Delhi

New Delhi

CC/225/2022

Mr. Mahender - Complainant(s)

Versus

Star Health And Allied In.Co.Ltd. - Opp.Party(s)

22 May 2023

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-VI

(NEW DELHI), ‘M’ BLOCK, 1STFLOOR, VIKAS BHAWAN,

I.P.ESTATE, NEW DELHI-110002.

Case No.225/2022

IN THE MATTER OF:

 

MR. MAHENDER

A-481, J.J. COLONY, BHARAT VIHAR

SECTOR-15, KAKROLA,

NEW DELHI-110078                                                    ....COMPLAINANT

 

 

VERSUS

 

STAR HEALTH AND ALLIED IN.CO. LTD.

1st FLOOR, HIMALAYA HOUSE,

23, KASTURBA GANDHI MARG,

NEW DELHI-110001                                                ....OPPOSITE PARTY

 

Quorum:

 

Ms. Poonam Chaudhry, President

Sh. Bariq Ahmad, Member

Sh. Shekhar Chandra, Member

 

                                                                                                                      Date of Institution:-09.09.2022                                                                                                                                                                              Date of Order   : -  22.05.2023.

 

ORDER

 

POONAM CHAUDHRY, PRESIDENT

 

 

1. The present complainant has been filed under Section 12 & 35 of Consumer Protection Act, 1986 (in short CP Act) against the Opposite Party (in short OP) alleging deficiency of services.
2. Briefly stated the facts of the case that complainant had taken a online health insurance policy bearing no. P/160000/01/2022/008037 on 23.10.2021   valid with effect from 18.10.2021 to 22.10.2022 for the sum insured of Rs.3,00,000/- (Rs. Three Lakhs only).
3. That the complainant got admitted in the AAKASH EYE & GENERAL HOSPITAL for treatment on 17.12.2021 and remained hospitalized till 22.12.2021. The said hospital generated the final bill of Rs.56,814/- (Rupees Fifty Six Thousand Eight Hundred Fourteen) which was paid by complainant. Complainant claimed the aforesaid bill amount from the opposite party, but the same was rejected/repudiated by the opposite party vide letter dated 28.01.2022 stating as under:

It is observed that the indoor case records TRP chart are in stereotyped manner and written at a single stretch. thus there is discrepency in the records which amounts to misrepresentation of facts.

 

As per terms and conditions of the policy issued to you, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim.

4. It is further stated that complainant thereafter sent a letter on 21.03.2022 to the insurance company but no response was received. The complainant was left with no option but to approach this Court/Commission. Hence, the present complaint.
5. It is alleged that the present case has been filed within the period of limitation, the cause of action to file the present complaint arose when the claim of the complainant was rejected by the opposite party on 28.01.2022.
6. It is further alleged that the residence of the complainant is situated at "KAKROLA" New Delhi, as such this Court/Commission has jurisdiction to entertain the present complaint.
7. It is prayed that OP be directed to pay a sum of Rs.56,814/- (Rupees Fifty Six Thousand Eight Hundred Fourteen) to the complainant with pendent elite and future interest @ 18 % p.a. from the date of repudiation of claim 28.01.2022 till its realization. OP be also directed to verify and produce the medical treatment record and bills of complainant’s treatment from 17.12.2021 to 22.12.2021. Cost of litigation be also awarded.
8. Notice of the complaint was issued to OP, upon which OP entered appearance and filed written statement contesting the case on various grounds inter alia that the complaint is not maintainable, as no cause of action ever arose in favour of the complainant and the same is hit by Section VII Rule 11 of CPC.
9. It was also alleged that respondent denies each and every allegation, averments made in the complaint which is contrary to and / or inconsistent with what has been stated in the reply and nothing stated in the said complaint is be deemed to have been admitted until the same is expressly admitted hereinafter.
10. It was further stated that complainant has obtained the policy i.e. : Young Star Insurance Policy for self, the sum Insured was Rs.3,00,000/- (Rupees Three Lakh) on 23.10.2021 valid from 23.10.2021  to 22.10.2022  vide Policy no. : P/160000/01/2022/008037 from OP. At the time of inception of the policy, the terms and conditions were explained to the complainants. The terms and conditions of the policy were already explained to the complainant at the time of proposing the policy and were served on the complainant along with the police Schedule and also upon issuance of insurance policy.
11.  It was further alleged that on 17.12.2021 the complainant was hospitalized at Aakash Eye & General Hospital, Delhi from 17.12.2021 to 22.12.2021 for the treatment of Entric Fever & Acute Hepatitis and the complainant had submitted the documents for reimbursement of the claim i.e. Rs.56,814/- (Rupees Fifty Six Thousand Eight Hundred Fourteen).
12. It was also alleged after perusal of the documents, it was observed that Indoor case Records and TPR chart were in stereotyped manner and written at  single stretch. Complainant had intimated the answering respondent about his hospitalization on 05.01.2022, whereas the conditions 2(d) of the policy provides that  "Upon the happening of the event, notice with fully particulars shall be sent to the company within 24 hours from the date of occurrences of the event irrespective of whether the event is likely to give rise to claim under the policy or not.

 

13. It was further alleged respondent rejected the claim vide letter dated 28.01.2022 and 25.03.2022 as the complainant violated the terms and conditions of the policy. It was submitted that the condition no. 1 of policy relates to Disclosure of Information and provides that: "The policy shall be void and all premium paid thereon shall be forfeited to the company, in the event of misrepresentation, mis deception or non-disclosure of material fact by the policy holder.”

 

14.  As per the condition no. 6: - Fraud: "If any claim made by insured person, is in respect of fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are ued by the insured person or anyone acting on his/ her behalf of obtain any benefit under this policy, all benefits under this policy and the shall be forfeited."
15.  It was alleged that the parties are to abide by the terms and conditions of contract. It was prayed that the complaint be dismissed.
16. Complainant thereafter filed rejoinder reiterating therein the averments made in the complaint and denying all the allegation made in the written statement. Both parties filed their evidence by affidavits. Complainant relied upon the treatment record and bills issued by Aakash Eye and General Hospital. OP on the other hand reiterated the contents of its written statement in its written statement and relied on the policy.  
17. We have heard the AR of the complainant and counsel  for  OP and perused the evidence and material on record as well as their written arguments.
18. It is admitted case that complainant had obtained the policy in question from OP which was valid with effect from 23.10.2021 to 22.10.2022. It is the case of complainant that he was hospitalized during the continuance of the policy. On the other hand it is the case of OP that the terms and conditions of the policy were explained to the complainant and served on the complainant. It is also the case of OP the claim of complainant was rejected for violation of the terms and conditions of the policy.
19. It is to be noted that OP has not filed any document to show that the terms and conditions of the policy were communicated or served on the insured/complainant. Moreover, OP had accepted the premium from complainant for the policy in question. OP also did not bring anything on record to show that claim was filed on false statement/documents.
20. As regard the liability of Insurance Company in case the terms and conditions of the policy wherein exclusion clause was included were not communicated or served on the insured, it has been held by the Hon’ble Supreme Court in M/s Modern Insulators  Ltd. Vs. The Oriental Insurance Company 2000 (2) SCC 734 as under :

“It is the fundamental principle of insurance law that utmost good faith must be observed by the contracting parties and good faith forbids either party from non-disclosure of the lads which the parties known. The insured has a duty to disclose and similarly it is the duty of the insurance company and its agents to disclose ill material facts in their knowledge since obligation of good faith applies to both equally.

In view of the settled position of law we are of the opinion that the view expressed by the National Commission is not correct. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant respondent cannot claim the benefit of the said exclusion clause.Therefore, the finding of the National Commission is untenable in law.”

 

21. We accordingly hold that OP was deficient in providing services and direct OP i.e. Star Health and Allied Insurance Company Limited to pay Rs.56,814/- (Rupees Fifty Six Thousand Eight Hundred Fourteen) to the complainant with interest @ 9% per annum from date of repudiation of claim within four weeks of date of receipt of order failing which OP will be liable to pay interest @ 12% per annum till realization. We also direct OP to pay compensation of Rs.50,000/- (Rupees Fifty Thousand) for mental agony and Rs.10,000/- (Rupees Ten Thousand only) towards litigation expenses to the complainant.

A copy of order be sent to all the parties free of cost. The order be also uploaded on the website of the Commission (www.confonet.nic.in).

File be consigned to the record room along with a copy of the order.

 

 

Poonam Chaudhry

(President)

 Bariq Ahmad                                                                                                                 Shekhar Chandra

    (Member)                                                                                                                               (Member)