Haryana

StateCommission

A/362/2020

STAR HEALTH AND ALLIED INSURANCE CO. LTD. AND ANOTHER - Complainant(s)

Versus

PARVEEN KUMAR AND ANOTHER - Opp.Party(s)

MOHAN LAL SINGHI

28 Sep 2020

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                                                 

                                                                  First Appeal No.362 of 2020                                                  Date of Institution:18.09.2020                                                              Date of Decision: 28.09.2020

 

1.      Star Health and Allied Insurance Co. Ltd., First Floor on ICICI Bank Ltd, Ferozepur Branch Office, Through Its Branch Manager.

2.      Star Health and Allied Insurance Co. Ltd., KRM Centre, VI Floor No. 2, Harrington Road, Chetpet, Chennai, 600034 Through Its Managing Director/General Manager.

…..Appellants

Versus

1.      Parveen Kumar S/o Late Smt. Om Pati Wife of Moti Ram, Resident of Shop-cum-House No. 76, Anaj Mandi Pehowa, District Kurukshetra.

2.      Amit Kumar Agent Code No. BA0000 170265 of Star Health and Allied Insurance Company Limited, Resident of Near Tiba Farm, Opposite Tagore Public School, Kurukshetra Road, Pehowa, District Kurukshetra.

                    …..Respondents

CORAM:   Hon’ble Mr. Justice T.P.S Mann, President.

                    Mr. Harnam Singh Thakur, Judicial Member.

         

 

Present:-    Shri Nitesh Singhi, counsel for the appellants.

O R D E R

HARNAM SINGH THAKUR, JUDICIAL MEMBER:

          Star Health and Allied Insurance Company Limited, Branch office Ferozepur and Star Health and Allied Insurance Company Limited, Harrington Road, Chetpet, Chennai, (hereinafter referred to as ‘opposite parties’) have filed the instant appeal under section 41 of the Consumer Protection Act, 1986 for challenging the order dated 21.01.2020 passed by learned District Consumer Disputes Redressal Forum, Kurukshetra whereby complaint preferred by Parveen Kumar (hereinafter referred to as ‘Complainant’) was allowed against the opposite parties No. 2 and 3 and directed them in the following manner:-

1. To revive the policy in question after deducting the amount of Rs. 20,520/- from the awarded amount.
2. To pay the amount of Rs. 3,92,792/- (Rs.4,13,312/- - 20,520/-) alongwith interest @ 6% per annum w.e.f. 03.08.2016 i.e. the date of the filing the present case, till its realization to the complainant.
3. To pay Rs. 10,000/- as compensation for mental agony and physical harassment suffered by the complainant.
4. To pay Rs. 5,000/- as litigation expenses.
5. The opposite parties No. 2 & 3 are further directed to comply with the aforesaid directions within the period of 30 days from the date of preparation of certified copy of this order, failing which, the complainant will be at liberty to initiate proceedings under Section 25/27 of the Act against the OPs.

 

2.      The brief facts of the case are that in the year 2013, complainant was issued a Senior Citizen Red Carpet Insurance policy  bearing No. P/211114/1/2014/000979 in the name of his mother namely Om Pati for the period from 24.10.2013 till 23.10.2014 for a sum of Rs. Five lakhs. The opposite parties received full and final premium of Rs. 20,225/- including all taxes and the policy is being renewed year by year. On 02.02.2016, his mother became ill and admitted at Amrit Dhara Hospital Pvt. Ltd., Karnal where she remained under treatment upto 07.02.2016. Thereafter, she admitted for treatment in Medanta-The Medicity Global Health Pvt. Ltd., Gurgaon and remained there as indoor patient upto 16.02.2016. On 16.02.2016, she was treated at Saraswati Mission Hospital, Pehowa and died on 18.02.2016. Complainant has spent a sum of Rs. 10,00,000/- on treatment of his mother. He lodged the medical claim of his mother without any delay from the opposite parties, but the O.Ps. have rejected the medical claim of his mother due to non-disclosure of material fact. Thus, there was deficiency in service on the part of the O.Ps.

3.      O.Ps. filed reply controverting his averments.  Opposite parties stated that insured admitted in Amritdhara Hospital, Karnal on 03.02.2016 for the treatment of coronary artery disease, acute coronary syndrome and was discharged on 07.02.2016. As per discharge summary, insured was diagnosed as hypertension, diabetes mellitus, old coronary artery disease. Opposite parties further stated that the insured was admitted in Medanta Hospital on 07.02.2016 for treatment and as per discharge summary for the period of hospitalization from 19.06.2013 to 20.06.2013, the insured is a known case of diabetes mellitus, parkinsonism and left PUJ obstruction, who underwent robotic pyeloplasty on 17.05.2013, which is prior to inception of the medical insurance policy. Further stated that, at the time of inception of the policy, the insured has not disclosed the above-mentioned medical history/health details of insured person in the proposal form. Other averments etc. also were denied and requested to dismiss the complaint.

4.      After hearing both the parties, District Consumer Disputes Redressal Forum, Kurukshetra (In short “District Forum”) allowed the complaint and relief mentioned in Para No. 1 of the order.

 5.     Feeling aggrieved therefrom, Opposite parties No. 2 & 3 have preferred this appeal.

6.      There is delay of 192 days in filing the present appeal. Although, there is no reasonable cause to explain the delay of 192 days in filing and re-filing the present appeal, yet, in the interest of justice, delay in filing the appeal is condoned.

 7.     Arguments have been advanced by Sh. Nitesh Singhi, the learned counsel for the appellant. With his kind assistance the entire records as well as the original record of the Appellate file including whatever the evidence has been led on behalf of the parties had also been properly perused and examined.

8.      During the course of arguments, it is contended by learned counsel for appellants/opposite parties that learned District Forum has not appreciated the facts and legal position while passing the impugned order. It has also not appreciated that complainant/respondent No. 1 has not complied with the terms and conditions of the insurance policy. Past medical history shows that complainant’s mother was suffering from Type II diabetes mellitus, parkinsonism, left DJ stenting, Left pyleoplasty and this fact was concealed by complainant while filling up the application for issuance of insurance policy. Thus, appellants were justified while repudiating the claim of complainant. Hence, it is submitted by learned counsel for appellants that impugned order passed by learned District Forum be set aside by accepting the appeal.

9.      Having heard the learned counsel for appellants and careful perusal of the learned District Forum record, we are of the considered view that the appeal is devoid of merits. It is pertinent to mention that the impugned policy was termed as “Red Carpet Insurance Policy for Senior Citizens” and admittedly the complainant’s mother was around 70 years of age at the time of taking the said policy. It is also worthwhile to note that special premium of the policy for senior citizen was taken by the appellants/insurance company. It is a fact of common knowledge that senior citizens particularly near to age of 70 years are prone to diseases like diabetes mellitus, parkinsonism etc. as in the case in hand. Thus, before issuing insurance policy, it was incumbent upon the agent of the insurance company that before accepting the premium such senior citizen should have been medically examined as per IRDAI guidelines. Learned District Forum has rightly relied upon the case of Manish Goyal Vs. Max Bupa Health Insurance Co. Ltd. and Others 2018 (2) CLT, 205 that “ If the opposite parties themselves, failed to adhere the instructions issued by Insurance Regulatory and Development Authority of India (IRDAI), by putting the insured to through medical examination, being her age more than 45 years, and were interested in collecting premium from the complainant, as such, now at this stage, they cannot evade their liability.”

10.    In these circumstances, it becomes immaterial whether such pre existing disease was disclosed or not by the senior citizen/complainant’s mother at the time of taking the policy and acceptance of special premium by the insurance company/appellants. Thus, appellants are estopped by their own act and conduct from repudiating the claim of complainant’s mother being a senior citizen. Hence, it can be safely concluded that appellants were not justified while declining and repudiating the claim of complainant.

11     As a sequel of above discussion, we do not find any illegality or perversity in the impugned order passed by the learned District Forum. The appeal is dismissed in limine being bereft of merits.        

 

28th  September, 2020      Harnam Singh Thakur                  T.P. S. Mann

                                                Judicial Member                             President

 

M.K