Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 38.
Instituted on : 22.01.2015.
Decided on : 08.09.2016.
Kesar Dass son of Sh. Gurditta Mal, R/o 917/16, Quilla Mohalla, Rohtak.
………..Complainant.
Vs.
- M/s Star Health and Allied Insurance Company Limited, New Tank Road, Valluvarkottam High Road Nungambakkam, Chetpet, Chennai 600034.
- M/s Star Health and Allied Insurance Company Limited, Branch Office, Rothak, Naraina Complex, 2nd Floor, Near Chhotu Ram Chowk, Rohtak.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.JOGINDER KUMAR JAKHAR, PRESIDENT.
MS. KOMAL KHANNA, MEMBER.
SH. VED PAL, MEMBER.
Present: Sh.K.L.Katyal, Advocate for the complainant.
Sh.R.K.Suhag, Advocate for the opposite parties.
ORDER
SH. JOGINDER KUMAR JAKHAR, PRESIDENT :
1. The present complaint has been filed by the complainant with the averments that complainant got himself insured with M/s Star Health and allied Insurance Company Limited under the Medi Classic Insurance Policy(Individual) vide Policy No.P/211118/01/2014/000091 dated 14.05.2013 for a sum of Rs.200000/-. It is averred that on 17.03.2014 the complainant was got admitted in PGIMS, Rohtak with a complaint of Chest pain and pain in right arm, which he suffered on day earlier on 16.03.2014. For certain unavoidable circumstances, he had to shift from PGIMS, Rohtak to Holy Heart Advanced Cardiac Care and research Centre for his medical treatment on 26.04.2014 for his treatment of the ailment he envisaged and he had spent a sum of Rs.189035/-. After that complainant lodged a claim for payment thereof with the opposite parties but the opposite parties had repudiated the same on the plea of concealment of pre-existing disease. It is averred that at the time of insurance, the complainant was quite right and was not suffering from any disease and hence the question of pre-existing disease does not arise. It is averred that opposite party even renewed the policy of the complainant on 14.05.2014 and had mentioned NIL in the column of ‘pre-existing disease’ whereas the complainant had already intimated the opposite party with regard to his treatment for heart disease under the period of earlier policy in April 2014. Hence the question of mentioning of nil pre-disease does not arise. This is the only reason they rejected the renewed policy on 31.07.2014 and cancelled the same vide letter dated 04.07.2014 and refused the amount of Rs.4028/- by deducting a sum of Rs.1337/- whereas they were liable to refund the whole amount. It is averred that the act of opposite parties is illegal and amounts to deficiency in service. As such it is prayed that opposite parties may kindly be directed to pay a sum of Rs.189035/- with interest, compensation and litigation expenses to the complainant.
2. On notice opposite parties appeared and filed their written reply submitting therein that the claim lodged by the complainant was repudiated by the opposite parties. The claim was rightly and legally repudiated as the insured had a past history and a known case of Coronary artery Disease, Unstable Angina IIBM, Triple Vessel diseases which is proved from the discharge summary dated 26.04.2014. The treating doctor certificate which formed part of claim form stated that the present ailment is the complications of past history. The discharge summary of the previous admission dated 17.03.2014 revealed that the insured is a known case of Ischemic Heart Disease(IHD) since 8-9 years and was hospitalized before 7 years ago. It is averred that the claim of the complainant has rightly been repudiated by the opposite parties as the complainant has intentionally concealed the true facts about his disease. All the other contents of the complaint were stated to be wrong and denied. Opposite parties prayed for dismissal of complaint with costs.
3. Both the parties led evidence in support of their case.
4. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.CW1 to Ex.CW41 and has closed his evidence. On the other hand ld. Counsel for the opposite parties has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.15 and has closed his evidence.
5. We have heard ld. counsel for the parties and have gone through the material aspects of the case carefully.
6. In the present case insurance and treatment taken by the complainant/life assured from Holy Heart Hospital for the period from 26.04.2014 to 01.05.2014 i.e. during the period of insurance is not disputed. After the treatment life assured/complainant filed the claim under the policy with the opposite parties but the opposite parties vide their letter Ex.C34 had repudiated the claim on the ground that from the discharge summary of Pt.B.D.Sharma Post Graduate Institute of Medical Science for the period of hospitalization from 17.03.2014 to 20.03.2014 that the insured patient is a known case of ischemic heart disease for the past 8 to 9 years and was admitted for similar complaints 7 years back at PGIMS which is prior to inception of the medical insurance policy. The present ailment of the insured patient is a complication of the pre-existing cardio vascular disease. Hence the company is not liable to make any payment in respect of any claim. To prove their contention, opposite parties have placed on record copy of discharge card Ex.R1 whereby it is submitted that the patient was admitted to PGIMS 7 years ago for the similar episode.
7. After going through the file and hearing the parties it is observed that the claim of the complainant has been repudiated by the opposite parties on the ground of concealment of pre-existing disease. But to prove their contention, opposite parties have only placed on record copy of discharge card Ex.R1. A thorough perusal of this document shows that the patient was admitted to PGIMS 7 years ago but it is also mentioned therein that “Not on regular treatment, no records available”. In this regard it is observed that the complainant might have been admitted to the PAGIMS 7 years back on account of chest pain but it does not mean that he was suffering from heart disease from that day. Moreover, he was not on regular treatment since that period as no record of medical treatment of life assured prior to taking the policy has been placed on record. Even the medical record of PGIMS is not supported with the affidavit of the doctor who treated the life assured for the alleged disease. It is also observed that the alleged policy is a Medi-Classic Insurance Policy and the life assured might have been medically examined by the opposite party at the time of proposal for the policy and no such disease was detected at that time. Hence in the absence of cogent and convincing evidence, opposite parties have failed to prove the fact that life assured was suffering from heart disease at the time of proposal for the policy. In this regard ld. counsel for the complainant has reliance has been placed upon the law cited in 2016(2)CLT 322 titled as Shanti Devi Vs. Tata AIG Life Insurance Co. Ltd. whereby Hon’ble National Commission, New Delhi has held that “No history given in hospital which lead to the suggestion that the insured was aware about disease-Report of the investigator does not point out any evidence which may lead to the conclusion that at the time of submitting proposal form, the insured was aware that he was suffering from disease-Held-Thus, it cannot be said that the insured obtained the insurance policy by concealing material fact regarding his ailment as a result of hormonal disorder”. It is also observed that the proposal form Ex.R6 placed on record by the opposite parties is merely a photocopy which is not properly visible and it is not proved from it that there were questions regarding the health condition which were not disclosed by the life assured/complainant. Reliance has been placed upon the law cited in 2016(2)CLT357 titled as Mohit Kohli Vs. Aviva Life Insurance Co. Pvt. Ltd. & Anr. whereby Hon’ble National Commission, New Delhi has held that: “Contention of the petitioner that the insurance brochure does not ask for any medical examination prior to the issuance of save Guard Policy and therefore, the Insurance company cannot repudiate on the ground of suppression of material facts regarding health-Held-Plea cannot be sustained as the Proposal Form did have questions regarding the health condition which was not disclosed by the Petitioner/complainant”, as per II(2013)CPJ 60 titled Life Insurance Corporation of India & Anr. Vs. Raj Kumar Sharma it is held that: “Neither inquiry officer was examined nor his affidavit had been tendered into evidence by appellant to prove that LA was suffering from peptic ulcer at the time of filling the proposal form-Evidence of inquiry officer was withheld for unknown reasons-In repudiation letter no name and identity of person is disclosed from whom ‘LA’ had taken treatment and no proof to this effect was produced-Appellant had failed to prove that LA suffering with peptic ulcer and she had deliberately made wrong report/answer to agent at the time of filling proposal form-Repudiation not justified”, as per 2001(3)CLT633 Joginder Kaur & Others Vs. Life Insurance Corporation of India & another Hon’ble Punjab State Commission, Chandigarh has held that: “OP failed to lead direct evidence to prove that the life assured was suffering from any prior ailment or disease-Merely producing copy of hospital record/medical certificate as evidence does not mean that the contents thereof are necessarily true-it would not be acted upon or relied upon unless the writer thereof is subjected to examination and cross examination before the District Forum-The mere fact that the death occurred only after 11 months of taking the Insurance Policy is not a suspicious circumstances to deny the relief to the complainants-Order of District Forum dismissing the complaint set aside”. In view of the aforesaid law which are fully applicable on the facts and circumstances of the case, it is observed that the repudiation of claim by the opposite parties is illegal and unjustified and the complainant is entitled for the claim as per policy. On the other hand law cited by ld. counsel for the opposite parties 2015(4)CLT 379 titled as Bajaj Allianz Vs. Raj Mittal and 1(2015)CPJ 523 (NC) titled as Reena Kansal Vs. United India Insurance Co. are not applicable on the facts and circumstances of the case as in the present case it is not proved that the life assured was suffering from pre-existing disease.
8. In view of the facts and circumstances of the case, it is observed that complainant is entitled for the claim amount as spent by him on his treatment as per bills which are placed on record as Ex.C5, Ex.C6, Ex.C9 to Ex.C12, Ex.C18, Ex.C19, Ex.C26, Ex.C32 and Ex.C33 total amounting to Rs.189035/-. As such opposite parties are directed to pay the amount of Rs.189035/-(Rupees one lac eighty nine thousand and thirty five only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 22.01.2015 till its actual realization and shall also pay a sum of Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant maximum within one month from the date of decision failing which the awarded amount shall carry further interest @ 12% p.a. from the date of decision. Complaint is allowed accordingly.
9. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
08.09.2016.
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Joginder Kumar Jakhar, President
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Komal Khanna, Member.
……………………………………….
Ved Pal, Member.
