Delhi

New Delhi

CC/223/2022

Mr. Raja Gautam - 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.223 /2022       

IN THE MATTER OF:

 

Mr. Raja Gautam

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, 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   : -    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. Briefly stated the facts of the case are that the complainant  had  taken a on line health insurance policy bearing no. P/160000/01/2022/007856 dated 18.10.2021 from OP. The said policy was valid from 18.10.2021 to 17.10.2022 for the sum insured of Rs.3,00,000/- (Rupees Three Lacs Only).
2. It is further alleged that the complainant got admitted in the Mahavir Multispeciality Hospital for treatment on 02.01.2022 at 07:48 AM and remained hospitalized till 06.01.2022 at 06:10 PM.  The said hospital generated the final bills Rs.41,237/- (Rupees Forty One Thousand Two Hundred Thirty Seven) which was paid by complainant.
3. The complainant thereafter claimed the aforesaid bill amount  from the OP, but the same was rejected by the OP vide letter dated 03.02.2022  on the ground that it was observed from the documents and details available with OP the documents were stereotyped and there were multiple discrepancies in documents. The same were fabricated for claim purpose which amounts to misrepresentation of facts.
4. It was also alleged complainant sent a letter on dated 03.02.2022 to the insurance company but no response was received from the OP. It is also stated the present case has been filled within the period of limitation. The cause of action arose to file present case i.e. when the claim of the complainant was rejected by opposite party vide letter dated 03.02.2022. The residence of the complainant is situated at “kakrola” New Delhi  as such this Commission has jurisdiction to try the complaint.
5. It is prayed that OP be directed to pay sum of Rs.41,237/- (Rupees Forty One Thousand Two Hundred Thirty Seven) to the complainant with pendent elite and future interest @18% p.a. since 03/02/2022 till its realization. OP be also directed to verify and produce the medical treatment record and bills of complainant of treatment of complainant from 02.01.2022, 07:78 AM to 06.01.2022 at 06:10 PM. The cost of litigation charges be also awarded in favour of the complainant and against the opposite party.
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 the complaint 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 complaint has been filed on the basis of false and frivolous facts.
7. It was further 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 be deemed to have been admitted until the same is expressly admitted hereinafter.
8. It was alleged that the complainant had obtained the Policy i.e. Young Star Insurance Policy for himself and the sum Insured was Rs.3,00,000/- (Rupees Three Lakh)  on 18.10.2021 for a period of 18.10.2021 to 17.10.2022 vide Policy No. P/160000/01/2022/007856 from the respondent and at the time of inception of the policy, the terms and conditions were explained to the complainant.
9. It was further stated 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 was also alleged that the bare perusal of the documents shows that the insured patient has taken the treatment in the hospital, which is an excluded provider hospital as per the Exclusion No. 11 in 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. That the complainant has intimated the answering respondent about the hospitalization on 14.01.2022, whereas the condition 2(d) of the above policy states that “upon the happening of the 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”. It was alleged that the documents submitted by the complainant for reimbursement of the claim were in stereotyped manner with multiple discrepancies with the sole purpose of reimbursing the fraudulent claim from the respondent company.
12.  The OP/respondent rejected the claim of the complainant vide letter dated 03.02.2022, as the complainant violated the terms and conditions of the above policy. As per the condition no.1:- Disclosure of Information: “ 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.” It is further submitted that as per the condition no.6:- Fraud: “If any claim made by the 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 used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy and the shall be forfeited.” It was prayed that complaint be dismissed.
13. 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 affidavit.
14. 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.
15. It is admitted case that complainant had obtained the policy in question from OP which was valid with effect from 18.10.2021 to 17.10.2022 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 was also the case of OP the claim of complainant was rejected for violation of the terms and conditions of the policy.
16. Complainant stated in the rejoinder  no documents 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 the 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.41,237/- (Rupees Forty One Thousand Two Hundred Thirty Seven only) 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)