Delhi

New Delhi

CC/224/2022

Mr. Basant Lal - Complainant(s)

Versus

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

01 May 2023

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-VI

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

I.P.ESTATE, NEW DELHI-110002.

Case No.224 /2022       

IN THE MATTER OF:

 

 

Mr. Basant Lal

A-481, J.J. Colony, Bharat Vihar,

Sector-15, Kakrola

New Delhi-110078                                                       ....Complainant

 

                                      VERSUS

          Star Health and Allied Insurance Company Limited.

            1^st Floor, Himalalya 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   : -    01.05.2023

ORDER

 

POONAM CHAUDHRY, PRESIDENT

 

 

1. The present complaint has been filed under Section 12 and 35 of the Consumer Protection Act, 1986 (in short CP Act) against Opposite Party (in short OP) alleging deficiency of services.
2. Briefly stated the facts of the case are that the complainant had taken a on line health insurance policy bearing no. P/160000/01/2022/007779 on 16.10.2021 from opposite party. It is further alleged that said policy was valid from 16.10.2021 to 15.10.2022 for the sum insured of Rs.3,00,000/- (Rupees Three Lacs Only).
3. That the complainant got admitted in the Mahavir Multispeciality Hospital for treatment on 17.07.2022 and remained hospitalized till 28.07.2022. The said hospital generated the final bills of Rs.1,89,940/- (Rupees One Lakh Eighty Nine Thousand Nine Hundred Forty) which was paid by complainant. The complainant claimed the aforesaid bill amount before the opposite party, but the same was rejected by the opposite party vide letter dated 11.08.2022 with reason Excluded Provider (Hospital).
4. It is further stated that the complainant sent a letter on dated 20.08.2022 to the OP/insurance company but no response was received.  The complainant was thus left with no option but to approach this Court, hence, the present complaint. It is also alleged that the present case is being filled within the period of limitation. The cause of action arose when the claim of complainant rejected by opposite party on 11.08.2022. It is further alleged that the residence of the complainant is situated at “kakrola” New Delhi, hence, this Court has jurisdiction to entertain the present complaint.
5. It is prayed that OP be directed to pay a sum of Rs.1,89,940/- (Rupees One Lakh Eighty Nine Thousand Nine Hundred Forty) to complainant with pendent elite and future interest @18% p.a. from the date of repudiation of claim till its realization. Opposite party be also directed to verify and produce the medical treatment record and bills of complainant of treatment of complainant from 17.07.2022 at 10:46 PM to 28.07.2022 at 07:32 AM. The cost of litigation be awarded.
6. Notice of the complaint issued to opposite party, pursuant to which OP entered appearance and filed written statement contesting the complaint on various grounds inter alia that it is not maintainable, as no cause of action ever arose in favor of the complainant and the same is hit by Section VII Rule 11 of CPC. It was also alleged that the complaint has been filed on the basis of false and frivolous facts.
7. It was further alleged that OP/ respondent denies each and every allegation, averments and statement 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 deemed to have been admitted until the same is expressly admitted.
8. It was alleged that complainant obtained the Policy i.e. Young Star Insurance Policy (Individual) for self and the sum Insured was Rs.3,00,000/- (Rupees Three Lakh)  on 16.10.2021 for a period of 16.10.2021 to 15.10.2022 vide Policy No. P/160000/01/2022/007779 from the answering respondent and at the time of inception of the policy, the terms and conditions were explained to the complainant.
9. That as per the terms and conditions of the policy, which were already explained to the complainant at the time of proposing policy and the same was served to the complainant along with the policy Schedule.
10. It is further stated that on 17.07.2022 the insured was hospitalized at Mahaveer Multispecialty Hospital, Uttam Nagar, Delhi with effect from 17.07.2022 to 28.07.2022 for the treatment of viral hepatitis with Septicemia and the complainant has submitted the documents for reimbursement of the claim i.e. Rs.1,89,940/- (Rupees One Lakh Eighty Nine Thousand Nine Hundred Forty). It was alleged that the insured patient has taken the treatment in the above mentioned hospital, which is an excluded provider hospital as per the Exclusion No.11 of the terms of the policy which states that “Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website/notified to the policy holder are not admissible. However, in case of life threatening situations or following an accident expenses up to the stage of stabilization are payable but not the complete claim”.
11. It was further alleged that the complainant had intimated to the answering respondent about the hospitalization on 09.08.2022, whereas the condition 1(d) of the above policy states that “Upon the happening of event, notice with full particulars shall be sent to the company within 24 hours from the date of occurrence of the event irrespective of whether the event is likely to give rise to a claim under the policy or not”.
12. The OP/respondent rejected the claim vide letter dated 11.08.2022, as the complainant violated the terms and conditions of the above policy. It is prayed that the complaint be dismissed.
13. The complainant thereafter filed rejoinder stating that as regards exclusion of Mahavir Multispecialty hospital. OP install any signboard at the said hospital to show that it was excluded and neither it was mentioned in the terms and conditions of policy that the said hospital was excluded.  Both the parties thereafter filed their evidence by way of affidavit.
14. We have heard the AR of complainant and Counsel for OP and perused the evidence and material on record as well as their written arguments.
15. It is admitted case that complainant had obtained the policy in question from OP which was valid with effect from 16.10.2021 to 15.10.2022 and complainant was hospitalized during the continuance of the policy. 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.
16. It is to be noted complainant stated in the rejoinder  no document was given to complainant regarding the exclusion of Mahavir Multispeciality hospital neither it was stated in the terms and conditions of the policy that the said hospital was excluded.
17. 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 premium from complainant for the policy in question.
18. As regard the liability of Insurance Company in case the terms and conditions of the policy were not communicated to 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.”

 

19. 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.1,89,940/- (Rupees One Lakh Eighty Nine Thousand Nine Hundred Forty) 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.25,000/- (Rupees Twenty Five Thousand only) 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)