Chandigarh

DF-I

CC/79/2018

Pankaj Taneja - Complainant(s)

Versus

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

Inderpal Singh Issar

30 May 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

 

 

                               

Consumer Complaint No.	:	CC/79/2018
Date of Institution	:	05/02/2018
Date of Decision	:	30/05/2019

 

 

Pankaj Taneja s/o S.M. Rana House No.46, Sector 18A, Chandigarh 160018.

… Complainant

V E R S U S

Star Health and Allied Insurance Company Limited, through its Managing Director/Manager.

Local Offices – SCO 110-111, 1^st Floor, Sector 34-A, Chandigarh 160034

SCO No.257, 2^nd Floor, Sector 44C, Chandigarh 160047

Register & Corporate Office 1 New Tank Street Valluvarkottam High Road, Nugambakkam, Chennai 600034.

… Opposite Parties

 

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                    

ARGUED BY	:	Sh. Inderpal Singh Issar, Counsel for complainant
	:	Sh. Gaurav Bhardwaj, Counsel for OPs

Per Rattan Singh Thakur, President

1.         Brief allegations are, on 18.11.2016 complainant had purchased the Senior Citizen Red Carpet Health Insurance Policy from the OP for his parents namely Sh. S.M. Rana, aged 70 years and Smt. Anuriti Taneja, age 67 years 11 months.  The policy was valid upto midnight of 17.11.2017 and the complainant paid premium of Rs.51,750/-. The sum assured was Rs.10.00 lakhs each. Maintained, complainant’s father Sh. S.M. Rana was admitted in hospital due to weakness, fever etc. on 22.5.2017 and was diagnosed with liver cirrhosis and portal hypertension at Max Hospital, Mohali.  It was a cashless policy, however, the claim of the complainant was not processed by the OP and ultimately on 25.5.2017 complainant had paid the amount of Rs.60,000/- of bill raised of hospital from his own pocket.  Later on, claim on being submitted to OP was rejected/ repudiated on the ground that father of the complainant had pre-existing disease of Irritable Bowel Syndrome (IBS) and Bronchial Asthma which was concealed. Hence, the present consumer complaint with the prayer for directing the OP to reimburse the amount of Rs.60,000/- alongwith interest, compensation and costs of litigation. 
2.         OP contested the consumer complaint, filed reply and, inter alia, raised preliminary objections of complainant has no cause of action and the contract of insurance is based on principle of ‘Uberrima Fide’ i.e. utmost good faith; the insurance of the father of the complainant namely Sh. S.M. Rana, aged 70 years was done without pre medical screening. The complainant and his father had concealed the pre-existing disease i.e. asthma and Irritable Bowel Syndrome (IBS) of which there was reference in the treatment chart by the Max Super Specialty Hospital while he was treated for  cirrhosis of liver.  Hence, due to non-disclosure of facts i.e. pre-existing disease at the time of purchase of policy, the claim was repudiated.  On these lines, the cause is sought to be defended.
3.         Rejoinder was filed and averments made in the consumer complaint were reiterated.
4.         Parties led evidence by way of affidavits and documents.
5.         We have heard the learned counsel for the parties and gone through the record of the case. After appraisal of record, our findings are as under:-
6.         Per pleadings of the parties, the admitted facts are, complainant had taken a health insurance policy from the OP for his parents namely Sh. S.M. Rana and Smt. Anuriti Taneja on payment of premium of Rs.51,750/- and admittedly the complainant’s father was hospitalized at Max Hospital on 22.5.2017 i.e. during the continuity of the policy and the diagnosis was liver cirrhosis and portal hypertension. The claim was denied by the OP as there was reference of pre-existing disease irritable bowel syndrome and asthma.
7.         In simple words, irritable bowel syndrome is a disease of auto immune system while asthma is on account of allergic reactions and it had no nexus or connection with the disease the complainant was hospitalized and treated for i.e. liver cirrhosis and portal hypertension. Liver cirrhosis is not a disease or say any allergic reaction or say auto immune system.  Same is the case with portal hypertension. Thus, logically the ground of repudiation given does not appear to be just and reasonable.
8.         Admittedly, OP was aware of the fact that Sh. S.M. Rana, father of the complainant was aged 70 years i.e. to say in the autumn of his life and average age as per the latest data of WHO in India has been assessed as around 68 years. Sh. S.M. Rana had already crossed this average age and with the aging process, every part of the human body degenerates otherwise life cannot be terminated unless there is a degeneration of the body which will be followed with the termination of life. Any disease at juncture and at the fag end of life can develop as the system becomes weak with degenerative changes.  Thus, it does not lie in the mouth of the OP to say that asthma and IBS were pre-existing diseases though no authentic proof to this effect has been produced on record except for say passing reference.  While a contra affidavit has been submitted that
   Sh. S.M. Rana had no pre-existing disease. Assigning of such reasons that there was a pre-existing disease when the life of a senior citizen at the age of 70 years by and large is disease in itself though there may be certain exceptions. Handsome amount of Rs.51,750/- was received by the OP as premium and even then genuine claim for treatment of liver cirrhosis and portal hypertension was repudiated and denied by the OP without assigning any cogent reasons.
9.         We have already concluded that the treatment was done in the hospital for liver cirrhosis and portal hypertension as is made out from the rejection letter annexed at page 52. No medical record has been shown to reflect that bronchial asthma as well as irritable bowel syndrome has any connection with liver cirrhosis and portal hypertension.  The Hon’ble Apex Court in case titled as Sulbha Prakash Motegaonkar & Ors. Vs. Life Insurance Corporation of India, Civil appeal No.8254 of 2015 held as under :-

              “We are of the opinion that the National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischemic heart disease and myocardial infarction had nothing to do with his lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified.”

 

10.         In view of the facts we have already referred supra, and the authoritative precedent of the Hon’ble Apex Court, the present consumer complaint deserves to succeed and the same is accordingly partly allowed. OP is directed as under:-

 

1. To reimburse amount of Rs.60,000/-to the complainant alongwith interest @ 9% per annum from the date of repudiation i.e. 20.6.2017 till realization.
2. To pay an amount of Rs.40,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay Rs.10,000/- to the complainant as costs of litigation.

11.         This order be complied with by the OP within thirty days from the date of receipt of its certified copy, failing which, it shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
12.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
30/05/2019	[Suresh Kumar Sardana]	[Rattan Singh Thakur]
hg	Member	President