Delhi

West Delhi

CC/16/122

Kapil Arora - Complainant(s)

Versus

Star Health alliet Insurance - Opp.Party(s)

16 May 2019

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (WEST)

       150-151; COMMUNINTY CENTER ; C-BLOCK; JANAK PURI; NEW DELHI

 

CASE NO. 122/2016

 

Kapil Arora

S/o Shri Hansraj Arora

R/o A-4, 2^nd Floor,

Shivaji Vihar, Rajouri Garden,

New Delhi-110027                                                           ..…. Complainant

VERSUS

Star Health & Allied

Insurance  Co. Ltd.,

Through its Manager/Principle Officer

Office at :-

C-8, Third Floor, New Krishna Pak,

Janak Puri West Near

JanakPuri West Metro Station

NewDelhi-18

 

Also At:-

 

1^st Floor, Himalaya House

23 Kasturba Gandhi Marg,

New Delhi—1

 

Also At:-

 

KRM Center, Plot No. 2,

4^th Floor, Harrington Road, Chetpet,

Chennai-600031                                                             …..Opposite Party

 

 

O R D E R

 

K.S. MOHI, PRESIDENT

 

The complainant has filed the present complaint against the O.P under section 12 of Consumer Protection Act, 1986.  The Complainant had taken  Mediclaim Insurance Policy namely “FAMILY HEALTH OPTIMA INSURANCE POLICY”   from OP valid  for the period  from 13.01.2015 to 12.01.2015   having policy No.  P/161118/01/2015/008977, in the self name alongwith  his wife  Ms Kanika Arora  and  his son Master Kartik  Arora.  The son  of complainant was born on 20.03.2012 and his name  was added in the aforesaid policy.  When Master  Kartik was barely 13 months suffered from fever and loose motion  for which he was take to  Sir Ganga Ram Hospital on 10.04.2013  and was  discharged  on 13.04.2013  when nothing abnormal was found  by doctors. The complainant spent Rs. 37,031 and the respondent settled the said amount.  It has been further   averred in the complint that in the first week  of July, 2013when Master Kartik  visited Sir Ganga Ram Hospital in OPD,  Doctor doubted little murmur  sound and verbally advised for  next visit  after 6 months. Master Kartik visited Fortis  Escorts Hospital on 24.12.2013 where Dr. asked him to go for  routine check-up.  Again on 16.03.2015 when complainant went to Escorts Hospital  for routine check-up  of Master Kartik  doctor advised for hear surgery of Master Kartik and was admitted in the hospital on 20.07.2015. The hospital raised the bill of Rs. 3,07,777/-.  The complainant filed claim for reimbursement  of the aforesaid expenses which was rejected by OP vide letter dated 28.07.2015 on false ground .  Hence the present case for total  sum of Rs. 4,57,777/- with interest.

2.     OP filed statement taking preliminary objection that the complainant  inter-alia that complainant suppressed the material  information while obtaining  the insurance policy from OP  by not disclosing actual  affairs in-respect of her health thus breached the contract and lost its entitlement under the policy.   The complainant obtained policy in 2011 which was renewed for the year 2015-2016 wherein complainant clearly answered “No”  to every sort of  previous medical  history.   Accordingly, the insurance cover was granted to the complainant for an enhanced sum of                 Rs. 4,00,000/-.  It is further stated that on receipt of the pre authorized request from the treating hospital  alongwith the OPD card and other documents it was observed that  as per discharge summary the insured obtained wasa case of cardiac murmur detected  at the age of  6 months from the year 2012  prior  to policy inception and this way fact was not disclosed in the policy and amounted suppression of material fact.  The case of the complainant was got examined by OP from Doctor who opined  that insured has history of medical  condition named above  and previous Discharge Summaries  dated 26.12.2013, 07.07.2014 and  16.03.2015 revealed that the insured  patient had history of Restrictive peri membranous Ventricular Septal defect which was not mentioned  in the Proposal Form.  The insured has per medical record was shown to :-

17.09.2012	Dr. Majumdar
25.03.2013	Dr. Neeraj  Aggarwal
10.04.2013	Emergency  admission from 10.04.2013 to 13.04.2013
16.04.2013	Dr. Neeraj Aggarwal
29.11.2013	Dr. Neeraj Aggarwal
15.04.2015	Dr. Neeraj Aggarwal

 

It has been further stated by OP that condition No. 3.0 related to excluded Exclusion which excluded re-existing disease until 48 months of continuous  coverage have elapsed. Since it was a case of pre-existing disease which amounted the suppression of material facts so was hit by exclusion clause of the policy .  The complaint deserves to be dismissed.

3.     Complainant has filed his affidavit affirming the facts alleged in the complaint. He has mentioned documents Ex.CW-1/A to Ex CW-1/I. He has also filed rejoinder.  On the other hand Sh. P.C. Tripathy, Vice President of Star Health  & Allied Insurance  Co.  Ltd. has filed affidavit in evidence testifying all the facts as stated in the written statement.  Parties have also filed their respective written submissions.

4.     We have gone through the record of the case as well as written submissions filed by both the parties.

5.     Controversy involved in the present case is as to whether the complainant is entitled  to claim or not.  The only ground  taken by the  OP  for rejection of the claim is that  complainant  concealed the pre existing  disease  also gave wrong information in the proposal form, therefore, as per  Exclusion  Clause the claim was not payable .  Needless to say that pre- existing disease is one for which the insured  had taken  medical treatment  or was admitted in the hospital soon before inception of the policy. In the instant case the complainant has been regularly taking the mediclaim policies of the respondent probably since the year 2011 and the name of the patient i.e. son of the complainant, was included  in the policy in the  year 2013.  It needs to be  mentioned here that patient  was  admitted by Ganga Ram Hospital in April 2013 and hospital raised medical bill of  Rs. 37,031/-  which was paid by complainant vide claim No.  CLI/2014/16118/0006104 in respect of policy No. P/16/1118/01/2013/00006560.  This  fact  has been  categorically  admitted by OP in the written statement which explicitly  demonstrates  that the OP was very much aware of the disease being suffered by patient and that OP did not make efforts to get the patient medically  examined from the doctors of the OP  before further  admitting him to the medical claim policy.  The  OP  can not be permitted to play hot and cold meaning  hereby the OP did not  get the  patient  medically examined before issuing policy  and  when justified claim  was filed, OP  took up the plea of  pre existing disease.  OP did not  file  the  affidavit  of the concerned doctor who treated patient.   The  National  Commission  in case titled  Tarlok Chand  Khanna  Vs United India Insurance Company  Ltd.  Revision Petition No. 686 of 2007 decided on 16.08.2011  held:-

“That the onus to prove that patient had pre existing  disease was on the Respondent  leading  cogent evident. It also held  that  most of the people are totally unaware of the symptoms  of the disease that  they suffered  and hence they can not  made to  liable to suffer because the Insurance Company relies on their  clause  4.1  of the policy in a mala fide manner to repudiate all the claims.“    

 

7.     Keeping in view  the aforesaid  discussion we are of the view that the rejection of claim was unjustified and a uncalled , therefore, it amounted to deficiency in service.

8.     In view of the observation  stated above we pass an award in the sum of Rs. 3,07,777/-  in favour of  complainant to be paid by OP  within 45 days from receipt of this order failing which  interest @ 6% from the date of institution  of complaint till realization shall be levied.  We also award a sum of Rs. 10,000/- towards mental agony, harassment  and litigation expenses.

 Copy of this order be sent to the parties as per rules.

File be consigned to the record room. 

Announced this___16TH___ day of    May_ ___ 2019.

 

 

 ( K.S. MOHI )                                                  (PUNEET LAMBA)                      PRESIDENT                                                              MEMBER