District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.638/2019.
Date of Institution: 24.12.2019.
Date of Order: 19.12.2022.
Raj Narayan Jha, son of late Shri Inder Narayan Jha resident of House No. F-39, Old Press Colony, NIT, Faridabad, District Faridabad.
…….Complainant……..
Versus
1. M/s. Star Health and Allied Insurance Co. Limited, Shop No.1, First Floor, Krishna Palace, Near Deepak Complex, Ajronda, Faridabad – 121006 through its Branch Manager/principal Officer.
2nd address:- M/s. Star Health and Allied Insurance Co. Limited, Unit NO.13, Ground floor, Tribhuvan complex, Ishwar Nagar, Mathura Road, New Delhi – 110 025.
3rd address:- M/s. Star Health and Allied Insurance Co. Limited, Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High road, Nungambakkam, Chennai – 600 034.
2. Ravi Tiewari, Senior Manager, M/s. Star Health and Allied Insurance Company Limited, Shop No.1, First floor, Krishna Palace, Near Deepak Complex, Ajronda, Faridabad – 121006.
3. Shekhar Kumar Mishra, Agent, M/s. Star Health and Allied Insurance Company Limited, Shop No., First floor, Krishna Palace, Near Deepak Complex, Ajronda, Faridabad – 121006.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Gajraj Singh, counsel for the complainant.
Sh. D.C.Dhankar, counsel for opposite parties Nos.1 & 2.
Opposite party No.3 ex-parte vide order dated 01.09.2021.
ORDER:
The facts in brief of the complaint are that the complainant obtained a mediclaim policy from United India Insurance Company Limited and remained continue since 30.03.2010 worth Rs.5,00,000/-. Later on, the opposite party No.3 agent allured the complainant to get transferred/port the abovesaid mediclaim policy in the opposite party NO.1 Insurance company, by saying that they would give more benefits than the above said insurance company.. The daughter of the complainant namely Km. Purnima Jha became seriously ill on 04.05.2015, as she was suffering from Seizure Disorder, hence at that time said Km. Purnima Jha got admitted in Asian Institute of Medical Sciences, Sector-21A, Faridabad, on 04.05.2015 and remained admitted as indoor patient in the said hospital upto 07.05.2015. During that the complainant informed the opposite parties immediately about the ailment of his daughter and at that time there was no any objection from any side. Opposite party NO.3 visited to the complainant and he allured the complainant that the complainant should transfer/port the above said insurance policy, with a further assurance that there would be same facilities/benefits. Opposite party NO.2 called the complainant in his office and after seeing the documents and after clearing each and every fact, he assured the complainant that he would port the above said insurance policy of the complainant on the same terms and conditions as well as same benefits. Hence, at that time the above said mediclaim policy was transferred/ported in the opposite party No.1 insurance company for an amount of Rs.5,00,000/- (which includes the insurance of the complainant, his wife Mrs. Shobha Jha and his two children namely Varun Jha and Km. Purnima Jha) on 30.03.2017, bearing policy NO. P161116/01/2017/006868. The above named daughter of the complainant again became sick on 07.06.2018 hence she was taken to Fortis Escorts Hospital, Neelam Bata Road, NIT, Faridabad, on the same day, then after due medically check up there was same problem, as she was suffering from Left Parietalparasagittal Calcified Neurocystricercosis with Recurrent Break through Right Focal Sensory Seizures and she got admitted as an indoor patient in the above said hospital on 07.06.2018 and remained upto 09.06.2018 and at that time the complainant spent a total amount of Rs.58,843/-. The complainant submitted his claim form with the opposite parties and completed all requisite formalities to their entire satisfaction at that time and requested them to release the payment of claimed amount, but the opposite parties instead of releasing the payment, had rejected the claim of the complainant with remarks “Pre-disease” on 08.06.2018. The complainant sent legal notice dated 23.10.2019 to the opposite parties but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay an amount of Rs. 58,843/- alongwith interest @ 18% p.a. from the date of its due till its realization.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite parties Nos.1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 & 2 refuted claim of the complainant and submitted that the complainant availed a Family Health Optima Insurance Plan vide policy No. P/161116/01/2018/007994 for the period 30.03.2018 to 29.03.2019 covering Mr. Raj Narayan Jha – Self, Mr. Shobha Jha – spouse and Two dependent child Mr. Varun Jha, Mr. Purnima Jha for the sum insured of Rs.10,00,000/- and the saidpolicy was FHO (Family) Revised 2017 and the said policy was port from M/s. United India Insurance Company to the answering opposite party vide policy NO. P/161116/01/2017/006868 for the period of 30.03.2017 ato 29.03.2018 and that the complainant was well versed with the terms and conditions of the policy which were properly explained to the complainant at the time of porting the policy and the same was served to the complainant alongwith the policy schedule and also it was clearly stated in the policy schedule that “The Insurance under the policy was subject to conditions, clauses, warranties, exclusions etc. are attached”. The insured patient Ms. Purnima Jha was admitted in the Fortis Hospitals Limited- Faridabad on 07.06.2018 for the treatment of Focal Seizure and the hospital had raised a pre authorization request for availing cashless facility for the treatment of the treatment of Focal seizure the same was reviewed and observed that:
- As per the OPD assessment form dated 23.12.2017, the insured was a follow up case of seizure disorder, single seizure since 2015 April.
- As per the discharge summary dated 06.04.2015 of Escorts Fortis Hospital and Research Centre, Neelam Bata Road, Faridabad, the patient is a diagnosed with seizure disorder (presented with focal onset seizure with secondary generalization) – Multiple seizure and cause neurocysticercosis.
- From the above findings, it was known case of Neurocystiercosis since 2015 and insured patient was suffering this medical complication prior to policy port which was not disclosed by the complainant at the time of porting of the policy thus the claim was rejected vide letter dated 08.06.2018. hence, the cashless authorization was rejected as per condition N. 6 of the policy and the same was communicated to the insured vide letter dated 08.06.2018. During the scrutiny of the above claim papers, observe that the complainant had not declared the details; Neurocystiercosis (relating to Ms. Purnima Jha) which were found to be pre existing at the time taking the policy for the first time during 30.03.2017 to 29.03.2018 this amounts to non disclosure of material facts which was condition No.12 in the policy. Hence, it was a pre-existing disease the present admission and treatment of the insured patient was for the pre-existing disease and its related complications. Opposite parties Nos. 1 & 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Case called several times since morning but none appeared on behalf of opposite party No..3. No more wait was justified. Hence, opposite party No.3 was hereby proceeded against ex-parte vide order dated 01.09.2021.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties– M/s. Star Health and Allied Insurance Company Limited with the prayer to: a) pay an amount of Rs. 58,843/- alongwith interest @ 18% p.a. from the date of its due till its realization. b) pay Rs. 50,000/- as compensation for causing mental agony and harassment. c) pay Rs. 11,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Raj Narayan Jha, Ex.C1 – Family Medicare Policy, Ex.C2 - Certificate for the purpose of deduction under section 80, Ex.C-3 – Family Medicare Policy valid from 30.03.2014 to 29.03.2015, Ex.C-4 – Family Medicare Policy 2014 valid from 30.03.2015 to 29.03.2016, Ex.C5 – Family Medicare Policy valid from 30.03.2016 to 29.03.2017, Ex.C-6 – Family Health Optima Insurance Plan valid from 30.03.2017 to 29.03.2018, Ex.C-7 – Family Health Optima Insurance Plan valid from 30.03.2018 to 2903.2019,, Ex.C-8 – Discharge summary, ,Ex.C-9 – Inpatient record,, Ex.C-10 – MRI Brain with contrast,, Ex.C-11 – EEG Report, Ex.C-12 – Discharge summary from Fortis escorts,, Ex.C-14 – Inpatient bill, Ex.C-15 to C-17 – bills, Ex. C-18 – Rejection of Pre-Authorization for cashless treatment,, Ex, C-19 – legal notice,, Ex.C-20 to C-25 – postal receipts, Ex.C-26 – Adhaar card,
On the other hand counsel for the opposite parties strongly agitated
and opposed. As per the evidence of the opposite parties Ex.CW1/A – affidavit of Sh. Sumit Kumar Sharma, senior Manager of M/s. Star Health and Allied Insurance Co. Ltd., First floor Himalaya House 23, Kasturba Gandhi Marg, New Delhi, Ex.R-1 – terms and conditions,, Ex.R-2 – Family Health Optima Insurance Plan, valid from 30.03.2017 to 29.3.2018,, Ex.R-3 –Portability Form,, Ex.R-4 – Proposal form,, Ex.R-5 – notification, Ex.R-6 – letter dated 18.06.2018 regarding Non Disclosure of pre-existing disease,, Ex.R-7 – Endorsement schedule,, Ex.R-8 – Pre Authorization Request Form, Ex.R-9 – Star Medical Officer FVR (Pan India) – Revised, Ex.R-10 – Query on pre authorization, Ex.R-11 – prescription, Ex.R-12 – OPD Assessment form, Ex.R-13 – Discharge of request, Ex,.R-14 – letter regarding Query on pre authorizations,, Ex.R-15 – letter dated 08.06.2018 Rejection of pre-authorization for cashless treatment,.
7. In this case, the complainant obtained a mediclaim policy from United India Insurance Company Limited and remained continue since 30.03.2010 worth Rs.5,00,000/-. Later on, the opposite party No.3 agent allured the complainant to get transferred/port the abovesaid mediclaim policy in the opposite party NO.1 Insurance company, by saying that they would give more benefits than the above said insurance company.. The daughter of the complainant namely Km. Purnima Jha became seriously ill on 04.05.2015, as she was suffering from Seizure Disorder, hence at that time said Km. Purnima Jha got admitted in Asian Institute of Medical Sciences, Sector-21A, Faridabad, on 04.05.2015 and remained admitted as indoor patient in the said hospital upto 07.05.2015. During that the complainant informed the opposite parties immediately about the ailment of his daughter and at that time there was no any objection from any side. As per Annexure C-1, the above said mediclaim policy was transferred/ported in the opposite party No.1 insurance company for an amount of Rs.5,00,000/- (which includes the insurance of the complainant, his wife Mrs. Shobha Jha and his two children namely Varun Jha and Km. Purnima Jha) on 30.03.2017, bearing policy NO. P161116/01/2017/006868. It is evident from Ex.C2 to C4, the above named daughter of the complainant again became sick on 07.06.2018 hence she was taken to Fortis Escorts Hospital, Neelam Bata Road, NIT, Faridabad, on the same day, then after due medically check up there was same problem, as she was suffering from Left Parietalparasagittal Calcified Neurocystricercosis with Recurrent Break through Right Focal Sensory Seizures and she got admitted as an indoor patient in the above said hospital on 07.06.2018 and remained upto 09.06.2018 and at that time the complainant spent a total amount of Rs.58,843/-. Opposite party has repudiated the claim of the complainant vide letter dated 08.06.2018 on the ground that “As per submitted documents patient was a known case of Neurocystiercosis since 2015. 4.6 which was prior to policy port in star and not disclosed at the time of port hence claim rejected as non disclosure of material facts.
8. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant as per the T&C of the policy within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 19.12.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
