DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/48/2023
Date of Institution: 21.04.2023
Date of Decision: 25.09.2024
Rakesh Kumar Singla, aged about 55 years, son of Lachhman Dass resident of Salema Patti, Main Bazar, Dhaula, District Barnala.
…Complainant
Versus
1. Star Health and Allied Insurance Company Ltd., 2nd Floor, Above Delhi Tractor and Combines, Opposite Punjab National Bank, Pucca College Road, Barnala through its Branch Manager.
2. Star Health and Allied Insurance Company Ltd., No. 15, SRI Balaji Complex, 1st Floor, Whites Lane, Roy Apettah, Chennai-600014 through its Branch Manager/Authorized Person.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Dhiraj Kumar Adv counsel for complainant.
Sh. Rohit Jain Adv counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Smt. Urmila Kumari : 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 obtained a cashless cashless family Mediclaim Policy from 24.08.2022 to 23.08.2023 of the OPs after the payment of premium on 04.08.2022 and insurance form was also filled on 04.08.2022. It is alleged that on that day the complainant has no knowledge of disease and the OPs issued a Policy bearing No. P/211229/01/2023/000833. It is further alleged that the complainant got insured himself and his wife Asha Rani Singla through the above said policy. The complainant previously insured from IFFCO TOKIO General Insurance Company Limited from 24.08.2018 to 23.08.2021. It is further alleged that the complainant feels left flank pain and he was admitted at RG Stone and Super specialty Hospital, Ludhiana on 31.01.2023 for his treatment and the complainant was discharged from hospital on 01.02.2023 and in this regard Rs. 45,950/- was paid by the complainant to the hospital. It is alleged that in this regard cashless claim was applied by the hospital, which was rejected on 01.02.2023 by the OPs with false reason "It is observed from the submitted medical records that the insured patient has above disease since 15.08.2022, which confirms that the insured patient has above disease prior to our policy." However, the policy was obtained by the complainant on 04.08.2022 and form for policy was also filled on 04.08.2022. Thereafter, the complainant applied for claim of Rs. 45,950/- alongwith claim form, original bills, copy of policy/ID Card, original discharge summary, treatment record, original doctors prescriptions, copy of cancelled cheque, copy of PAN card, copy of Aadhar Card etc. before the OPs but the OPs again rejected the claim of the complainant with false reason by letter dated 07.03.2023 and Rs. 45,950/- is due against OPs. It is further alleged that the complainant has issued a notice dated 27.03.2023 through his counsel to the OPS but the Ops have not bothered to reply the same. As such, the act and conduct of the opposite parties comes within the definition of the unfair trade practice as well as deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to make the payment of Rs. 45,950/- alongwith interest.
- To pay Rs. 25,000/- towards mental tension and harassment.
- Further, to pay Rs. 20,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking legal objections interalia on the grounds that the complainant has no locus-standi to file the present complaint. The present complaint is not legally maintainable and the same deserves to be dismissed. The complainant dragged the opposite parties in false litigation, so the opposite parties are entitled to get Rs.10,000/- as compensation/ special costs from the complainant. The complainant has no cause of action to file the present complaint etc.
4. On merits, it is admitted to the extent that the complainant obtained Star Health Assure Insurance Policy covering RAKESH KUMAR SINGLA (Self) sum insured on and ASHA RANI SINGLA Spouse for sum insured of Rs. 05,00,000/- vide policy No. P/211229/01/2023/000833 for the period from 24.08.2022 to 23.08.2023 THIS POLICY IS PORTED FROM IFCOTGI (24.08.2018 to 23.08.2022) TO OUR COMPANY FROM 24.08.2022. it is further admitted that the complainant was discharged from Hospital on 01.02.2023 and cashless claim was applied by the hospital and the same was rejected on 01.02.2023 by the opposite parties on the ground "It is observed from the submitted medical record that the insured patient has the disease since 15.08.2022, which confirms that the insured patient has above disease prior to the policy in question and submitted claim form, and other documents for reimbursement of the claim with the opposite parties and the opposite parties repudiated the claim of the complainant vide letter dated 07.03.2023. It is further alleged that the Policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy and the complainant has accepted the Policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form. It is alleged that the terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. Moreover it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED". It is further alleged that the insured has requested for cashless and submitted the documents for hospitalization on 30.01.2023 in RG STONE AND SUPER SPECIALITY HOSPITAL LUDHIANA towards the treatment of URETERIC CALCULUS. It is further alleged that as per the documents received by the opposite parties (Query reply from hospital), the patient has been suffering from this disease/condition Since-15/08/2022, which is prior to porting of the first policy and it is clear from the ultrasound dated 15.08.2022. So, due to the non disclosure of above disease, the opposite parties are not able to consider the claim admissibility. It is further alleged that as per Condition No.1 of the policy issued to the insured, if there is any misrepresentation/non-disclosure of material facts 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. Hence, the claim was rejected and the same was informed to the insured vide letter dated 07.03.2023. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
5. The complainant filed rejoinder to the written version of opposite parties and denied the averments as mentioned in the version.
6. The complainant tendered into evidence affidavit of complainant as Ex C-1, copy of policy of Star Health & Allied Insurance as ExC-2 (containing 10 pages), copy of policy of Iffco Tokio General Insurance as Ex.C-3 (containing 3 pages), copy of OPD card as Ex.C-4, copy of discharge summary as Ex.C-5 (containing 4 pages), copies of bills are Ex.C-6 to C-10, copy of cashless rejection letter as Ex.C-11, copy of repudiation of claim as Ex.C-12 (containing 3 pages), copy of legal notice as Ex.C-13, postal receipts are Ex.C-14 & Ex.C-15 and closed the evidence.
7. The opposite parties tendered into evidence affidavit of Sumit Kumar as Ex.OPs-1, copy of proposal form as Ex.OPs-2 (containing 4 pages), copy of probability form as Ex.OPs-3, copy of policy as Ex.OPs-4 (containing 4 pages), copy of policy as Ex.OPs-5 (containing 4 pages), copy of terms and conditions are Ex.OPs-6 (containing 10 pages), copy of IRDA guidelines as Ex.OPs-7 (containing 10 pages), copy of cashless request letter as Ex.OPs-8 (containing 6 pages), copy of claim form as Ex.OPs-9 (containing 4 pages), copy of discharge summary as Ex.OPs-10 (containing 4 pages), copy of ultrasound report as Ex.OPs-11, copy of prescription slip as Ex.OPs-12, copy of final bill as Ex.OPs-13, copy of rejection letter as Ex.OPs-14 & OPs-15, copy of repudiation letter as Ex.OPs-16, copy of bill assessment sheet as Ex.OPs-17 and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file.
9. It is admitted case of the opposite parties that the complainant obtained Star Health Assure Insurance Policy covering RAKESH KUMAR SINGLA (Self) sum insured on and ASHA RANI SINGLA Spouse for sum insured of Rs. 05,00,000/- vide policy No. P/211229/01/2023/000833 for the period from 24.08.2022 to 23.08.2023 (as per Ex.C-2 & Ex. O.Ps-4) and THIS POLICY IS PORTED FROM IFCOTGI (24.08.2018 to 23.08.2022). It is further admitted case of the opposite parties that the complainant was discharged from Hospital on 01.02.2023 and cashless claim was applied by the hospital and the same was rejected on 01.02.2023 by the opposite parties i.e. Ex.O.Ps-14.
10. Ld. Counsel for the complainant argued that the complainant feels left flank pain and he was admitted at RG Stone and Super specialty Hospital, Ludhiana on 31.01.2023 for his treatment and the complainant was discharged from hospital on 01.02.2023 (as per Ex.C-5) and in this regard Rs. 45,950/- was paid by the complainant to the hospital. It is argued that in this regard cashless claim was applied by the hospital, which was rejected on 01.02.2023 (Ex.C-11) by the opposite parties with false reason "It is observed from the submitted medical records that the insured patient has above disease since 15.08.2022, which confirms that the insured patient has above disease prior to our policy." It is further argued that the policy was obtained by the complainant on 04.08.2022 and form for policy was also filled on 04.08.2022. It is further argued that the complainant applied for claim of Rs. 45,950/- alongwith claim form, original bills, copy of policy/ID Card, original discharge summary, treatment record, original doctors prescriptions, copy of cancelled cheque, copy of PAN card, copy of Aadhar Card etc. before the opposite parties but they again rejected the claim of the complainant with false reason by letter dated 07.03.2023 (Ex.C-12) and Rs. 45,950/- is due against opposite parties. It is further argued that the complainant has issued a notice dated 27.03.2023 (Ex.C-13) through his counsel to the opposite parties but they have not bothered to reply the same.
11. On the other hand, Ld. Counsel for the opposite parties argued that the Policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy and the complainant has accepted the Policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form. It is further argued that the terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule and it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED". It is further argued that the insured has requested for cashless and submitted the documents for hospitalization on 30.01.2023 in RG STONE AND SUPER SPECIALITY HOSPITAL LUDHIANA towards the treatment of URETERIC CALCULUS. It is further argued that as per the documents received by the opposite parties (Query reply from hospital), the patient has been suffering from this disease/condition Since-15/08/2022, which is prior to porting of the first policy and it is clear from the ultrasound dated 15.08.2022, so due to the non disclosure of above disease, the opposite parties are not able to consider the claim admissibility. It is further argued that as per Condition No.1 of the policy issued to the insured, if there is any misrepresentation/non-disclosure of material facts 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, hence the claim was rejected and the same was informed to the insured vide letter dated 07.03.2023 Ex.O.Ps-16.
12. It is the specific case of the opposite parties that the insured had pre-existing disease and this fact has not been disclosed by the insured/complainant at the time of filing the proposal form or at the time of purchasing the policy or at the time of porting the policy in question which amounts to misrepresentation/non-disclosure of material facts. It is further argued that as per Condition No.1 of the policy issued to the insured, if there is any misrepresentation/non-disclosure of material facts 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, hence the claim was rejected and the same was informed to the insured vide letter dated 07.03.2023 Ex.O.Ps-16. We have gone through the repudiation letter dated 7.3.2023 Ex.O.Ps-16 vide which it is mentioned that "It is observed from the submitted medical records that the insured patient has above disease since 15.08.2022, which confirms that the insured patient has above disease prior to our policy. The present admission and treatment of the insured patient is for non disclosed disease”. On the other hand, Ld. Counsel for the complainants argued that the insured has suffered from the above said problem in the month of January 2023 and in this regard the complainant was got admitted on 31.1.2023 where he remained admitted from 31.1.2023 to 1.2.2023 and was treated for Left lower ureteric stone and Procedure on Date: Left URSL with DJS done under G.A. on 31.1.2023 Left U Orifice dilated, Left URS done Laseer Lithotripsy done, DJS done and to prove this fact the complainant has placed on record Discharge Summary i.e. Ex.C-5. Further, in Ex.C-5 it is nowhere mentioned in the history that the patient had the above said disease since 15.8.2022 as alleged by the opposite parties. Further, the opposite parties (insurance company) have failed to place on record any cogent evidence to prove that they have medically examined the insured at the time of porting the policy in question or filling the proposal form or at the time of issuing the policy. Moreover, in the proposal form placed on record by the opposite parties Ex.O.Ps-2 in the column of Health History it is mentioned “No” from which it shows that at the time of porting the policy or issuing the insurance policy in question to the insured/complainant the opposite parties have not conducted any medical examination of the insured. So, at this stage how the opposite parties could have raised the objection that the insured had pre-existing disease prior to the policy inception date. The complainant to prove his case has placed on record copy of Family Health Protection insurance policy of IFFCO TOKIO GENERAL INSURANCE CO. LTD Ex.C-3 which was valid from 24.8.2021 to 23.8.2022. The complainant also placed on record copy of insurance policy of opposite parties which was valid from 24.8.2022 to 23.8.2023 and the proposal/collection date is mentioned as 4.8.2022. So, it is proved that the complainant has port his above said insurance policy from Iffco Tokio General Insurance Company Limited to Star Health and Allied Insurance Company Limited on 4.8.2022, so the plea of the opposite parties that the complainant has the above said disease (i.e. 15.8.2022) prior to porting of the first policy is not tenable. We are of the view that it was in the hands of insurance company to see and not to port the policy or issue the policy where person is not entitled to claim on account of treatment of Pre-existing disease. We have thoroughly gone through the insurance policy produced by the opposite parties as Ex.O.Ps-4 and on the 3rd Page of the said insurance policy a table exists in which it is clearly mentioned in the column of Pre-Existing Disease “Covered”. The opposite parties admitted while porting the insurance policy in question that pre-existing diseases are covered. So, we are of the view that at this stage the opposite parties cannot be escaped from their liabilities by raising these types of unreasonable and unjustified grounds. The learned counsel for the complainant also relied upon the judgment of the 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 is proved that the claim of the complainant/insured 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.
14. The complainant to prove his claim has placed on record copy of bill and receipts Ex.C-6 to Ex.C-9 which shows that Rs. 45.950/- has been spent on the treatment of complainant in the above said hospital.
15. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 45,950/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as 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:
25th Day of September, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
