Chandigarh

DF-I

CC/328/2016

Paramvir Singh - Complainant(s)

Versus

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

Ashwani Talwar

19 Dec 2016

ORDER

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

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

Consumer Complaint  No	:	328 of 2016
Date  of  Institution	:	11.5.2016
Date   of   Decision	:	19.12.2016

 

 

 

 

 

Paramvir Singh s/o Sh. Hardiljit Singh resident of House No.975, Sector 7, Panchkula, Haryana 134109.

….Complainant

Vs.

 

M/s Star Health & Allied Insurance Company Ltd. Branch office, Chandigarh SCO 130-131 4^th floor, Sector 34-A, Chandigarh through its Branch Manager.

 

…… Opposite Party 

 

BEFORE:  

 

MRS.SURJEET KAUR                  PRESIDING MEMBER

SH. SURESH KUMAR SARDANA          MEMBER

 

 

For Complainant	:	Aftab Singh, adv.
For OP	:	Sh. Gaurav Bhardwaj, Adv.

 

PER SURJEET KAUR, PRESIDING MEMBER

 

 

 

                The facts, in brief, are that the complainant purchased mediclaim insurance policy for himself and his family i.e. his wife and daughter from the OP by paying a premium of Rs.20,730/- for the policy amount of Rs.7.50 lacs for the period from 21.5.2014 to 20.5.2015.  It is pleaded that for the first time in his life on 3.8.2014 the complainant suffered pain and pressure in chest and accordingly he got his echo cardiagraphy test done  and it was revealed that everything was not all right. Therefore, on 23.8.2014 he got himself admitted in the Medanta Hospital wherein the procedure of aortic valve replacement was done on 25.8.2014 and the complainant was discharged on 3.9.2014.  It is further pleaded that the complainant upon admission in the hospital informed the OP regarding his hospitalization and sought the cashless facility and the requisite pre-authorisation request was sent through hospital. However, the OP vide Annexure C-13 denied the said facility.  Thereafter the complaiannt vide letter dated 26.9.2014 submittd the claim for Rs.4,02,208/- and attached all the bills.  But the the OP unlawfully repudiated the claim of the complainant vide Annexure C-22 on the ground that the disease is existing prior to inception of the policy.  Thereafter the complainant made various communications with the OP but to no effect.  The complainant approached the Insurance Ombudsman, which only awarded Rs.2.00 lacs to the complainant to which the complainant is not satisfied. Feeling aggrieved with the repudiation of his claim the complainant has filed the instant complaint seeking various reliefs.  

2.      Notice of the complaint was sent to Opposite  Party seeking its version of the case.
3.           The OP filed its written statement stating therein that  the contract of insurance is based on principles of uberrima fide’ i.e. utmost good faith. The contract is based on information provided by one party to the contract i.e. proposer/insured. Based on the information provided by the insured, the insurance company accepts or rejects the proposal.  It is averred that it is the duty of the proposer to disclose all the material facts to the insurer so that the insurer evaluates the materials fact and decide to accept or reject the proposal.  It is further averred that health details are to be disclosed as the cotract is regarding the health insurance only.  But in the instant case the complainant suppressed the material fact with regard to his health and has not disclosed the disease suffered by him and the diagnosis/treatment taken by him prior to the taking of the policy.  It is averred that  on extensive examination by the OP  it was found that the complainant was symptomatic of stable angina, difficulty in breathing and chronic and long standing calcified aortic valve disease. The complainant was having knowledge about the same on 10.4.2014 that he is having severe left ventricular hypertrophy, yet he did not disclose the same in the proposal form, which was given on 20.5.2014.  As such the complainant was suffering from pre-existing disease at the time of inceiption of policy.  Thus OP repudiated the claim of the complainant after due application of mind and as per terms and conditions of the policy. The remaining allegations were denied, being false. Pleading that there is no deficiency in service on its part, a prayer for dismissal of the complaint has been made.

4.     The complainant has filed a rejoinder, wherein he has reiterated all the averments, contained in the complaint, and repudiated those, contained in the written version of Opposite Parties.

 

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 have perused the record carefully.

 

7.     Learned counsel for the complainant contended  that  the complainant availed health insurance policy valid from 21.5.2014 to 20.5.2015 from OP after undergoing through required formalities as required by the OP. It has further been contended that as per the proposal form the complainant was not suffering from any ailment and was completely fit and got the insurance under the policy in dispute. It has been urged that unfortunately the complainant during the currency of the above insurance policy was diagnosed with some ailment under which the aortic valve was declared as thickened calcified and having restricted opening. Therefore, the complainant got echo done and found that he was suffering from some cardio disease and therefore, undergone the aortic valve replacement.

 

8.     The main grouse of the complainant is that  despite widely covered under the above policy the OP refused  for cashless treatment and also declined the reimbursement of claim raised.  Challenging the rejection by the OP being illegal and arbitrary the complainant filed the complaint before the Insurance Ombudsman  and vide award Annexure 27  he was granted relief of Rs. 2.00 lacs but being unsatisfied with the partial settlement of the claim the complainant preferred to file the present complaint.

 

9.     On the contrary, the learned counsel for the OP submitted that it rightly rejected the claim of the complainant only after thorough examination of the documents and the terms and conditions of the policy. It has been submitted that from the medical record of the complainant it is revealed that he was medical history of his disease which he concealed and did not disclose against the column mentioned in the proposal form mandating true disclosure of his health status. It has further been averred that insurance contract is a contract based on good faith and the principle of oberrima fide. The complainant was duty bound to disclose all correct facts about his health at the time of proposal but he failed to do so.

 

10.     It is pertinent to note that as per
Annexure C-27 the copy of award of the Insurance Ombudsman it is clearly mentioned  at page 140  of the paper-book that under the column 21 captioned as Result of hearing with both parties (observation and conclusion)   it is specifically mentioned that “there was no adverse medical report to show that the patient was suffering from any disease as all his test reports are found to be okay.” In this report only it is specifically mentioned that there is no adverse finding suggesting that insured was aware of any disease. In this view of the matter, we are of the opinion that the present award in favour of the complainant by the Ombudsman points out that certainly he did not conceal any fact about his ailment.  Therefore, the award of the Insurance Ombudsman cannot be ignored and it cannot be believed from mere oral assertion of the OP that the complainant was suffering from certain pre-existing disease.  It is also noteworthy that anyone can develop illness at any stage of life. So far as the question of date mentioned over the report of ECG as 10.4.2014 is concerned it is actually 4.10.2014 as per American system of date which is  normally used. This fact is corroborated by perusal of Annexure C-31 where the date mentioned is 8.20.2014 and not 20.8.2014. Even this fact does not prove that complainant concealed any fact at the time of purchase of policy.

 

11.     At the outset, it is right to said that denial of the claim by the OP is not genuine for the reason that the record reveals that before issuing the policy in question OP must follow the procedure of medical test or medical examination and only after declaring the consumer who comes to avail policy, medically fit it should issue the policy.  The claim of the OP is that the complainant was having previous history of ailment is totally baseless without any cogent evidence.  In our opinion once there is no mention of any history of disease in the proposal form, which is the document of OP itself then there is no question of concealment of pr-existing disease by the complainant. It is the duty of the OP not to rely only upon the disclosure made by the complainant but to enquire the truthfulness of the disclosure made by the complainant in the proposal form but also to conduct medical test of the complainant prior to issuance of the policy. Thus in our considered opinion the OP has wrongly repudiated the rightfull claim of the complainant without any cogent reason and justification. Hence there is deficiency on its part.   

12.     In the light of above observations, we are of the concerted view that the Opposite Party is found deficient in giving proper service to the complainant and having indulged in unfair trade practice by repudiating his genuine claim. Hence, the present complaint of the Complainant deserves to succeed against the Opposite  Party, and the same is allowed, qua them. The Opposite is directed  to:-

 

a)      To pay an amount   Rs.3,70,611.89

     to   the complainant towards his claim as per bill generated by the   hospital.

 

b)      To make payment of Rs.15,000/- to the complainant towards compensation for     causing mental and physical      harassment.

 

c)      To make payment of Rs.7,000/- to the complainant as litigation expenses.

 

 

13.     The above said order be complied with by the Opposite Party, within 30 days from the date of receipt of its certified copy, failing which the amounts at Sr. No.[a] shall carry interest @12% p.a. from the date of claim till  realization & [b] shall carry interest @12% per annum from the date of filing of the present Complaint, till actual payment, besides payment of litigation costs.

 

14.     The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

19.12.2016                         

Sd/-

 (SURJEET KAUR)

PRESIDING MEMBER

 

Sd/-

 (SURESH KUMAR SARDANA)

MEMBER