Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 582.
Instituted on : 26.11.2018.
Decided on : 06.10.2020.
Nitin Garg age 31 years, s/o Prem Chand Garg R/o H.No.1558/17, Bhola Shakar Gali, Jhajjar road, Rohtak, Haryana-124001.
………..Complainant.
Vs.
- Star Health and Allied “Insurance Co. Ltd. Ashoka Plaza, 3rd floor, Delhi Road, Rohtak.
- Star Health and Allied Insurance Co. Ltd., Grievance Department No.1, New Tank Street, Velluvar Kottam High Road, Nugambakkam, Chennai-600034.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. RENU CHAUDHARY, MEMBER.
MS. TRIPTI PANNU, MEMBER.
Present: Sh.Vipin Gopal Advocate for the complainant.
Sh.Gulshan Chawla, Advocate for opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that the complainant had taken an insurance policy titled “Family Health Optima Insurance Plan” from respondent vide policy No.P/211118/01/2017/000422 for the period from 17,.05.2016 to 16.05.2017 and the complainant himself alongwith his spouse Preeti and daughter Navya were insured under the above said policy. The complainant was blended with a daughter on 29.10.2016 and he submitted an application on dated 08.12.2018 to respodnentno.1 for inclusion of name of his newly born daughter in his existing Health Policy and submitted the relevant documents with the insurance company. The complainant had received an “Endorsement Schedule-Inclusion of new born” by the respondent having endorsement no.P/211118/01/2017/000422/001 w.e.f. 10.12.2016 declaring that new born baby of the complainant included under the policy. The above said policy was got renewed by the complainant from respondents on dated 05.05.2017 vide policy No.P/211118/01/2018/000492. The complainant’s daughter Avni fell ill and admitted to Verma Nursing home Rothak on dated 05.08.2017. the complainant had paid a total amount of Rs.40244/- for hospital charges, laboratory charges, medicine charges etc. The complainant submitted the claim for reimbursement of the bills under claim intimation. After that the complainant received a letter from the respondents to deposit some additional documents within 15 days to further proceedings of the claim which were deposited by the complainant in time. But the claim was rejected by the respondents on the ground that there was HIE Sequelae in a premature baby with low birth weight and birth asphyxia, which is prior of medical insurance policy. Hence it is the existing disease. As per exclusion No.1 of the policy, company is not liable to make any payment in respect of expenses of the treatment of the pre-existing disease/condition until 48 month of continuous coverage has elapsed, since inception of the policy. Complainant did not hide any disease of his daughter Avni while including her name in the existing policy. Because he submitted her discharge card issued by PGIMS Rohtak. The act of opposite parties is illegal and amounts to deficiency in service. “Hence this complaint and it is prayed that opposite party may kindly be directed to disburse the claim amount of rs.40244/- alongwith interest thereon @ 18% per annum and Rs.30,000/- as harassment to the complainant.
2. After registration of complaint, notice was issued to the opposite party. Opposite party in its reply has submitted that opposite party issued policy No.P/211118/2017/000422 for the period of 17.05.2016 to 16.05.2017 covering Nitin Garg, Preeti and Navya for the insured limit for Rs.500000/-. Thereafter the request was received in the office of answering respondent for addition of name of Avni in the policy schedule. The answering opposite party relying upon the information given in the proposal form, issued the endorsement schedule, including in the name of Avni, in the policy schedule vide endorsement dated 10.02.2016(this date is wrongly mentioned in written statement whereas the actual date is 10.12.2016). It is further correct that opposite party continued/renewed the policy for the period 17.05.2017 to 16.05.2018 vide policy no.P/211118/01/000492. On receiving the documents regarding admission of Avni at Vijay Verma Kids Care Hospital alongwith claim form, same were forwarded to the expert for analyzing of the claim on merits. After going through the entire documents it became crystal clear that in the discharge summary of Vijay Verma Hospital, the baby was treated for septicemia and on scrutiny of medical record it was observed that the baby was diagnosed HIE Sequale/late onset of septicemia with history of birth asphyxia, she was a preterm baby(31 days) and was kept in NICU. The HIE sequelae in a premature baby with low birth weight and birth asphyxia, which is prior to inception of medical insurance policy. Hence it is a pre existing disease and as per Exclusion No.1. of the policy, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/condition until 48 months of continuous coverage has elapsed, since inception of the policy. As such the claim was rightly repudiated by the opposite party. There is no deficiency in service on the part of opposite parties and dismissal of complaint has been sought.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C20 and has closed his evidence on dated 08.02.2019. Ld. counsel for the opposite party has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R4 and closed his evidence on 26.08.2019.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. After going through the file and hearing the parties it is observed that the claim of the complainant has been repudiated by the opposite party vide its letter Ex.R14 on the ground that the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/condition, until 48 months of continuous coverage has elapsed, since inception of the policy. In the present complaint, the policy was issued on 17.05.2016 and a written request has been made by the complainant for endorsement of name of his newly born daughter namely Avni, which has been placed on record by the respondent officials as Annexure-JN-R alongwith the other documents but the same has not been exhibited. As per this application itself, the complainant had attached three documents with this application. The bare perusal of this application itself shows that discharge card of Avni(baby of the Preeti) has been attached with the application and these documents have been placed on record by the respondent itself as Ex.R11(discharge summary of Avni, baby of Preeti). The detail of baby at the time of birth has been mentioned in this discharge card. The respondent officials has issued a policy and the endorsement in the policy was made on 10.12.2016 after considering all the required and requisite documents which have been demanded by the respondent and the same has been supplied by the complainant. But thereafter, opposite parties repudiated the claim of the complainant on the ground of pre-existing disease of Avni(baby of Preeti). The complainant made a plea in his evidence in para no.6 of the affidavit that : It is pertinent to mention that HIE Sequelae in a premature baby with low birth weight and birth asphyxia, which is prior of medical insurance policy. Hence it is the existing disease. As per exclusion No.1 of the policy, company is not liable to make any payment in respect of expenses of the treatment of the pre-existing disease. But the same is not a pre-existing disease and the opposite party deliberately issued the policy after taking into consideration the discharge card of Avni d/o Nitin Garg issued by PGIMS, Rohtak. The admission and discharge summary of child w.e.f. 05.08.2017 to 11.08.2017 in Verma Nursing Home is Ex.R7. Moreover, the baby child suffered from Septicemia only. Septicemia is not a genetic disease. In fact it is a bacterial infection elsewhere in the body, such as lungs or skin, enters the blood stream. This is dangerous because the bacteria and their toxins can be carried through the blood stream to your entire body. Moreover, initially the endorsement was made by the company on dated 10.12.2016 in the existing policy i.e. for the period 17.05.2016 to 16.05.2017. Thereafter the insurance company received the claim form from the complainant and the company perused all the documents again and made an endorsement No.P/211118/01/2018/00042/001 on dated 31.10.2017 and the type of endorsement was changed in risk column. Meaning thereby, prior this endorsement the company issued the policy but this endorsement was made after receiving the claim from the complainant and this endorsement is afterthought of the company. Meaning thereby, the baby was fully covered under the policy issued w.e.f. 17.05.2016 to 16.05.2017 and thereafter from 17.05.2017 to 16.05.2018, as the opposite party issued an “Endorsement Schedule-Inculsion of New Born” bearing no.P/211118/01/2017/000422/001 placed on record as Ex.P2. As per this Endorsement schedule, opposite party declared the newly born baby Avni included in the policy No. P/211118/01/2017/000422 w.e.f.10.12.2016. It is further submitted in this document that all other terms, conditions and warranties of the policy remain unaltered. Hence the issuance of endorsement schedule on 31.10.2017 placed on record as Ex.R5, changing the risk element, under the head, pre existing disease: “All neurological diseases and its complications” is the afterthought of the opposite party just to decline the claim of the complainant is illegal and not binding upon the rights of the complainant. Hence in view of the aforesaid reasons, the repudiation of claim by the opposite parties is illegal and amounts to deficiency in service. Somehow, the respondents have partly admitted the claim of the complainant in their written statement in para no.9, to the effect that if all the opponents are held liable to pay the claims of the complainant, the liability of the opponent as per the terms and conditions shall be limited to Rs.31150/- and the same is also settled as per document Ex.R15.
6. In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite parties to pay the amount of Rs.31150/-(Rupees thirty one thousand one hundred and fifty only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 26.11.2018 till its realization and also to pay Rs.5000/-(Rupees five thousand only) on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
06.10.2020.
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Nagender Singh Kadian, President
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Renu Chaudhary, Member.
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Tripti Pannu, Member.
