Chandigarh

DF-I

CC/1086/2016

Gurdeep Singh - Complainant(s)

Versus

Star Health and Allied Insurance Co. Ltd. - Opp.Party(s)

Jatin Khurana

23 Feb 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

============

Consumer Complaint  No	:	CC/1086/2016
Date  of  Institution	:	22/12/2016
Date   of   Decision	:	23/02/2018

 

 

 

 

 

(1)  Gurdeep Singh S/o Sh. Inder Singh

(2)  Kuldeep Kaur W/o Sh. Gurdeep Singh, resident of Plot No. 377, Phase-IX, Industrial Area, Mohali.

 

……… Complainants.

 

Versus

 

(1)  The Chief Executive Officer, Start Health and Allied Insurance Company Limited, Registered & Corporate Office 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai.

 

(2)  The Branch Head, Start Health and Allied Insurance Company Limited, SCO No. 130-131, 4^th Floor, Sector 34-A, Chandigarh.

……… Opposite Parties.

 

BEFORE:   MRS.SURJEET KAUR             PRESIDING MEMBER

          SH.SURESH KUMAR SARDANA      MEMBER

 

For Complainant	:	Sh. Jatin Khurana, Advocate.
For Opposite Parties	:	Sh. Gaurav Bhardwaj, Advocate.

 

PER MRS.SURjeet kaur, PRESIDING MEMBER

 

 

          Sh. Gurdeep Singh and his wife Mrs. Kuldeep Kaur (hereinafter called the Complainants) have preferred the instant consumer complaint under Section 12 of the Consumer Protection Act, 1986, against the Chief Executive Officer, Star Health & Allied Insurance Co. Limited and Others (hereinafter called the Opposite Parties), alleging that they purchased one “Senior Citizen Red Carpet” Health Policy, covering them for their medical treatment, from the Opposite Parties on 28.01.2016, which was valid upto 27.01.2017, after depositing the requisite premium of Rs.29,541/- and completing all the formalities. On 05.11.2016, Complainant No.2 got admitted in IVY Hospital, Mohali, on account of heart problem and was discharged on 07.11.2016. On the entire treatment, Complainants spent Rs.2,31,705/-, which they claimed from the Opposite Parties. However, to their utter shock and dismay, the said claim was erroneously rejected by the Opposite Parties on flimsy grounds. With the cup of woes brimming, the Complainant has filed the instant consumer complaint, alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties.

 

1.      Notice of the complaint was sent to Opposite Parties seeking their version of the case.

 

1.      Opposite Parties in their joint reply have pleaded that the Complainant has suppressed the material information with regard to her health and has not disclosed the disease suffered by her prior to the taking of the policy. The claim of the Complainant was thus rightly repudiated. Pleading that there is no deficiency in service or unfair trade practice on their part, Opposite Parties have prayed for dismissal of the complaint.

 

1.      The Complainant also filed replication to the written statement filed by the Opposite Parties, wherein the averments as contained in the complaint have been reiterated and those as alleged in the written statement by the Opposite Parties have been controverted.

 

1.      Parties were permitted to place their respective evidence on record in support of their contentions.

 

1.      We have heard the Ld. Counsels for the Complainant, as well as Opposite Party and have also perused the material placed on record.

 

1.      Admittedly, the Complainants purchased one “Senior Citizen Red Carpet Health Insurance Policy, covering them from their medical treatment, from the Opposite Parties on 28.1.2016, which was valid upto 27.1.2017 and the premium for the same was Rs.29,541/-.

 

1.      The sole grouse of the Complainants is that their genuine claim, in respect of the treatment taken by Complainant No.2, was denied by the Opposite Parties on totally flimsy grounds in a sheer mechanical manner on the ground that Complainant No.2 has suppressed the material information with regard to her health and has not disclosed the pre-existing disease prior to taking the Policy.

 

1.      The key controversy swirls around the short question, “whether the Opposite Parties are well within their rights in repudiating the genuine claim of the Complainants”? 

 

1.      Having bestowed our anxious consideration to the matter, we are of the opinion that in the light of the material on record, answer to the question posted has to be in the negative.

 

1.      A bare perusal of Annexure R-3, which is a copy of Schedule in respect of Senior Citizens Red Carpet Health Insurance Policy, annexed by the Opposite Parties themselves, shows that there is a specific mention of ‘Nil’ in the details of pre-existing diseases relating to Complainant No.2 (Kuldeep Kaur). Importantly, this document has been prepared by the Opposite Parties themselves. Thus the plea taken by the Opposite Parties that the Complainant No.2 has not disclosed the pre-existing disease prior to taking the policy is not well founded. At any rate, the Opposite Parties were very much aware of the fact that Complainant No.2 is not suffering from any of the pre-existing disease. Needless to mention here that it was for the Opposite Parties only to get the thorough check up of the Complainants done before issuing the policy in question. We are of the concerted opinion that issuing the health policy to the Complainants without verifying their health status prima facie proves negligency on the part of the Opposite Parties themselves and later on, repudiating the genuine claim of the Complainants without any concrete evidence amounts to unfair trade practice.   

 

1.      It is an admitted fact that the Complainants were having a valid policy during the period of treatment of Complainant No.2. From the documents submitted by the Complainants as well as the Opposite Parties, one thing is evident that there had not pre-existing disease to the Complainant. The Opposite Parties have miserably failed to produce any documentary evidence against the Complainant No.2 to substantiate that ever before she had undergone any treatment for the said disease. As there is no proof against the Complainant No.2 having suffered the said disease earlier, we have to consider that the Opposite Parties failed to prove that the pre-existing disease was within the knowledge of the Complainant. In the absence of any proof regarding any treatment undergone by the Complainant No.2 prior to the inception of the insurance policy, the claim of the Complainants is to be allowed in toto. We find no suppression of material facts on the part of the Complainants and the pre-existing disease was not proved by the Opposite Parties also.

 

1.      In the result, the instant consumer Complaint deserves to succeed. The same is accordingly allowed qua Opposite Parties. Opposite Parties are, jointly and severally, directed as under: -

[i]  To pay the entire amount incurred by the Complainants on the medical treatment of Complainant No.2 along with interest @ 9% per annum with effect from 07.11.2016 (date of repudiation of claim), till it is paid.

 

[ii] To pay to the Complainants Rs.10,000/- as compensation for mental and physical pain, and inconvenience on account of deficiency in service on the part of Opposite Parties.

 

[iii] To pay to the Complainants Rs.7,000/- as costs of litigation.

 

1.      This order be complied with by Opposite Parties within thirty days from the date of receipt of its certified copy, failing which, it shall make the payment of the amount mentioned at Sr. No. (ii) above, with interest @9% per annum from the date of this order, till realization, apart from compliance of directions at Sr.No.(i) and (iii) above.

 

1.      Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

23^rd February, 2018                                                              

                                          Sd/-

(SURJEET KAUR)

PRESIDING MEMBER

 

                                           Sd/-          

 (SURESH KUMAR SARDANA)

       MEMBER

“Dutt”