DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

Complaint Case No : CC/143/2020

Date of Institution : 11.08.2020

Date of Decision : 01.02.2022

Rakesh Kumar son of Sh. Satpal Kumar resident of near baba Chownk, Arya School, Bhadaur, District Barnala, Punjab. …Complainant

Versus

1. Star Health and allied Insurance Company Limited through its Managing Directors registered address at Office No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai.

2. Mr. Vipan Kumar, intermediary Star Health and allied Insurance Company Limited, Branch Office at SCO 133, 2nd Floor, above tata motor finance, Near Hotel Sweet Milan, Goniana Road, Bathinda.

…Opposite Parties

Complaint under the Consumer Protection Act 2019

Present: Sh. Nitin Bansal Adv counsel for complainant.

Sh. Rohit Jain Adv and Sh. Lokeshwar Sewak Adv counsel for opposite party No. 1.

Opposite party No. 2 exparte.

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Smt. Urmila Kumari : Member

3. Sh. Navdeep Kumar Garg : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The complainant Rakesh Kumar filed the present complaint under Consumer Protection Act 1986 against Star Health and Allied Insurance Company Limited and another. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant purchased the policy from the opposite parties of Family Health Optima Insurance plan on 18.6.2015 for himself, his wife, son and daughter for sum insured of Rs. 3,00,000/- of health and accident insurance for each member and at that time the daughter of the complainant was of 10 months around. The said policy was continued vide policy No. P/211217/01/2020/000567 dated 18.6.2019 protected till 17.6.2020, covered for an amount of Rs. 3,50,000/- for the whole family health and accident insurance for each member. 

3. It is further alleged that on 14.3.2019 the daughter of the complainant namely Ishika Garg was having significant chest infection and under the supervision of Dr. Baldeep Singh vide receipt dated 14.3.2019 of Rs. 550/- of Deep Nursing Home and Child Hospital, Ludhiana. On 25.7.2019 she again with chest infection and and under the supervision of Dr. Baldeep Singh dated 25.9.2019 of Rs. 850/- of Deep Nursing Home and Child Hospital, Ludhiana and on 27.9.2019 she was having significant finding of Down Syndrome with thrombocytopenia with anemia with chest infection and under the supervision of Dr. Arpita and further Dr. Baldeep Singh of Deep Hospital an amount of Rs. 15,000/- paid to the hospital vide receipt dated 1.10.2019. It is further alleged that on 1.10.2019 the complainant wrote a letter to the opposite party No. 1 to lodge claim of the complainant's daughter in order to get her treatment whereby it is found that the Ishika is suffering from Down Syndrome which the opposite party No. 1 declined the claim by stating the reason of Non Disclosure of Pre-existing disease. 

4. It is further alleged that after the complainant took her daughter to Dayanand Medical College, Ludhiana on 6.10.2019 whereby she was admitted to the hospital and it was found that Ishika was suffering from Morphological and Immunophenotypic findings are consistent with precursor B-lymphoblastic leukemia concluded as Accute leukemia with Down Syndrome till 18.10.2019 and complainant paid an amount of Rs. 1,03,149.75. The complainant's daughter on 21.10.2019 till 3.11.2019 consequently visited the DMC, Ludhiana for Chemotherapy and test for which they have paid total amount of Rs. 20,729/- vide separate bills. After that she from 13.11.2019 till 20.5.2020 consequently visited the DMC, Ludhiana for Chemotherapy and test for which they have paid amount of Rs. 29,690/- vide separate bills. The complainant's daughter during her treatment various NGO has helped the complainant to get her daughter treated. The complainant need more money for the treatment of Ishika as the treatment will continue for next three years but the opposite party No. 1 did not pay any heed to reply the claim of the complainant. Further, the opposite party during the renewal of policy has deleted the name of Ishika Garg from the policy. The act of the opposite parties is unfair trade practice and deficiency in service. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to release Rs. 1,70,745/- of claim amount paid by the complainant and Rs. 1,79,255/- of the pending claim amount for the future treatment totaling Rs. 3,50,000/- and directed the opposite party No. 1 to clear further bill of medical treatment alongwith interest up to date at clear further bill of medical treatment alongwith interest up to date at the rate of 12% per annum. 

2) The opposite parties may be directed to add the name of the daughter Ishika Grg in the renewal policy P/21121/01/2020/000567 issued on 30.6.2020. 

2) To pay Rs. 1,00,000/- on account of compensation for mental agony and harassment and Rs. 5,000/- as litigation expenses. 

3) Any other fit relief may also be given. 

5. Upon notice of this complaint, opposite party No. 1 filed written version taking preliminary objections that the complainant has no locus standi to file the present complaint and present complaint is not maintainable. The complainant has not come to this Commission with clean hands. The maximum quantum of liability under the terms of the policy shall be Rs. 24,689/- in claim No. CLI/2020/211217/0490613 and CLI/2020/211217/0517496 on submission of claim documents and deducting the non payables. 

6. On merits, it is admitted the complainant purchased one Health Insurance Policy from the opposite parties on 18.6.2015 for sum assured of Rs. 3,00,000/-. Further, it is observed from the medical records of the said hospital that the insured patient is known case of down syndrome which is prior to date of commencement of first year policy. Rest of contents of the complaint are denied by the opposite party NO.1. However, it is admitted that the answering opposite party has deleted the name of Ishika from the policy. The true facts are that the insured availed Family Health Optima Insurance plan for himself and his family for the sum assured of Rs. 3,00,000/- from 18.6.2019 to 17.6.2020. The insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. Further, the insured preferred two claim in the 5th year of the policy of Ishika alleging that she was admitted in Deep Nursing Home and Children Hospital, Ludhiana from 27.9.2019 to 1.10.2019 with diagnose Downs Syndrome with Thrombocytopenia with Anemia with Chest Infection and submitted final bill of Rs. 26,154/-. The insured requested a cashless towards the treatment of Acute Febrile Illness at Deep Nursing Home and Children Hospital, Ludhiana on 27.9.2019 which was initially approved for Rs. 9,100/-. However, complainant submitted additional documents for enhancement. Further, it is noted that the insured has PED which was not disclosed, so the pre-authorization was rejected vide letter dated 1.10.2019. Subsequently the insured submitted claim for reimbursement of medical expenses for treatment of Down Syndrome with Thrombocytopenia with anaemia with chest infection. On scrutiny it is noted that as per discharge summary of Deep Hospital the insured has down syndrome which is prior to date of commencement of first year policy. At the time of inception of first year policy of insured from 18.6.2015 to 17.6.2016 insured has not disclosed the said medical history of the insured person in the proposal form which amounts to misrepresentation of material facts for which company is not liable to make any payment in respect of any claim. The rejection of reimbursement claim is conveyed to the insured vide letter dated 1.1.2020. The insured submitted second claim No. 0490613 alleging admission of Ishika in DMC and Hospital, Ludhiana from 6.10.2019 to 18.10.2020 with diagnose Acute Leukemia, Medical Management, Medical Management Pre Auth/reimbursement for cashless alone and treating hospital claim amount if pre authorization for Rs. 25,900/-. The insured again requested a cashless of medical expenses towards the treatment at DMC and Hospital on 8.10.2019 which was rejected vide letter dated 12.10.2019. The complainant submitted claim only for Rs. 26,154/-. Rest of contents of complaint are denied by the opposite party No. 1 and lastly prayed for the dismissal of the present complaint with costs. 

7. The opposite party No. 2 not appeared before this Commission despite service so the opposite party No. 2 was proceeded against exparte vide order dated 29.9.2020.    

8. In support of his complaint, the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy Ex.C-2, copy of reports and bills of Deep Nursing Home Ex.C-3, copy of letter issued by opposite party No. 1 Ex.C-4, copy of medical report/treatment/final bill from 6.10.2019 to 18.10.2019 Ex.C-5, copy of bill dated 18.10.2019 Ex.C-6, copy of bills from 21.10.2019 to 3.11.2019 Ex.C-7, copy of bill dated 31.10.2019 Ex.C-8, copies of bills dated 13.11.2019 till 20.5.2020 of DMC Ex.C-9, copy of renewal policy Ex.C-10, ECHO report dated 13.2.2015 Ex.C-11 and closed the evidence. 

9. To rebut the case of the complainant, the opposite party No. 1 tendered in evidence affidavit of Rajiv Jain Ex.OP-1/1, copy of terms and conditions Ex.OP-1/2, copies of policies 2018-19, 2019-20 Ex.OP-1/3 and Ex.OP-1/4, copy of proposal form Ex.OP-1/5, copy of pre authorization letter Ex.OP-1/6, copy of cashless authorization letter  Ex.OP-1/7, copy of discharge summary Ex.OP-1/8, copies of rejection letter dated 1.10.2019 Ex.OP-1/9 and Ex.OP-1/10, copy of final bill  Ex.OP-1/11, copy of claim form Ex.OP-1/12, copy of repudiation letter dated 1.1.2020 Ex.OP-1/13, copy of assessment sheet Ex.OP-1/14, copy of request for cashless Ex.OP-1/15, copy of cashless authorization letter dated 8.10.2019 Ex.OP-1/16, copy of case summary dated 12.10.2019 Ex.OP-1/17, copy of rejection letter dated 13.10.2019 Ex.OP-1/18 and closed the evidence. 

10. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments also filed by both the parties. 

11. After hearing the arguments of the learned counsel for the parties and on the perusal of the documents on record we found that the complainant himself, his wife Seema, son Keshav and daughter Ishika were insured with the opposite party No.1. It is admitted by the opposite party No. 1 that the complainant purchased the Health Insurance policy from the opposite party No. 1 on 18.6.2015 for the sum insured of Rs. 3,00,000/-. Lastly, the complainant has taken the said mediclaim policy from 18.6.2019 to 17.6.2020 as per Ex.OP-1/4. The daughter of complainant namely Ishika was insured with the opposite party No. 1 since 2015. 

12. The daughter of complainant namely Ishika Garg first time suffered with chest infection on 14.3.2019. Thereafter diagnosed that she has suffered with the disease of Down Syndrome with thrombocytopenia with anemia and chest infection with Accute leukemia. The complainant took the treatment from Deep Nursing Home and Child Hospital, Ludhiana and Dayanand Medical College and Hospital, Ludhiana and spent Rs. 1,70,745/- on her treatment. The complainant wrote letter dated 1.10.2019 to the opposite party No. 1 and lodged the claim in order to get her treatment but opposite party No. 1 declined the claim by stating the reason of Non Disclosure of Pre-existing disease. The complainant tendered the said letter as Ex.C-4. Thereafter, the opposite party No. 1 during the renewal of policy has deleted the name of Ishika Garg from the policy issued on 30.6.2020. The copy of policy is Ex.C-10. The expenditure bills of treatment were exhibited by the complainant as Ex.C-3, Ex.C-6, Ex.C-7, Ex.C-8 and Ex.C-9. 

13. The learned counsel for the complainant argued that the complainant has no knowledge regarding that the daughter of complainant namely Ishika Garg was suffered with the disease of Down Syndrome with Accute leukemia. He first time came to know when she suffered with the chest infection on 25.9.2019. On the other hand the opposite party No. 1 had denied the claim of the complainant on the ground of concealment of pre-existing disease.

14. The opposite party No. 1 has relied upon the terms and conditions of the policy but they have failed to prove that the opposite party No. 1 has supplied the copy of terms and conditions of the policy to the complainant. The opposite party has taken the premium of said Ishika Garg since 2015. The complainant has never taken any claim of said Ishika Garg from 2015 to 2019. It is not proved by the opposite party No. 1 that the complainant intentionally concealed the disease of his daughter namely Ishika Garg. Rather as per the evidence produced by the complainant he first time came to know regarding the said disease in the year 2019. 

15. Learned counsel for the complainant has given the judgment of Hon'ble Punjab and Haryana High Court At Chandigarh having CWP No. 6456 of 1994 decided on 2.7.2013 titled Amarjeet Kaur Versus Life Insurance Corporation of India and another vide which Hon'ble High court has allowed the claim of the petitioner. In the said case the deceased was died due to Leukemia and the insurance company had taken the objection of concealment of pre-existing disease. In view of this judgment in the present case by not paying the claim to the complainant is clear cut unfair trade practice and deficiency in service on the part of the opposite party No. 1. 

16. In view of the above discussion, present complaint is partly allowed against the opposite party No. 1 and opposite party No. 1 is  directed to pay Rs. 1,70,745/- to the complainant paid by him for the treatment of his daughter namely Ishika Garg alongwith interest at the rate of 7% per annum from the date of filing of present complaint till actual realization. The opposite party No. 1 is also directed to pay Rs. 20,000/- to the complainant as compensation for mental tension and harassment and Rs. 5,500/- as litigation expenses. 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:

        1st Day of February 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Urmila Kumari)

Member

 

(Navdeep Kumar Garg)

Member