BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.369 of 2015
Date of Instt. 26.08.2015
Date of Decision : 04.08.2016
Vippen Sethi aged about 60 years son of Sudarshan Sethi R/0 H.No.288, Guru Teg Bahadur Nagar, Jalandhar.
..........Complainant
Versus
1.M/s Star Health & Allied Insurance Co.Ltd., Regd.& Corporate Office:-1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai, through its MD/Chairman.
2.M/s Star Health & Allied Insurance Co.Ltd., EH 198, 2nd Floor, Nirmal Complex, GT Road, Jalandhar (PB), through its Branch Manager.
.........Opposite parties
Complaint Under the Consumer Protection Act.
Before: S. Bhupinder Singh (President)
Sh.Parminder Sharma (Member)
Present: Sh.RK Bhalla Adv., counsel for the complainant.
Sh.AK Arora & Sh.Nitish Arora Advts, counsels for the Ops.
Order
Bhupinder Singh (President)
1. The complainant has filed the present complaint under the Consumer Protection Act against the opposite parties (hereinafter called as OPs) on the averments that complainant purchased one star health insurance policy named as Senior Citizen Red Carpet Insurance Policy bearing No.P/161125/01/2015/003102 valid from 27.3.2015 to 26.3.2016 for a sum of Rs.2 Lakhs from OPs. During the validity of the said policy, the complainant suffered with chest pain and was admitted in Global Hospital, Jalandhar on 23.5.2015 and was diagnosed as CAD, Inferior Wall, MI, Hypothyroidism/BR Asthama. The complainant was medically treated there and was discharged on 26.5.2015 and during this period, complainant had to pay Rs.2,15,000/- as hospital expenses, Rs.8554/- for medicine and Rs.4250/- as lab charges. The complainant lodged claim with the OP alongwith all relevant documents but the OPs repudiated the claim of the complainant vide letter dated 11.8.2015 on the ground that complainant has not disclosed that he was a patient of hypertension for the past 8 years and the present coronary artery disease is a sequel of long standing hypertension. Complainant submitted that he was not suffering from any disease of hypertension. He never got any treatment for hypertension before the inception of the policy in question. OPs, therefore, wrongly repudiated the claim of the complainant. On such averments, the complainant has prayed for directing the OPs to pay Rs.2,15,000/- alongwith Rs.11,771/- as claim of the complainant. He has also claimed compensation and litigation expenses.
2. Upon notice, OPs appeared through counsel and filed written reply pleading that complainant has submitted his duly signed proposal form after fully understanding terms and conditions of the policy. In the said proposal form, the complainant has not disclosed that he had been suffering from hypertension for the past 8 years. On the basis of the proposal form, the policy was issued to the complainant. The policy was valid for the period from 27.3.2015 to 26.3.2016. The complainant was admitted in Global Hospital, Jalandhar on 23.5.2015 and was diagnosed as CAD, Inferior Wall, MI, Hypothyroidism/BR Asthama and was discharged on 26.5.2015. The complainant lodged claim with the OP alongwith relevant documents and the history and physical examination form on which it has been mentioned that complainant has past history of hypertension from 8 years and Hypothyroidism. So, OPs submitted that OPs have rightly repudiated the claim of the complainant.
3. In support of his complaint, learned counsel for the complainant has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C21 and closed her evidence.
4. On the other hand, learned counsel for opposite parties has tendered affidavits Ex.OP/A and Ex.OP-B alongwith copies of documents Ex.OP/1 to Ex.OP/12and 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 obtained star health insurance policy named as Senior Citizen Red Carpet Insurance Policy bearing No.P/161125/01/2015/ 003102 for the period 27.3.2015 to 26.3.2016 with a sum assured Rs.2 Lakhs from OPs. Complainant suffered chest pain and was admitted in Global Hospital, Jalandhar on 23.5.2015 and was diagnosed as CAD, Inferior Wall, MI, Hypothyroidism/BR Asthama. The complainant was medically treated there and was discharged on 26.5.2015 and complainant had to pay Rs.2,15,000/- as hospital expenses, Rs.8554/- for medicine and Rs.4250/- as lab charges. The complainant lodged claim with the OP alongwith all relevant documents but the OPs repudiated the claim of the complainant vide letter dated 11.8.2015 on the ground that complainant has not disclosed that he was a patient of hypertension for the past 8 years and the present coronary artery disease is a sequel of long standing hypertension. Complainant submitted that he was not suffering from any disease of hypertension. He never got any treatment for hypertension before the inception of the policy in question. OPs, therefore, wrongly repudiated the claim of the complainant. Learned counsel for the complainant submitted that all this amounts to deficiency of service on the part of the OPs qua the complainant.
7. Whereas the case of the OPs is that complainant has submitted his duly signed proposal form after fully understanding terms and conditions of the policy. In the said proposal form Ex.OP4, the complainant has not disclosed that he had been suffering from hypertension for the past 8 years. On the basis of the said proposal form Ex.OP4, the OP issued policy Ex.OP3 with schedule of the policy Ex.OP1 with a sum assured Rs.2 Lakhs, the policy for the period from 27.3.2015 to 26.3.2016. The complainant was admitted in Global Hospital, Jalandhar on 23.5.2015 and was diagnosed as CAD, Inferior Wall, MI, Hypothyroidism/BR Asthama and was discharged on 26.5.2015. The complainant lodged claim with the OP alongwith relevant documents and the history and physical examination form Ex.OP8 on which it has been mentioned that complainant has past history of hypertension for the last 8 years and Hypothyroidism. OPs also obtained certificate from Global Hospital Ex.C5 which shows that the complainant has history of hypertension for the last 8 years and the complainant has not disclosed this fact in his proposal form Ex.OP4 before obtaining the policy in question from the OPs. The present coronary artery disease as a sequel of long standing hypertension and the insured/patient has this disease prior to inception of the policy. So, learned counsel for the OPs submitted that OPs have rightly repudiated the claim of the complainant. As such, there is no deficiency in service on the part of the OPs qua the complainant.
8. From the entire above discussion, we have come to the conclusion that complainant obtained star health insurance policy named as Senior Citizen Red Carpet Insurance Policy bearing No.P/161125/01/2015/003102 Ex.OP1 from the OPs for the period from 27.3.2015 to 26.3.2016 with sum assured Rs.2 Lakhs. Complainant suffered chest pain and was admitted in Global Hospital, Jalandhar on 23.5.2015. He was diagnosed as case of CAD, Inferior Wall, MI, Hypothyroidism/BR Asthama as per certificate of Global Hospital, Jalandhar Ex.OP5 and as per treatment record of the complainant Ex.OP6 to Ex.OP9. Complainant was medically treated in that hospital and was discharged on 26.5.2015 and during this period, the complainant paid Rs.2,15,000/- as hospital expenses as per bill Ex.C6, apart from expenses on medicines and lab test charges. The photocopies of the bills are Ex.C7 to Ex.C19. Complainant lodged claim with the OPs alongwith all the relevant documents. OPs repudiated the claim of the complainant vide letter Ex.C1 on the ground that as per the history of the patient recorded by Global Hospital, Jalandhar on 23.5.2015 Ex.OP8, the patient (complainant) was known case of HTN for 8 years but the complainant has not disclosed these facts in this proposal form Ex.OP4 to obtain the policy in question from the OPs. The OPs relying upon this past history of the patient/ complainant written by the doctor at the time of admission of the complainant in the Global Hospital, on 23.5.2015 that the history of the complainant was K/C/O HTN from 8 years repudiated the claim of the complainant. But the OP neither examined the said doctor of Global Hospital who recorded the past history of the complainant/patient nor this document Ex.OP8 shows as to who told the concerned doctor the past history of the patient/ complainant because patient/complainant was admitted in the hospital in serious condition having heart ailment; nor the OP could produce any previous medical record of the complainant in the form of certificate of the doctor or medical prescription slip to prove that before taking the policy the patient/complainant was suffering from hypertension and was taking the medicines/treatment for the same nor the OP filed any certificate or affidavit of the doctor or medical officer/medical practitioner to prove that he treated the complainant for disease hypertension for the last 8 years. It has been held by Hon'ble Rajasthan State Commission in case Life Insurance Corporation of India and Anr Vs Sampati Devi 2006(3) CPJ 32 that diseases hypertension and vertigo can not be treated as diseases in the same manner as the diseases such as kidney, heart and brain, which directly affect the life span of a person. Hypertension and vertigo are not permanent diseases and they sometimes increase and sometimes they reduce and a person suffering from these diseases can survive for a longer period. So, non disclosure of such diseases does not amount to suppression of material fact or misstatement in real sense. Therefore, the appellants were not justified in repudiating the claim of the respondent/ complainant on the ground of suppression of material fact.
9. It has been held by Hon'ble Uttarakhand State Commission in case Life Insurance Corporation of India Vs. Bina Joshi 2010 (1) CPJ 77 that “past history of policy holder can not be made basis for repudiation of claim, in the absence of affidavit of the certifying doctor”. The same view has been taken by Hon'ble HP State Commission in case LIC Vs. Amar Chand 2009 (1) CPR 427.
10. Learned counsel for the OPs submitted that the Hon'ble National Commission in case Diwan Surender Lal Vs. Oriental Insurance Co.Ltd & Anr 2009(1) CPJ 117 has held that “where medical history given by complainant himself to treating doctor, not denied. The insurer has rightly repudiated the medical claim”. We have gone through this judgment of the Hon'ble National Commission; in that case, the complainant himself told his medical history to the treating doctor and he did not deny the same. However, in the present case, the OP has failed to produce and prove any evidence on record as to who stated the past history of the complainant/insured to the doctor at the time of his admission in Global Hospital, Jalandhar on 23.5.2015. Whereas, the complainant has specifically denied this fact that he has any knowledge that he was suffering from hypertension before his admission in the Global Hospital or prior to the inception of the policy in question. Moreover, the OP in that case has also produced the hospital admission record of past illness of the complainant but here in this case no such past medical record of the complainant has been produced by the OP to prove that the complainant was suffering from hypertension prior to the inception of the policy. So the facts of the said case Diwan Surender Lal Vs. Oriental Insurance Co.Ltd. & Anr (Supra) were totally different from the facts of the present case.
11. In view of above discussion, we hold that the OPs have wrongly repudiated the claim of the complainant vide letter dated 11.8.2015 Ex.C1. Consequently, we partly allow the complaint with cost and the OPs are directed to pay the sum insured to the complainant under the policy in question Ex.OP1 i.e. Rs.2 Lakhs (even though the complainant has spent more than the sum insured as is evident from the medical bills produced by complainant), within one month from the date of receipt of copy of order, failing which OPs shall be liable to pay interest @ Rs.9/- % per annum, on this amount Rs.2 Lakhs, from the date of filing of the complaint till the payment is made to the complainant. The OPs are also directed to pay the cost of litigation to the tune of Rs.3000/- to the complainant. Copies of the order be sent to the parties free of cost under rules. File be consigned to the record room.
Dated Parminder Sharma Bhupinder Singh
04.08.2016 Member President
