Chandigarh

DF-II

CC/325/2014

Naresh Kumar Juneja - Complainant(s)

Versus

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

Sukaam Gupta, Adv.

30 Jan 2015

ORDER

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

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Consumer Complaint  No	:	325 of 2014
Date  of  Institution	:	02.07.2014
Date   of   Decision	:	30.01.2015

 

 

 

 

 

Naresh Kumar Juneja, Age 70 years, R/o #353, Sector 9-D, Chandigarh.

                                     

             Complainant

 

Versus

 

Star Health and Allied Insurance Co. Ltd., SCO No.257, 2^nd Floor, Sector 44-C, Chandigarh through its Manager.

 

 Opposite Party

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         SH.JASWINDER SINGH SIDHU       MEMBER

        

 

Argued By:  Sh.Sukaam Gupta, Counsel for the complainant.

Sh.Gaurav Bhardwaj, Counsel for the OP.

 

 

PER JASWINDER SINGH SIDHU , MEMBER

 

 

          As per the case of the complainant, he took a Mediclaim policy i.e. Senior Citizen Red Carpet Insurance Policy from Opposite Party for himself in the year 2012, having sum insured of Rs.3.00 lacs (Ann.C-1 colly.).  The said policy was got renewed from 31.3.2013 to 30.3.2014 and the sum insured was enhanced to Rs.5.00 lacs (Ann.C-2 colly.). It is averred that the complainant, while in Delhi, suddenly fell ill and severe chest pain on 6.2.2014 and was taken to Fortis Escorts Hospital, Delhi, where an angiography was done.  Subsequently, he was admitted in the said Hospital on 7.2.2014 for further treatment.  The pre-authorization was sent to Opposite Party on 7.2.2014, which was rejected on the ground that the complainant is suffering from pre-existing disease (Ann.C-3).  The complainant remained admitted under treatment till 9.2.2014 during which period, angioplasty and other treatment was given to him and Rs.3,69,529/- were spent on the said treatment.  The said amount was paid by the complainant (Ann.C-4 Colly. & Ann.C-5).  The complainant duly provided the bills and treatment record in original to the Opposite Party for reimbursement of the amount spent, but the Opposite Party illegally repudiated his claim on 3.5.2014 on the ground that he was suffering from pre-existing disease (Ann.C-6).  It is pleaded that the treatment taken in the year 1997 and 2006 by the complainant were fully disclosed to the insurance company.  It is also pleaded that the last treatment by the complainant was taken in the year 2006 and the first proposal was made in the year 2012.  Alleging the said repudiation as illegal and deficiency in service, the present complaint has been filed.

 

2]       The Opposite Party has filed reply and admitted the issuance of policy, treatment taken by the complainant during the currency of said insurance policy as well as the amount spent thereon by the complainant himself, as a matter of record.  It is denied that the complainant has disclosed his previous ailments to the OPs.  The policy was issued to the complainant based upon the proposal form filled by him and all terms & conditions were explained to him (Ann.R-1).  It is stated that the pre-authorization was rightly rejected as the treatment sought for was for the pre-existing disease and the complainant failed to disclosed the said fact in his proposal form and gave specific answer ‘NO’ in the relevant column. The claim of the complainant was legally repudiated as per Condition No.7 of the policy.  It is submitted that the complainant has suppressed the material information with regard to his health and has not disclosed the disease suffered by him prior to the taking of the policy. Rest of the allegations have been denied with a prayer to dismiss the complaint.

 

3]       Parties led evidence in support of their contentions.

 

4]       We have heard the ld.Counsel for the parties and have also perused the record.

 

5]       The complainant has preferred the present complaint on the ground that he had subscribed for a “Senior Citizen Red Carpet Insurance Policy” from the Opposite Party in the year 2012 valid from 31.3.2012 to 30.3.2013 and thereafter, the same was got renewed in the year 2013 valid from 31.3.2013 to 30.3.2014.  During the currency of the second policy, the complainant suffered an ailment on 7.2.2014 for which he was hospitalized at Fortis Escorts Heart Institute, Delhi and incurred an amount of Rs.3,69,529/- as hospitalization charges.  The complainant lodged his claim with the Opposite Party, which was ultimately denied by it vide its letter dated 03.5.2014 claiming that the complainant had already suffered a Coronary Heart disease in the year 1997 and also had a past history of UGI Bleed in 2006 prior to the inception of the policy and that the complainant not having disclosed his previous medical history/health details in the proposal form, the same amounted to mis-representation/non-disclosure of material facts and therefore, on this ground the claim was denied.   

 

6]       The Opposite Party while contesting the complaint of the complainant has heavily relied upon documents Ann.R-1, which is the proposal form and also a questionnaire in which the complainant was asked to disclose whether he had ever suffered from or was suffering from any of the mentioned diseases. This questionnaire is found to be answered in negative and therefore, as the complainant had already undergone treatment in the year 1997 and 2006, meaning thereby that the complainant preferred not to answer the questions in the affirmative and therefore, he had mislead the Opposite Party about his health status and therefore, the claim of the complainant deserved to be rejected on account of suppression of material facts.  Thus, Opposite Party has prayed for dismissal of the complaint.

 

7]       We have perused the documents placed on record by the Opposite Party on the basis of which the claim of the complainant was repudiated citing the reasons so mentioned in the repudiation letter.  It is also important to go through the terms & conditions of the policy wherein the terms pre-existing disease, as defined in the Policy document and the relevant Exclusion clauses, read as under:-

“Pre-Existing Disease means any condition, ailment or injury or related condition(s) for which the insured person had signs or symptoms and/or were diagnosed and/or, received medical advice/treatment within 48 months prior to the inception of the insured persons first policy with the Company….. 

        

EXCLUSIONS

The company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of:

 

1. All Pre-existing disease as defined in the policy existing and suffered by the insured person for which treatment or advise was recommended or received during the immediately preceding 12 months from the date of proposal.

Xxxxxxxx

5.  50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the Insured.”

 

8]       It is important to mention here that the complainant, who is a 70 years old man and has categorically stated in Para No.6 of his complaint that at the time of filling-up of the proposal form for the health insurance policy from the Opposite Party, he was hale and hearty and that the fact with regard to the treatments taken in the year 1997 and 2006 was disclosed to the insurance company.  The complainant has also stated in Para No.7 of his complaint that he had never received any treatment in any hospital 48 months prior to taking of the policy or in the preceding 12 months from the date of proposal.  The last treatment taken by the complainant was in the year 2006 and the first proposal for the policy in continuance was filled-up in the year 2012, therefore, the pre-existing clause or the allegation of non-disclosure of previous ailments, did not disqualify the complainant from his rightful claim.  The complainant has also filed a duly sworn affidavit in support of his contentions as mentioned in the complaint. 

 

9]       The fact that the Opposite Party has merely placed on record the copies of the diagnostic reports, whereas the claim about the disclosure of the previous ailment, as claimed by the complainant in his complaint, has not been controverted with the cogent evidence by the Opposite Party.  However, the Opposite Party while contesting the amount of relief claimed by the complainant to the tune of Rs.3,69,529/- has claimed that the actual claim, if at all payable, is only limited to Rs.1,80,000/- as per the relevant column of limit of company’s liability mentioned on Page 17 of the terms & conditions of the insurance policy, placed on record by the complainant himself.  The complainant has not controverted this fact by either filing rejoinder in reply to the version of the Opposite Party or explaining this issue in any other manner.  Therefore, in these set of circumstances, we feel that the complainant is only entitle to a maximum of 70% of the amount as mentioned in the liability clause of the policy terms & conditions, limited to the maximum of Rs.1,80,000/-.  The Opposite Party therefore should have settled the claim of the complainant on the aforementioned terms & conditions of the policy as well as the applicable exclusion clauses as applicable to the pre-existing disease and such a failure on its part certainly amounts to deficiency in service towards the complainant. 

 

10]     Hence, in view of the foregoing discussion, we allow the complaint of the complainant against the Opposite Party.  Therefore, the Opposite Party is directed as under:-

 [a] To pay 1,80,000/-, as per Clause-G of the terms & conditions of the policy, to the complainant.

[b] To pay Rs.15,000/- to the Complainant as compensation, on account of deficiency in service, unfair trade practice and causing mental agony and harassment as well as litigation expenses.

 

                The above said order shall be complied within 45 days of its receipt by the Opposite Party; thereafter, it shall be liable to pay for an interest amount @18% per annum on the amount mentioned in sub-para [a & b] of Para 10 above from the date of filing of this complaint i.e. 02.07.2014, till it is paid. 

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

30.01.2015                                 Sd/-

 (RAJAN DEWAN)

PRESIDENT

 

 

 

Sd/-

 (JASWINDER SINGH SIDHU)

                                                                     MEMBER

 

Om

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISTRICT FORUM – II

CONSUMER COMPLAINT NO. 325 OF 2014

PRESENT:   None   Dated the 30th day of January, 2015

O R D E R                      Vide our detailed order of even date, recorded separately; the complaint has been allowed against Opposite Party. After compliance, file be consigned to record room.

 

(Jaswinder Singh Sidhu)	(Rajan Dewan)
Member	President