after proper and thorough medical examination of the complainant by medical experts.

 

10]      The Opposite Parties have also further renewed the medical insurance policy of the complainant with effect from 23.8.2016 to 22.8.2017 too.  The Opposite Parties now at this stage cannot withdraw from its commitments as agreed upon under the insurance policy and cannot repudiate the claim of the complainant which is genuine. 

 

11]      The Hon’ble Punjab & Haryana High Court at Chandigarh in LPA No.1537 of 2011 (O&M), on identical facts, decided on 26.8.2011– IFFCO TOKIO General Insurance Company Ltd. Vs. Permanent Lok Adalat (Public Utility Services), Gurgaon and other, 2012(1) RCR (Civil) 901, has held that:-

 

"Mediclaim- Exclusion clause – Pre existing disease – Claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the Policy – Single judge allowed the claim on the ground that it was for Insurance Company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease – No interference called for in the order of Single Judge – Held, the pre-existing condition existed in the year 2002 which was five year prior to acquiring Insurance Policy – Claim cannot be denied.”

 

12]      The Opposite Parties by repudiating the genuine medical insurance claim of the complainant have suffered on account of deficiency of its service. 

13]      Keeping into consideration the observations made in the preceding paragraphs and judgment of Hon’ble Punjab & Haryana High Court ibid, we allow the present complaint with direction to the OPs to reimburse an amount of Rs.1,38,534/- to the complainant, which he had incurred on his treatment, within a period of 30 days from the date of receipt of certified copy of this order.

         The copy of this order be forwarded to the parties and file be consigned to record room.

Announced

31^th July, 2017           

                                           Sd/-

                                                                                (RAJAN DEWAN)

PRESIDENT

                    

                                                                                                Sd/-                                                                                (PRITI MALHOTRA)

                                                                                      MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER