DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/60/2023
Date of Institution: 19.05.2023
Date of Decision: 05.07.2024
Haminder Kumar son of Surinder Kumar resident of H.No. B-III/44, Sahoria Street, Barnala, Tehsil and District Barnala.
…Complainant
Versus
1. Star Health and Allied Insurance Company Limited, New Tank Street, Valluvar Kottam High Road, Nungambakam, Chennai-600034 through its Manager/Authorized Signatory.
2. Star Health and Allied Insurance Company Limited, 2nd floor, above Delhi Tractor & Combines, Opposite PNB Bank, College Road, Barnala-148101 through its Manager/Authorized Signatory.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Varun Singla Adv counsel for complainant.
Sh. Rohit Jain Adv counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover : President
2. Sh. Navdeep Kumar Garg : Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Star Health and Allied Insurance Company Limited & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant is the permanent resident of Barnala and one of the official/agent of opposite party contacted the complainant and told about their various insurance schemes. On believing the words, the complainant agreed to purchase Arigya Sanjeevani Policy and the complainant alongwith his family (wife namely Reema Bansal and two children namely Arshia Bansal and Ekankshi Bansal) were medically examined. Thereafter, the complainant paid an amount of Rs. 12,570/- and opposite parties issued one policy No. P/211229/01/2022/000876 and the complainant continued the said policy regularly without any discrimination and paid the premium amount of Rs. 12.570/- and issued Renewal Endorsement No. P/211229/01/2023/0001169 and the sum of Rs. 3,00,000/- was insured under the said policy. It is further alleged that during the subsistence of the policy, in the month of March, 2023 the complainant started facing Health issues and thereby taken to Adesh Institute of Medical Sciences & Research, Bathinda dated 20.3.2023 and was admitted for treatment and was discharged on 22.3.2023 where an expenditure of Rs. 41,045/- was made on the treatment of complainant (Pre Hospital Bills of Rs. 9,775/- + Hospital main bill of Rs. 31,270/-). It is further alleged that the complainant approached the opposite party No. 2 for the medical claim which is covered under the policy and the complainant submitted all the original documents as said by them and opposite party No. 2 assured that they will incur all the expenses of treatment as per the policy bought and will give the claim amount within a week. It is alleged that the opposite parties repudiated the claim and sent repudiation claim letter dated 31 March, 2023 to the complainant where the reasons for rejection was that “insured has undergone treatment for Altered Sensorium; Bronchial Asthma which is Pre-existing in nature”. Thereafter, after fully harrying the complainant on one pretext of the other and opposite parties refused to give the said claim which is withheld by opposite parties without any justified cause. As such, there is deficiency in service on the part of the opposite parties. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to pay the claim amount of Rs. 41,045/-.
- To pay Rs. 50,000/- on account of compensation for causing mental torture, agony and harassment to the complainant.
- Further, to pay Rs. 10,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking preliminary objections interalia on the grounds that the complainant has no locus-standi and has no cause of action to file the present complaint. The present complaint is not legally maintainable. The complainant dragged the opposite parties in false litigation. The complainant has not come with clean hands and complainant suppressed the material facts from this Commission etc.
4. On merits, it is admitted to the extent that the complainant purchased Arigya Sanjeevani Policy for himself and wife Reema Bansal, two children Arshia Bansal and Ekankshi Bansal from the opposite parties vide policy No. P/211229/01/2023/0001169 for the period from 5.10.2022 to 4.10.2023 and this policy is in continuation since 5.10.2021 and sum insured was Rs. 3,00,000/-. It is further alleged that the complainant disclosed existing disease related to “Respiratory System, ASTHMA SINCE LAST 8 YEARS, TAKING INHALER FORACORT 400, HAVING NO COMPLICATIONS, FIT AND FINE, HAVING NO DOCUMENTS” to the opposite parties at the time of taking the policy. It is further submitted that on 20.3.2023 the complainant was got admitted in Adesh Institute of Medical Sciences & Research, Bathinda and remained admitted upto 22.3.2023 and spent Rs. 41,045/- on his treatment. It is further admitted by the opposite parties that vide letter dated 31.3.2023 they repudiated the claim of the complainant on the ground mentioned therein. It is denied that the complainant has reported the matter with the opposite parties. It is also denied that the alleged claim is covered under the policy, rather claim related to existing disease related to Respiratory System is covered as per terms and conditions of the policy. It is further alleged that as per Exclusions No. 1 Pre-existing disease-Code Excl-01 (D) of the policy, the coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by insurer. Hence, the claim was rejected and the same was informed to the insured vide letter dated 31.3.2023. All other allegations are denied and prayed for the dismissal of complaint.
5. The complainant filed rejoinder to the written version filed by the opposite parties vide which the complainant denied the averments as mentioned in the written version.
6. To prove the case the complainant tendered into evidence affidavit of complainant Ex.C-1, copy of policy Ex.C-2 (containing 2 pages), copy of policy Ex.C-3, copies of bills & receipts are Ex.C-4 to Ex.C-8, copy of diagnosis sheet Ex.C-9 (containing 3 pages), copy of repudiation letter Ex.C-10 (containing 3 pages), copy of Adhaar Card Ex.C11 and closed the evidence.
7. To rebut the case the opposite parties tendered into evidence affidavit of Sumit Kumar Sharma Ex.O.Ps-1, copy of proposal form Ex.O.Ps-2 (4 pages), copy of policy Ex.O.Ps-3 (2 pages), copy of terms and conditions Ex.O.Ps-4 (6 pages), copy of request letter Ex.O.Ps-5 (6 pages), copy of letters dated 21.3.2023 Ex.O.Ps-6 to Ex.O.Ps-8, copy of claim form Ex.O.Ps-9 (4 pages), copy of prescription slip Ex.O.Ps-10 (2 pages), copy of progress sheet Ex.O.Ps-11 (3 pages), copy of history of patient Ex.O.Ps-12 (3 pages), copy of bill Ex.O.Ps-13, copy of repudiation letter Ex.O.Ps-14 (3 pages), copy of bill assessment sheet Ex.O.Ps-15 and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments filed by complainant.
9. It is not disputed between the parties that the complainant purchased Arigya Sanjeevani Policy for himself and wife Reema Bansal, two children Arshia Bansal and Ekankshi Bansal from the opposite parties vide policy No. P/211229/01/2023/0001169 for the period from 5.10.2022 to 4.10.2023 and this policy is in continuation since 5.10.2021 and sum insured was Rs. 3,00,000/- (as per Ex.C-3). It is also not disputed that on 20.3.2023 the complainant was got admitted in Adesh Institute of Medical Sciences & Research, Bathinda and remained admitted upto 22.3.2023 and spent Rs. 41,045/- on his treatment (as Ex.C-4 to Ex.C-8).
10. Ld. Counsel for the complainant argued that during the subsistence of the policy, in the month of March, 2023 the complainant started facing Health issues and thereby taken to Adesh Institute of Medical Sciences & Research, Bathinda dated 20.3.2023 and was admitted for treatment and was discharged on 22.3.2023, where an expenditure of Rs. 41,045/- was made on the treatment of complainant (Pre Hospital Bills of Rs. 9,775/- + Hospital main bill of Rs. 31,270/-). It is further argued that the complainant approached the opposite party No. 2 for the medical claim which is covered under the policy and the complainant submitted all the original documents as said by them and opposite party No. 2 assured that they will incur all the expenses of treatment as per the policy bought and will give the claim amount within a week. It is also argued that the opposite parties repudiated the claim and sent repudiation claim letter dated 31 March, 2023 (Ex.C-10) to the complainant where the reasons for rejection was that “insured has undergone treatment for Altered Sensorium; Bronchial Asthma which is Pre-existing in nature”. Ld. Counsel for complainant further argued that the opposite parties refused to give the said claim which is withheld by opposite parties without any justified cause.
11. On the other hand, Ld. Counsel for opposite parties argued that the complainant disclosed existing disease related to “Respiratory System, ASTHMA SINCE LAST 8 YEARS, TAKING INHALER FORACORT 400, HAVING NO COMPLICATIONS, FIT AND FINE, HAVING NO DOCUMENTS” to the opposite parties at the time of taking the policy. It is further argued that the opposite parties that vide letter dated 31.3.2023 (Ex.O.Ps-14) repudiated the claim of the complainant on the ground mentioned therein. It is further argued that as per Exclusions No. 1 Pre-existing disease-Code Excl-01 (D) of the policy, the coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by insurer, hence the claim was rejected and the same was informed to the insured vide letter dated 31.3.2023.
12. From the perusal of the record it is proved that in the month of March, 2023 the complainant started facing Health issues and thereby taken to Adesh Institute of Medical Sciences & Research, Bathinda dated 20.3.2023 and was admitted for treatment and was discharged on 22.3.2023 where an expenditure of Rs. 41,045/- was made on the treatment of complainant (Pre Hospital Bills of Rs. 9,775/- + Hospital main bill of Rs. 31,270/-). On the other hand, the opposite parties have repudiated the claim of the complainant on the ground that “It is observed from the submitted documents that the insured patient has undergone treatment for the above diagnose which is already incorporated in the above policy as pre-existing disease at the time of inception of the first medical insurance policy. Hence, the present admission and treatment of the insured patient is for the pre-existing disease”. Further, as per Exclusions No. 1 Pre-existing disease-Code Excl-01 (D) of the policy, the coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by insurer. Hence, the claim was rejected and the same was informed to the insured vide letter dated 31.3.2023. We are of the view that it was in the hands of insurance company to see and not to issue policy where person is not entitled to claim on account of treatment of Pre-existing disease. Moreover, there is nothing on record from the side of opposite parties that they have conducted the medical examination/investigation of the complainant and his family members at the time of issuing the policy. So, we are of the view that at this stage the opposite parties cannot escaped from their liabilities by raising these types of unreasonable unjustified grounds. The learned counsel for the complainant also relied upon the judgment of Hon'ble Punjab and Haryana High Court (DB) 2012 (1) RCR (Civil)-901 in which the Hon'ble High Court held that “Claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the policy. Single judge allowed the claim on the ground that it was for Insurance Company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. No interference called for in the order of Single Judge. Held the pre-existing condition existed in the year 2002 which was five years prior to acquiring Insurance Policy. Claim cannot be denied.
13. From the above discussion, it established that the claim of the complainant was repudiated by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties. Therefore, the present complaint is partly allowed against the opposite parties and the opposite parties are directed to pay Rs. Rs. 41,045/- alongwith interest @ 7% per annum from the date of filing the present complaint till its realization. The opposite parties are further directed to pay Rs. 5,000/- on the account of mental agony and harassment and Rs. 5,000/- on account of litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
5th Day of July, 2024
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
