Haryana

Kurukshetra

264/2018

Akhil garg - Complainant(s)

Versus

Star Health Allinz - Opp.Party(s)

Sudeep Malik

18 Oct 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KURUKSHETRA.

 

Complaint No.264 of 2018

Date of Instt.:4..12.2018

Date of Decision: 18.10.2021.

 

Akhil Garg aged about 28 years, son of Sh.Vinod Garg, r/o Pundri now Kurukshetra c/o Aggarwal Gifts & General Store, Bhagwan Nagar Colony, Near Devi Mandir Pipli (Kurukshetra).

 

                                                                        …….Complainant.                                              Versus

 

1.Star Health & Allied Insurance Company Limited, SCO No.94, First Floor, Sector 17, Backside Hotel Silver Sand, Kurukshetra.

2.Star Health and Allied Insurance Company Limited, 1, New Tank Street. Valluvar Kottam High Road, Nungambakkam, Chennai – 600034.

3.Smt.Usha Devi  Code No.BA0000299255 c/o Star Health  & Allied Insurance company Limited SCO No.94, First Floor, Sector 17, Backside hotel Silver Sand, Kurukshetra.

 

                ….…Opposite parties.

 

                Complaint under Section  12 of Consumer Protection Act.

 

Before       Smt. Neelam Kashyap, President.    

                   Shri Issam Singh Sagwal, Member.

                   Ms.Neelam Member.

                 

Present:     Sh.Sudeep Malik Advocate for the complainant.

                 Sh.Gaurav Gupta Advocate for OP No.1 and 2.

                 OP No.3 ex parte.

.

ORDER

                  

                 This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by Sh.Akhil Garg   against Star Health Allied & Insurance Company Limited etc -the opposite parties.

 

2.             The brief facts of the complaint  are that the complainant took a Medi claim insurance policy (individual) bearing No. P/21123/01/2018/001229 from the OP No.3 (Intermediary code No. BA0000299255) for a sum of Rs.3.00 lacs and the period of insurance was from 25.10.2017 to 24.10.2018. The complainant paid Rs.4720/- towards premium of the said policy and the policy was to cover medical expenses and the said policy was a cashless one.  At the time of issuance of the policy, the complainant was hale and hearty.  It is further submitted that on 16.01.2018,  the complainant suddenly felt mild chest pain for which he consulted BS Heart Care, Kurukshetra from where he was referred to higher centre and then the complainant was taken to Medanta Hospital, Gurgaon and from there he was taken to PGI, Chandigarh where Pace Maker was inserted lateron.  The complainant spent Rs.4,00,000/- on the treatment. The policy issued by the OP was cashless one but they refused to honour the bills of the hospital and assured the complainant that presently they are unable to pay the amount and asked him to pay the amount of bills and lateron he will be reimbursed the amount.  The complainant requested the Ops several times to pay the amount spent by him on his treatment but the Ops lingered on the matter and on 25.5.2018, a letter was received from the OP No.2 wherein the claim of the complainant was repudiated on account of Non disclosure of the material facts (i.e. about the existence of pre-existing disease) and the premium of Rs.4720/- was refunded by the Ops in the shape of demand draft which amounts to deficiency in services on the part of the Ops.  Thus, the complainant has filed the present complaint alleging deficiency in services on the part of the Ops and prayed for payment of the amount spent by him on the treatment alongwith compensation for the mental  harassment  caused to him and the litigation expenses.

 

3.             Upon notice OP no.1 and 2 appeared and filed written statement disputing the claim of the complainant.  It is admitted that the insured availed the  MEDICCLASSIC INSURANCE POLICY (INDIVIDUAL)  COVERING Akhil Garg self for the sum insured ofRs.3.00 lacs vide policy No.P/211123/01/2018/001229 for the period from 24.10.2017 to 24.10.2018.  The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant alongwith the policy schedule. Moreover,  it is clearly stated in the policy schedule “ The insurance under this policy is subject to conditions, clauses , warranties, exclusions etc. attached. The policy is contractual in nature and the claim arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing the being fully aware of such terms and conditions and executed the proposal form.

 

                It is further submitted that as per discharge summary for the period  17.1.2018 to 18.1.2018, the insured was diagnosed with Dilated Cardiomyopathy Severe LC Disfunction  (LVEF 20-25%) Left Bundle Branch Block Normal Coronaries.

                The ECHO report dated 12.01.2018 shows dilated Cardiomyopathy with EF 2—25%.

 

                Further,  at the time of processing the claim of the complainant the opponent has obtained specialist opinion and the specialist opined below as follows;

 

                ECHO report dated 12.1.2018 shows dilated Cardiomyopathy with EF 20-25%.

                No Recent evidence for any acute Coronary events or Cardiac Events.

                The above findings show long standing heart disease, which takes more than 3 months to develop.

                It is further submitted that  the complainant has submitted claim only for Rs.58,334/-  in the 3^rd month of the policy towards hospitalization at Global  Health Private Limited  on 17.01.2018 for treatment of Dilated Cardiomyopathy, Severe LV Dysfunction (LVEF 20-25%) Left Bundle Branch Block and Normal Coronaries and on scrutiny of papers and opinion of the specialist, the said disease of the assured was found pre existing at the time of proposal of the said insurance policy and as such the claim of the complainant has been rightly repudiated and there is  no deficiency in services on the part of the Ops.

 

4.             OP NO.3 was duly served upon but the OP No.3 failed to appear and contest the case, therefore, OP No.3 was proceeded against ex parte vide order dated 5.11.2019.

 

5.             The complainant in support of his case has filed his affidavit Ex.CW1/A and tendered documents Ex.C1 to Ex.C32 and closed his evidence.

 

6.             On the other hand, OP no.1 and 2 in support of their case have filed affidavit Ex.RW1/A and tendered documents Ex.R-1 to Ex.R-17 and closed their evidence.

 

7.             We have heard the learned counsel for the parties and gone through the case file very carefully.

 

8.             The learned counsel for the complainant while reiterating the averments made in the complaint has argued that complainant took a Medi Claim Insurance Policy (individual) bearing No.P/21123/01/2018/001229 from the OP No.3 (Intermediary code No. BA0000299255) for a sum of Rs.3.00 lacs and the period of insurance was from 25.10.2017 to 24.10.2018. The complainant paid Rs.4720/- towards premium of the said policy and the policy was to cover medical expenses and the said policy was a cashless one.  At the time of issuance of the policy, the complainant was hale and hearty.  It is further argued  that on 16.01.2018,  the complainant suddenly felt mild pain chest pain for  which he consulted BS Heart Care, Kurukshetra from where he was referred to higher centre and then the complainant was taken to Medanta Hospital, Gurgaon and from there he was taken to PGI, Chandigarh where Pace Maker was inserted lateron.  The complainant spent Rs.4,00,000/- on the treatment. The policy issued by the OP was cashless one but they refused to honour the bills of the hospital and assured the complainant that presently they are unable to pay the amount and asked him to pay the amount of bills and lateron he will be reimbursed the amount.  The complainant requested the Ops several times to pay the amount spent by him on his treatment but the Ops lingered on the matter and  Ops repudiated the claim of the complainant which amounts to deficiency in services on the part of the Ops.

                It is also argued on behalf of the complainant that the Ops cannot cancel the said policy before issuance of 30 days notice to the complainant as envisaged in term and condition no.13  of the said policy.

                It is also argued that the Ops sent the cheque as placed on record Mark A  but the said  alleged cancellation was not accepted by the complainant because  due and proper intimation before the alleged cancellation was not sent to the complainant as per term and condition no.13 of the policy.    It is also argued that the said cheque sent by the Ops has not been got encashed by the complainant till date. The learned counsel for the complainant has placed reliance on the law cited in case  Met Life India Insurance Co.Limited Vs. Usirikayala Screenivasa Rao  Law Finder  Doc Id # 753385. NIC Vs. Suraj Parkash  Law Finder Doc Id# 592844 and OIC Vs.Padma Motwani Appeal No.185 of 2005 decided by the Hon’ble Chhatisgarh State Commission on  15.09.2005.

9.             On the other hand, learned counsel for OP No.1 and 2 while reiterating the contentions made in the written statement has argued that that as per discharge summary for the period  17.1.2018 to 18.1.2018, the insured was diagnosed with Dilated Cardiomyopathy Severe LC Disfunction  (LVEF 20-25%) Left Bundle Branch Block Normal Coronaries. The ECHO report dated 12.01.2018 shows dilated Cardiomyopathy with EF 2—25%.

                Further, at the time of processing the claim of the complainant the opponent has obtained specialist opinion.

                It is further argued that the complainant has submitted claim for pre-existing disease only for Rs.58,334/-  in the 3^rd month of the policy towards hospitalization at Global  Health Private Limited  on 17.01.2018 for his treatment and it was found  a pre existing  disease at the time of proposal of the said insurance policy and as such the claim of the complainant has been rightly repudiated and there is  no deficiency in services on the part of the Ops.  The learned counsel for the Ops has placed reliance on the law cited in the authorities  Satwant Kaur Sandhu Vs. New India Assurance Co.   Law Finder Doc. If# 203511, P.C.Chako and another Vs. Chairman LIC  Law Finder Doc Id # 134190, United India Insurance Co.Limited Vs. Umrao Chand Daga  Law Finder Doc Id# 793376, Surinder Kaur Vs. NIC Limited Law Finder Doc Id# 780431 C.N.Mohan Raj Vs. New India Assurance Co.Limited  Law Finder Doc Id# 586911.

 10.                We are not agreed with the contention of the Ops because in  this case the policy in question was obtained by the  complainant/insured on 25.10.2017 and  he suddenly felt mild chest pain on 16.01.2018 i.e. after a period of more than three months.  The Ops has relied upon the ECHO report  dated 12.1.2018 and the Ops have stressed that the said findings show long standing heart disease which takes more than three months.  Even from the date of illness and date of treatment period of more than three months  has lapsed and the Ops have failed to place any documentary evidence to show that the disease of the complainant was pre existing. The Ops have only relied upon the opinion which cannot be made basis for the same. From the evidence led by the Ops it is not proved that the ailment of the complainant was existing and known to the complainant at the time of submitting the proposal form so there is no question of disclosure of the disease.  Therefore, we hold that the complainant/insured was not having knowledge about any pre existing disease if any and the claim of the complainant  has been wrongly withheld by the Ops which amounts to deficiency in services on the part of the Ops.

                In the authority NIC Vs. Suraj Parkash’s case (Supra) it is held as under:

                “Consumer Protection Act, 1986 Section 15 Mediclaim Insurance Policy- Claim for-Repudiation of- In present case, insured admitted for checkup, diagnosed having Aorto Occlusive Disease-Claim repudiated on ground of suppression of pre-existing disease- Complaint filed- Allowed by District Forum-Hence, appeal- There is no evidence produced in support that complainant knew about disease at time of taking of policy-Held , complaint was rightly allowed by District Forum-Appeal dismissed.”

                In the authority Met Life India Insurance Company’s case (Supra) it is held as under:

                “As for suppression of pre-existing disease, deceased came to know about renal failure on 4.1.2009-When this problem was not known to deceased at the time of submitting proposal form there was no question of disclosure of disease- No illegality, irregularity or jurisdictional error in the impugned order- Revision dismissed.”

11.            The learned counsel for the complainant has placed on the file Mark –“A” and has stated that the said cheque has not been got encashed by the complainant. It is also stated that the alleged cancellation, if any, is not sustainable because the Ops were required to give 30 days  notice by registered post before the cancellation of the policy as envisaged in  the term and condition no.13 of the policy.

                The perusal of condition no.13 of the said insurance policy shows that the company may cancel the policy on the grounds of misrepresentation or fraud etc. at the time of claim  or non cooperation by the insured person by sending the insured 30 days notice by registered letter at the last known address of the insured.  The  Ops have not issued thirty days prior notice for cancellation of the policy  to the complainant. Neither the complainant has not received any letter i.e. Ex.R-15 issued by the Ops nor   Ops have  also not placed on record any acknowledgement regarding receipt of the said letter. Therefore, cancellation of the policy, if any, is not justified and the present insurance policy issued to the complainant may be deemed to be continued.

                      In this context we are supported  by the law cited in case  OIC Vs. Padma Motwani’s case (Supra) wherein it is held as under:

                “Insurance  claim-Cancellation of policy-As per clause 5 of the policy, the insurer was authorized to cancel the policy on intimation to the insured-Policy cancelled with letter address to the Steel Workers Unjion and not to the insured-Cancellation not as per stipulated clause-Wife of insured held entitled to the benefit of the policy.”

12.            On the one hand, the Ops are denying the claim of the complainant and on the other last para of the written statement, the Ops are stating that “the maximum quantum of liability under the terms of the policy shall be Rs.30,074/-.As per the Ops vide mark A, when the Ops have cancelled the policy in question on the pre existing disease, then in our mind, the liability of paying Rs.30,074/- is not at all made out which the Ops are admitted.  When the Ops have admitted this liability, then in our mind, the Ops are liable to pay the entire amount of treatment spent by the complainant. The complainant in para No.5 of the complainant has specifically mentioned that from BS Heart Care Kurukshetra, he was referred to the higher Centre and then the complainant was taken to Medanta Hospital, Gurgaon and from where he was taken to PGI Chandigarh where Pace Maker was inserted lateron.  The complainant has also stated that he spent Rs.4.00 lacs on the treatment. The OP no.1 and 2 in the written statement has not stated in reply to this para in the written statement that Pace Maker was not inserted to the complainant. The complainant contacted the  doctors of PGI Chandigarh as per Ex.C-9 on 1.6.2018 where Pace Maker was inserted to the complainant. The insurance policy in question is for Rs.3.00 lacs as mentioned in the insurance policy Ex.C-1. The complainant has placed the medical bills on the file for more than Rs.3.50 lacs but in our view the complainant is entitled to Rs.3.00 on account of his treatment being the sum assured. For non payment of this amount there appears to be grave deficiency in services on the part of the OP No.1 and 2. Besides this, the complainant is also entitled to compensation for the mental harassment caused to him and the litigation expenses. In coming to our this conclusion, we draw support  from the  authorities cited on behalf of the complainant. The authorities cited on behalf of the Ops are not applicable to the facts and circumstances of the present case.

 

13.            In view of our above discussion, we accept the present complaint and direct the OP- No.1 and 2 to pay the sum assured i.e. Rs.3,00,000/- to the complainant alongwith interest  @ Rs.6% per annum from the date of  filing of the present complaint i.e. 4.12.2018 till its realization. The complainant shall also be entitled to Rs.20000/- as compensation for the mental harassment and agony caused to him and a sum of Rs.10000/- for  the litigation expenses. It is also made clear that if the OP No.1 & 2 failed to make the compliance of this order within a period of 45 days from the date of this order,   the complainant will  also be at liberty to initiate proceedings under Section 25/27 of the Act against the OP No.2. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. The complaint qua OP No.3 stands dismissed. File be indexed and consigned to the record-room, after due compliance.

 

Announced in open commission:

Dt.:18.10.2021.                                                    (Neelam Kashyap)

                                                                                  President.

 

 

(Issam Singh Sagwal),         (Neelam)     

 Member                              Member.