Chandigarh

DF-I

CC/330/2015

Naresh Kumar Juneja - Complainant(s)

Versus

Star Health and allied Insurance co. Ltd - Opp.Party(s)

Munish Goel

06 May 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

============

Consumer Complaint  No	:	CC/330/2015
Date  of  Institution	:	28/05/2015
Date   of   Decision	:	06/05/2016

 

 

 

 

 

Naresh Kumar Juneja, resident of House No.353, Sector 9-D, Chandigarh.

….Complainant

Vs.

 

[1]  Star Health and Allied Insurance Co. Limited, KRM Centre, VI Floor, No.2, Harrington Road, Chetpet, Chennai – 600031, through its Managing Director/ Director/ Authorized Signatory.

 

[2]  Star Health and Allied Insurance Co. Limited, SCO No.257, 2^nd Floor, Sector 44-C, Chandigarh, through its Regional Manager/ Manager/ Authorized Signatory.

 

…… Opposite Parties

 

BEFORE:   MRS.SURJEET KAUR             PRESIDING MEMBER

          SH. SURESH KUMAR SARDANA     MEMBER

 

 

For Complainant	:	Sh. Munish Goel, Advocate.
For Opposite Parties	:	Sh. Gaurav Bhardwaj, Advocate.

 

PER SURESH KUMAR SARDANA, MEMBER

 

 

 

          In brief, the Complainant had taken “Senior Citizen Red Carpet Insurance Policy” from Opposite Parties for himself in the year 2012 having sum insured of Rs.3.00 lacs and got the said medi-claim policy renewed for the period 31.3.2013 to 30.3.2014 and got enhanced the sum insured to Rs.5.00 lacs. The Complainant further got the said medi-claim policy renewed from Opposite Parties for the period 31.3.2014 to 30.3.2015 for sum insured of Rs.5.00 lacs (Annexure C-1 to C-3). It has been averred that during the existence of present Policy for the period 31.3.2014 to 30.3.2015 the Complainant felt ill and was taken to PGIMER, Chandigarh. The Complainant was diagnosed to be suffering from Acute Mycloid Leukemia. The Molecular Genetic Analysis report dated 29.1.2015, Bone Marrow Examination and Immunophenotyping report for acute leukemia are annexed as Annexure C-5 to C-7. It has been further averred that the Complainant was not suffering from this disease earlier and have no knowledge of the same prior to 29.1.2015. The Complainant was got admitted in Fortis Hospital on 31.1.2015 for the treatment of Acute Promyelocytic Leukemia-M3 for conducting Chemotherapy. The Complainant accordingly sought cashless facility from Opposite Parties, but the same was illegally refused vide letter dated 4.2.2015. The Complainant took treatment for the period from 31.1.2015 to 27.2.2015 at Fortis Hospital, Mohali. The discharge summary is annexed as Annexure C-9. The Complainant duly spent Rs.6,37,514/- on the said treatment (Bills Annexure C-10). After discharge from Fortis Hospital on 27.2.2015, the Complainant duly lodged the claim with the Opposite Parties for reimbursement of amount spent by him on his treatment. The Opposite Parties accepted the claim form but did not provide any receipt on the pretext that the Complainant would receive letter qua admissibility of his claim shortly. Thereafter, the Complainant further fell ill and was diagnosed to be suffering from Phemonia. The Complainant was got admitted for the treatment with Fortis Hospital, Mohali on 9.3.2015. The Complainant took the treatment was discharged on 21.3.2015. The Complainant spent Rs.4,68,085/- on his treatment (Bill Annexure C-13). It has been alleged that the Complainant received letter dated 10.3.2015, during his admission in hospital for the period 9.3.2015 to 21.3.2015, stating that his claim is repudiated on account of non-disclosure of material fact i.e. about the existence of pre-existing disease and they further cancelled the policy on pro-rata basis and refunded the premium for the remaining period. The Opposite Parties enclosed a Cheque of Rs.20,225/- along with letter dated 10.3.2015 (Annexure C-13 and C-14). Thereafter, the Complainant wrote letter dated 26.3.2015 to the Opposite Parties and submitted that he was not suffering from any pre-existing disease and also returned the draft sent by the Opposite Parties for the amount of Rs.20,225/- (Annexure C-15 and C-16). The Complainant further lodged claim with the Opposite Parties for reimbursement of amount spent by him on his treatment for the period 9.3.2015 21.3.2015, support by all relevant documents, but the Opposite Parties were bent upon not to process his genuine claim by adopting the stand that they had not received the documents; whereas the Complainant had two times submitted the documents with the Opposite Party No.2. With the cup of woes brimming, the Complainant thus constrained to file the instant consumer complaint, alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties.

 

2.     Notice of the complaint was sent to Opposite Parties, seeking their version of the case.

 

3.     Opposite Parties in their written statement while admitting the factual aspects of the case, have pleaded that the contract of insurance is based on the principles of ‘Uberrima Fide’ i.e. utmost good faith. The claim of the Complainant was repudiated by the answering Opposite Parties after due application of mind as per Condition No.7 of the terms and conditions of the policy as the Complainant has suppressed the material information with regard to his health and has not disclosed the disease suffered by him prior to the taking of the Policy. It has been urged that the Complainant had not submitted the documents i.e. complete medical record and instead of submitting the document he approached this Forum. It has been asserted that against the total bill submitted by the Complainant for Rs.6,37,514/-, the maximum liability of the Opposite Parties is Rs.1,80,000/- only which they are willing to pay, but the Complainant has not accepted the same. Denying all other allegations and stating that there is no deficiency in service or unfair trade practice on their part, Opposite Parties have prayed for dismissal of the complaint.

 

4.     The Complainant also filed rejoinder wherein the averments as contained in the complaint have been reiterated and those as alleged in the written statement by the Opposite Parties have been controverted.

 

5.     Parties were permitted to place their respective evidence on record, in support of their contentions.

 

6.     We have heard the learned counsel for the Opposite Parties and have perused the record. 

 

7.     The case of the Complainant is that he had taken medi-claim insurance policy from the Opposite Parties in the year 2012 and same was got renewed in the year 2013 and also in the year 2014, which was valid from 31.3.2014 to 30.3.2015 for sum insured of Rs.5,00,000/-. During the currency of the third policy the Complainant suffered an ailment on 31.1.2015 for which he was hospitalized for the treatment of Acute Promyelocytic Leukemia-M2 for which the Complainant incurred an amount of Rs.6,37,514/-. Prior thereto, the Complainant requested the Opposite Parties for the cashless facility, which was rejected vide letter dated 4.2.2015 (Annexure C-8). Thereafter, the Complainant again fell ill and was diagnosed to be suffering from Phemonia. The Complainant was got admitted for the treatment with Fortis Hospital, Mohali on 9.3.2015. The Complainant took the treatment was discharged on 21.3.2015. The Complainant spent Rs.4,68,085/- on his treatment (Bill Annexure C-13). It is observed that the Complainant received letter dated 10.3.2015, during his admission in hospital stating that his claim is repudiated on account of non-disclosure of material fact i.e. about the existence of pre-existing disease and they further cancelled the policy on pro-rata basis and refunded the premium for the remaining period.

 

8.     Here, it is apt to go through the terms & conditions of the policy wherein the terms pre-existing disease, as defined in the Policy document and the relevant Exclusion clauses, read as under:-

“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 inception of the insured persons first policy with the Company….. 

EXCLUSIONS

The company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of:

 All Pre-existing disease as defined in the policy existing and suffered by the insured person for which treatment or advise was recommended or received during the immediately preceding 12 months from the date of proposal.

xxxxxxxx

5.  50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the Insured.”

 

9.      It is important to note that the complainant, who is an old man and the last treatment taken by him was in the year 2014 and the first proposal for the policy in continuance was filled-up in the year 2012, therefore, the pre-existing clause or the allegation of non-disclosure of previous ailments, did not disqualify the complainant from his rightful claim. The complainant has also filed a duly sworn affidavit in support of his contentions as mentioned in the complaint. 

 

10.      The fact that the Opposite Parties have merely placed on record the copies of the diagnostic reports, whereas the claim about the disclosure of the previous ailment, as claimed by the complainant in his complaint, has not been controverted with the cogent evidence by the Opposite Parties.  However, the Opposite Parties while contesting the amount of relief claimed by the complainant has claimed that the actual claim, if at all payable, is only limited to Rs.1,80,000/- as per the relevant column of limit of company’s liability mentioned in the terms & conditions of the insurance policy, placed on record by the Opposite Parties themselves.  Therefore, in these set of circumstances, we feel that the complainant is only entitled to a maximum of 70% of the amount as mentioned in the liability clause of the policy terms & conditions, limited to the maximum of Rs.1,80,000/-.  The Opposite Parties therefore should have settled the claim of the complainant on the aforementioned terms & conditions of the policy as well as the applicable exclusion clauses as applicable to the pre-existing disease and such a failure on their part certainly amounts to deficiency in service towards the complainant. 

 

11.      It is important to note here that since the Opposite Parties had cancelled the policy of the Complainant on pro-rata basis, and refunded the premium of Rs.20,225/- to the Complainant on 10.3.2015 (Annexure C-13 & C-14), hence the amount spent by the Complainant on his treatment for Phemonia is not covered under the Policy. Pertinently, the Complainant had returned the draft send by Opposite Parties for an amount of Rs.20,225/- vide letter dated 26.03.2015 (Annexure C-15) which amount is still lying with them. It is not the case of the Opposite Parties that they had re-send the aforesaid amount to the Complainant. Furthermore, the Complainant has made a prayer for renewal of the policy for the period 31.3.2015 to 31.3.2016, but we are afraid that we cannot grant such a relief to the Complainant, at this stage, as the period for which the renewal of the policy has been sought, has already lapsed. Nevertheless, since the Policy had been cancelled and is in the lapsed state, we are of the concerted opinion that the Opposite Parties ought to have refunded the amount of Rs.20,225/- to the Complainant.     

 

12.      Hence, in view of the foregoing discussion, we allow the complaint of the complainant against the Opposite Parties.  Therefore, the Opposite Parties are, jointly and severally, directed as under:-

[a] To pay 1,80,000/-, as per Clause-G of the terms & conditions of the policy, to the complainant.

[b]  To pay Rs.20,225/- to the Complainant being the premium amount for the remaining period of the policy cancelled on pro-rata basis;

[c] To pay Rs.15,000/- to the Complainant as compensation, on account of deficiency in service, unfair trade practice and causing mental agony and harassment as well as litigation expenses.

 

13.      The above said order shall be complied within 30 days of its receipt by the Opposite Parties; thereafter, they shall be liable to pay for an interest amount @12% per annum on the amount mentioned in sub-para [a] to [c] above from the date of filing of this complaint, till it is paid. 

 

14.      The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

06^th May, 2016                                   Sd/-

(SURJEET KAUR)

PRESIDING MEMBER

 

                                         Sd/-

(SURESH KUMAR SARDANA)

MEMBER

“Dutt”