Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 23.
Instituted on : 10.01.2020.
Decided on : 04.07.2022.
Rajesh Kumar age 44 years s/o Sh. Kartar Singh R/o H.No.57/17, Udmi Pura Wakilo Wali Gali, Rohtak-124001(Haryana).
.......................Complainant.
Vs.
- Star Health and Allied Insurance Co. Ltd. Ashoka Plaza, 3rd Floor, Delhi Road, Rohtak-124001.
- Star Health and Allied Insurance Co. Ltd. New Tank Street, Valluvarkottam High Road, Nungambakkam, Chennai-600034.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR. SHYAM LAL, MEMBER
Present: Sh.Sunil Kumar, Advocate for the complainant.
Shri Gulshan Chawla, Advocate for the opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that he had applied for Health Insurance Plan–Family Health Optima Insurance-2017 from respondent no.1 & 2 in May 2017 and paid a sum of Rs.11586/- as premium of insurance plan. Opposite parties issued a policy no.P/211118/01/2018/000860 on dated 31.05.2017, basic floater sum insured Rs.300000/-. In the above said policy the complainant and his family members namely Sunita-Spouse, Anjali-Daughter and Varun-son were insured. The complainant was hale and healthy and was not suffering from any disease at the time of issuance of policy. The complainant paid the renewal amount in the year 2018 & 2019 and the policy is continuing upto 30.05.2020. The complainant suffered from Piles and treated himself first time on 14.01.2019 and after that he was admitted and operated for Pile Surgery on 01.06.2019 at Chowdhary Hospital Rohtak vide Admn. No.200/2019. The total expenditure in this treatment came Rs.46090/- The complainant filed a claim with the insurance company for reimbursement of hospitalization expenses for treatment of the alleged disease and submitted all the required treatment documents and bills. But the opposite party No.1 & 2 cancelled the claim and refused to pay the treatment expenses as remarks “You have not declared the details chronic Liver disease which were found to be pre-existing at the time of taking the policy for the first time during 31 May 2017 to 30 May 2018. This amounts to non disclosure of material facts”. The respondent no.1 & 2 also cancelled the insurance policy. It is the responsibility of opposite parties to pay the treatment expenses according to the terms and conditions of the policy. But they failed to pay the claim amount to the complainant. The act and conduct of the opposite party is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite parties may kindly be directed to pay the amount of claim alongwith interest @ 18% p.a. from the date of arise of claim till its realization and also to pay an amount of Rs.50000/- as compensation and Rs.11000/- as litigation expenses to the complainant.
2. After registration of complaint, notices were issued to the opposite parties. Opposite parties in their reply has submitted that opposite parties issued the policy no.P/211118/01/2018/000860 for the period 31.05.2017 to 30.06.2018 and which was subsequently renewed for the period 31.05.2018 to 30.05.2019. The alleged policy was issued only on the basis of declaration given by the complainant in the proposal form, subject to terms and conditions. The claim of the complainant was received in the office of answering opposite party wherein insured-patient was seeking reimbursement of hospitalization expenses for treatment of internal piles with bleeding PR, chronic liver disease with anemia. The patient was hospitalized for internal piles with bleeding PR, chronic liver disease with anemia for the period from 30.05.2019 to 03.06.2019 in Chowdhary Hospital, Rohtak. The insured has submitted the claim of Rs.46090/- for reimbursement of expenses incurred during hospitalization. Although the present admission and treatment of the inured patient is for internal piles with bleeding PR with anemia. It is observed from discharge summary dated 30.05.2019 that inured was diagnosed with internal piles with bleeding PR, chronic liver disease with anemia and has a complaint of Chronic Liver Disease and taking treatment regularly. Hence, the opponent have raised query to submit the previous treatment records and investigation report towards the diagnosis of Liver Disease and USG abdomen. The insured provided the incomplete documents towards the query raised by the opponent, on scrutiny of the query reply, it is observed from the out patient card dated 20.07.2017 of Pt. B.D.Sharma PGIMS, the patient has hepatitis C, portal hypertension and decompensated liver disease which confirms that the insured patient has long lasting decompensated liver disease, hepatitis c, portal hypertension prior to inception of the medical insurance policy. Further, inspite of request that the insured patient has not submitted the previous USG abdomen report, LFT report which amounts to non submission of required documents and non cooperation. The answering respondent served letter dated 09.10.2019, 24.10.2019, 08.11.2019 and 23.11.2019 for seeking documents. But getting no response, the claim of the complainant was rejected and the same was communicated to insured vide our letter dated 24.12.2019. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with costs.
3. Ld. Counsel for the complainants in their evidence has tendered affidavit Ex.CW1/A and documents Ex.C1 to Ex.C18 and has closed his evidence on dated 12.03.2021. Ld. Counsel for the Opposite party no.1 in his evidence has tendered affidavit Ex.RW1/A, Ex.RW1/B and document Ex.R1 to Ex.R15 and has closed his evidence on dated 01.10.2021.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case, the policy has been purchased by the complainant on dated 31.05.2017 and the sum assured was Rs.3 lac. The same has been renewed from time to time by the complainant. The complainant was admitted in Chowdhary Hospital on dated 30.05.2019 and discharged on 03.06.2019. In the hospital the complainant was treated for internal piles alongwith bleeding PR chronic liver disease with anemia. The complainant has submitted the claim of Rs.46090/- for reimbursement regarding the expenses incurred during the hospitalization by the complainant. Complainant submitted all the required documents to the respondent insurance company but the insurance company sought some clarifications from the complainant through letter Ex.R8. In this letter, the respondent asked the complainant to give an exact duration of chronic liver disease and when he was first diagnosed and through this letter they further demanded previous investigation reports USG abdomen and LFT. Some documents were demanded by the opposite party through letters Ex.R9 & Ex.R10 and the claim of the complainant has been repudiated by the opposite party vide letter dated 24.12.2019 placed on record as Ex.R11 on the ground that the complainant has a longstanding decompensated liver disease, hepatitis C, portal hypertension prior to inception of the medical insurance policy and this fact has been confirmed through patient OPD card dated 10.07.2017 of Pt. B.D.Sharma PGIMS, Rohtak. After considering the above mentioned facts and other relevant documents the claim has been repudiated under the condition no.3 & 6 of the policy.
6. We have minutely perused the documents placed on record by the parties. As per documents, the inception period of the policy was from 31.05.2017. The patient took treatment from PGIMS Rohtak for the very first time on dated 10.07.2017. The patient took treatment from Chowdhary Nursing Home on dated 30.05.2019 regarding internal piles with bleeding P/R with liver disease with anemia. In fact the complainant took treatment regarding the piles with bleeding PR and other diseases. The hepatitis ailment is merely an infection and it cannot be presumed that it was within the knowledge of complainant on dated 31.05.2017 when the policy came into existence that he was suffering from hepatitis. No doubt the complainant took treatment on dated 10.07.2017 from PGIMS Rohtak and the duration of the ailment has not been mentioned anywhere in the OPD card so it cannot be presumed that the complainant was suffering from hepatitis with infection at the time of inception of the policy. Even he himself did not know about the disease of hepatitis at the time of inception of policy and it is proved from the recording placed on record by the respondent as Ex.R15, which is the conversation took place between the complainant and authorized representative of the company who verified all the contents of the proposal form from the complainant. The authorized person of the company specifically asked from the complainant that whether the person proposed for insurance consulted/taken treatment or have been admitted for any illness, disease, injury or surgery and the complainant has specifically answered these questions as ‘No’. It was a medical health insurance policy and if the opposite party was having any doubt, they should have done the medical examination of the complainant/insured persons. Moreover, as per document Ex.C4 issued by Chowdhary Hospital, Dr.R.K.Chaudhary has submitted that : “The patient was operated for internal haemorrhoids on 01.06.2019, He consulted the undersigned for piles first time on 14.01.2019”. Meaning thereby, he consulted the alleged hospital after two years from the inception of policy. Hence from the documents placed on record by both the parties it is not proved that complainant/insured person was suffering from any disease at the time of inception of policy. Hence the repudiation of claim of the complainant is illegal and there is deficiency in service on the part of opposite parties. As such opposite parties are liable to pay the claim amount to the complainant. As per the complainant, he has spent an amount of Rs.46090/- on his treatment and to prove the same he has placed on record copy of bills Ex.C9 to Ex.C17 & certificate Ex.C18. As per certificate Ex.C18, the Chowdhary Hospital has certified that they have charged Rs.34200/- from the complainant and the complainant spent other amount on purchase of medicines, tests and surgical equipments etc. as is proved from the bills placed on record.
7. In view of the fact and circumstances of the case we hereby allow the compliant and direct the opposite parties to pay the amount of Rs.46090/-(Rupees forty six thousand and ninety only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 10.01.2020 till its realization and shall also pay a sum of Rs.5000/-(Rupees five thousand only) as compensation 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.
8. Copy of this order be supplied to both the parties free of costs.
9. File be consigned to the record room after due compliance.
Announced in open court:
04.07.2022.
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Nagender Singh Kadian, President
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Tripti Pannu, Member.
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Shyam Lal, Member
