Chandigarh

DF-I

CC/23/2019

Sh. Amarjit Singh - Complainant(s)

Versus

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

Deep Singh

08 Mar 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/23/2019
Date of Institution	:	15/01/2019
Date of Decision	:	08/03/2021

 

Sh. Amarjit Singh s/o Sh. Sadhu Singh aged 51 years, r/o Plot No.544, Phase-9, Industrial Area, SAS Nagar, Mohali.

… Complainant

V E R S U S

Star Health and Allied Insurance Co. Ltd., SCO No.130-131, 4^th Floor, Sector 34-A, Chandigarh 160022 through its Managing Director.

Second Address :

Star Health and Allied Insurance Co. Ltd., #1, new Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai 600034 through its Managing Director.

… Opposite Party

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                

ARGUED BY	:	Sh. Devinder Kumar, Counsel for complainant
	:	Sh. Satpal Dhamija, Counsel for OPs

 

Per Rattan Singh Thakur, President

1.      Averments are, complainant was having Family Health Insurance Plan from the New India Assurance Company since last many years. On being allured by the OP Insurance company for better coverage and service, he agreed to port his family health policy with it and paid the premium of ₹24,072/- vide cheque dated 5.4.2018. The policy was valid from 15.4.2018 to 14.4.2019. It provided the coverage to his wife, Mrs. Sukhwinder Kaur also. Maintained on 24.9.2018, Mrs. Sukhwinder Kaur had a medical emergency and was admitted in Fortis Hospital, Mohali where she was implanted with stents and remained in Hospital for about two days. The total cost of the medical procedure raised by the hospital was ₹3,33,748/- and on claim being submitted, OP repudiated the same vide letter dated 1.12.2018. Not only this, even OP had sent another letter/notice dated 3.12.2018 for the cancellation of the policy from 12.1.2019. Alleged, the action of the OP comes within the definition of deficiency in service and unfair trade practice. Hence, the present consumer complaint for directing the OP to pay the claim of ₹3,33,748/- alongwith interest, compensation of Rs.1,00,000/- and ₹20,000/- as litigation expenses.
2.     OP contested the consumer complaint, filed its written reply and, inter alia, raised preliminary objections of consumer complaint being not maintainable and the terms and conditions were explained to the complainant at the time of proposing the policy. Maintained, complainant had concealed the pre-existing disease of his wife, Mrs. Sukhwinder Kaur as she was hospitalized from 31.5.2007 to 1.6.2007 and was treated for retroperitoneal fibrosis and underwent ureterolysis with biopsy with DJ stent and was on tablet Tamoxifen from 2013. As such, the claim preferred was rightly repudiated. On these lines, the cause is sought to be defended.
3.     Rejoinder was filed by the complainant 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 perusal of record, our findings are as under:-
6.     Per paragraph No.6 of the consumer complaint, the definition of pre existing disease  as provided in the consumer information sheet (Annexure C-8) is as under :-

         “Pre-Existing Disease means any condition, ailment or injury or related condition(s) for which there were sign or symptoms and/or were diagnosed, and/or for which medical advice/ treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter.” 

 

7.     The date of the proposal of the present policy on the basis of which the claim was preferred is 15.4.2018. This means the complainant and his family was not entitled for the reimbursement of the treatment of the disease within 48 months prior to the first insurance issued by the insurer and renewed continuously. 
8.     Contents of the consumer complaint and written reply furnished shows Mrs. Sukhwinder Kaur had undergone ureterolysis with biopsy in the year 2007 for retroperitoneal fibrosis. It was talk of the year 2007 and the treatment in the form of tablets continued till 2013.  No record has been produced by the OP to say subsequent to the year 2013, she was on treatment for the disease of retroperitoneal fibrosis.  The present policy was taken/ported on 15.10.2018 i.e. to say the period of 48 months from the date of taking the present policy had stood expired. Therefore, the claim of the complainant did not fall in the exclusion clause of the policy.
9.     We may mention here, as per record even if it is assumed treatment of the previous disease continued till 2013, it is not the case of the OP retroperitoneal fibrosis disease is not curable or treatable meaning thereby this disease stood cured in the year 2013 and on the date of the present policy i.e. 15.4.2018, it cannot be said Mrs.Sukhwinder Kaur was suffering from any pre-existing disease which was under treatment so as to oust the claim per terms and conditions of the policy. The word used is pre-existing disease on the date of proposal and as per record the pre-existing disease was cured in the year 2013 and, therefore, it cannot be said she had concealed the disease so as to invoke this exclusion clause to deprive the complainant of the claim.
10.     Perusal of the record shows, the wife of the complainant was treated from 24.9.2018 for heart complication and angioplasty has no connection with the disease of retroperitoneal fibrosis. To this effect, the complainant has even obtained report (Annexure P-9) from Dr. P.N.Gupta, Consultant Surgeon & Urologist, P.N. Urology & Surgical Hospital (P) Ltd., who certified angioplasty has no relation with Tamoxifen (tablet) and that he was surprised to get this type of query from the insurance. Thus, even the previous disease which was treated and cured upto 2013 had no connection with the present policy for which the complainant’s wife was hospitalized and made the payment of ₹3,33,748/-.
11.     Our attention was also drawn to the Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests) Regulations, 2017 and as per clause 10 thereof freelook cancellation of life insurance policies has to be provided i.e. for forwarding the policy to the policy holder that he has a freelook period of 15 days from the date of receipt of the policy document and 30 days in case of electronic policies and policies obtained through distance mode, to review the terms and conditions of the policy. The present policy pertains to electronic mode and it is not the case of the OP the said period of 30 days to review the terms and conditions was provided to the complainant.  Thus, by repudiating the genuine claim of the complainant, the OP is proved to have indulged in deficiency in service and unfair trade practice.
12.     In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OP is directed as under :-

1. to pay the claim of ₹3,33,748/- to the complainant alongwith interest @ 8% per annum from the date of repudiation i.e. 1.12.2018 till realization.
2. to pay an amount of ₹15,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/- to the complainant as costs of litigation.

13.     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.
14.     Certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
08/03/2021	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	Member	President