Chandigarh

DF-II

CC/35/2018

Naveen Bansal - Complainant(s)

Versus

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

Ashish Bansal Adv. & Rashika Bansal Adv.

04 Dec 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	35/2018
Date of Institution	:	19.01.2018
Date of Decision	:	04.12.2018

 

                                       

                                               

Naveen Bansal s/o Sh.Ram Kala r/o H.No.611, Sector 8-B, Chandigarh

                                ...  Complainant.

Versus

1.     Star Health and Allied Insurance Co. Ltd., through its Zonal Manager, SCO No.257, Second Floor, Sector 44-C, Chandigarh.

 

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

…. Opposite Parties.

 

BEFORE: SHRI RAJAN DEWAN, PRESIDENT

SMT.PRITI MALHOTRA, MEMBER

SHRI RAVINDER SINGH, MEMBER

 

Argued by Sh.Ashish Bansal, Advocate for the complainant

                Sh.Gaurav Bhardwaj, Adv. for the  OPs.     

 

 

PER RAJAN DEWAN, PRESIDENT

1.         Briefly stated, the complainant along with his family consisting of his wife and two minor sons purchased a Medi-Claim Policy i.e. Health Optima Insurance Plan of the OPs, which was valid from 31.03.2017 to 30.03.2018 for basic floater sum assured of Rs.5 lacs (Annexure C-1).  It has been averred that at the time of inception of the policy nothing was explained to him and his signatures were obtained on blank form by giving assurance that it is a mere formality.   It has further been averred that on 08.10.2017, his son suffered high fever and as such he was taken to General Multi Specialty Hospital, Sector 16, Chandigarh in the emergency where he was advised certain tests and medicines.  Subsequently on 09.10.2017 the condition of his son became critical and as such he was got admitted at Bedi Hospital, Sector 33,Chandigarh where he was diagnosed to be suffering with Dengue. It has further been averred that the OPs were informed regarding the hospitalization and on 12.10.2017, the complainant received a letter of denial of pre-authorization for cashless treatment from the OPs.  According to the complainant, his son was admitted in the Bedi Hospital, Chandigarh on 09.10.2017 and was discharged on 13.10.2017 for the treatment of dengue fever with warning signs with syncopal attack and remained under the treatment of Dr.Fazila Mistry and Dr.Ramneek Bedi.  He incurred a sum of Rs.30,410/- on account of the treatment of his son namely Roopam Bansal during the said period.  It has further been averred that he submitted the claim along with the documents through his nephew on 13.10.2017 for reimbursement but the same was denied on the ground that his son had undergone urosurgery 7-8 years back and prior details of the treatment was not submitted, which is prior to the inception of the policy and not disclosed at the time of proposing the Insurance Policy. According to the complainant, the claim has been wrongly denied by the OPs. Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties, the complainant has filed the instant complaint.
2.         In their written statement, the OPs while admitting the factual matrix of the case have admitted that the  son of the complainant was admitted at Bedi Hospital on 09.10.2017 for the treatment of fever and submitted pre-authorization request for cashless treatment.  It was also admitted that the complainant’s son was admitted with complaints of fever with chills with vomiting since 2-3 days and the provisional diagnosis was fever with hepatomeghaly  Dengue.  It has further been pleaded that as the Filed Visit Report(FVR) the insured had undergone urosurgery 6-7 years ago and he had not submitted the prior treatment details and therefore, the request for authorization of cashless treatment was denied and the same was communicated vide letter dated 12.10.2017. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service on its part, a prayer for dismissal of the complaint has been made.
3.         The complainant filed rejoinder to the written reply of the Opposite Parties controverting their stand and reiterating his own.
4.         We have heard the learned counsel for the parties and have gone through the documents on record.
5.         It is well evident on record that the complainant obtained Family Health Optima Insurance Plan from the Opposite Parties commencing from 31.03.2017 till 30.03.2018 (Annexure C-1). 
6.         Admittedly, the complainant’s son was diagnosed with dengue fever with signs of syncopal attack and was treated for the same in Bedi Hospital, Sector 33,Chandigarh  for the period from 09.10.2017 to 13.10.2017 and incurred expenditures to the tune of Rs.30,410/- (Annexures C-6 to C-9).  The claim lodged by the complainant with the Opposite Parties under the policy for cashless authorization was denied vide letter dated 12.10.2017 (Annexure OP-4) on the ground that the complainant’s son had undergone urosurgery 7-8 years back, prior treatment details not submitted.
7.         In the backdrop of above evident facts, we have to see whether the repudiation done by the OPs is justified or not?  For such decision, it is pertinent to look into the reason quoted for the repudiation of the claim by the OPs.  The record reveals that it is so submitted by the OPs that during the investigation, while processing the claim lodged by the complainant, it was revealed that the complainant’s son had undergone urosurgery 7-8 years back, prior treatment details not submitted and, therefore, the cashless facility request was denied following the same the reimbursement claim was also denied.
8.         In view of the terms & conditions of the Policy, we have to see whether the complainant had suppressed any fact required to be disclosed at the time of inception of the policy.  The record before us divulge that no suppression has been made by the complainant as he was not under obligation to disclose about any illness/injury suffered by his or his family members next before the period of 48 months from the date of policy inception.  As per the terms and conditions of the policy in question, the 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 insured person’s first policy with any Indian insurer.  In the instant case, as per the version of the OPs themselves, the complainant’s son had undergone urosurgery 7-8 years prior to the taking the Insurance Policy in question. There is no record to show that the complainant’s son ever taken any treatment for the same within the period of 48 months prior to inception of the policy in question. So to our considered opinion, the case of the complainant definitely does not fall under the category of suppression of fact as alleged by the OPs. Reiterated that no independent evidence has been brought forward by the Opposite Parties to establish that the complainant’s son has ever taken any treatment during the 48 months period prior to inception of the policy in question. 
9.         From the above discussion, it is held that the Opposite Parties have wrongly & illegally rejected the claim of the complainant, which clearly amounts to gross deficiency in service and unfair trade practice on their part.  Therefore, the present complaint is allowed against the Opposite Parties with following directions:-

1. To reimburse the claim amount of Rs.30,410/- to the complainant;
2. To pay an amount of Rs.7,000/- as compensation for causing harassment & mental agony to the complainant;
3. To pay an amount of Rs.5,500/- towards litigation expenses.

10.           This order be complied with by the opposite parties, within 45 days from the date of receipt of its certified copy, failing which the amount at Sr.No.(i)  & (ii) shall carry interest @9 % per annum from the date of this order till actual payment, besides payment of litigation costs.
11.         Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

sd/-                         sd/-                 sd/-

Announced	[RAVINDER SINGH]	[RAJAN DEWAN]	(PRITI MALHOTRA)
04/12/2018	MEMBER	PRESIDENT	MEMBER