BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 260 of 2018
Date of Institution : 25.10.2018
Date of Decision : 27.03.2019
Amrik Singh son of Sh.Surjeet Singh resident of Nagar Palika Wali Gali, near Harpal Singh Convent School, Sirsa, District Sirsa.
……Complainant.
Versus.
- Star Health & Allied Insurance Co. Ltd., Ground Floor, Rathore Towers, near Hotel Mehak, Dabwali Road Sirsa District Sirsa, through its Divisional Manager/Auth. Person.
- Star Health & Allied Insurance C.Ltd. No.15 Sri Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai-600014, through its Managing Director/Auth. Person.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA………………. ……PRESIDENT.
SH. ISSAM SINGH SAGWAL ………MEMBER.
MRS. SUKHDEEP KAUR……………..MEMBER.
Present: Sh.Tarlochan Singh, representative on behalf of complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
The case of the complainant, in brief, is that the complainant purchased an Insurance policy No.P/211121/01/2017/001100 for himself, his wife Parveen Kumar and daughter Tavleen Kaur having validity from 09.11.2016 to 08.11.2017 with policy coverage of Rs.5,00,000/- and had paid Rs.1,50,000/- to the Ops. On 15.11.2016, the daughter of the complainant felt ill and was got admitted in PGI, Chandgiarh for treatment but after 20 days, the doctor had declared that the patient is suffering from blood cancer. The complainant has spent Rs.4 lakh on the treatment of his daughter since 15.11.2016 uptill today. He approached the Ops and submitted all the relevant documents and requested to pay the insured amount but they refused to pay the same on the ground that in the medical record at one plac, the doctor had written the date as 02.01.2015 in place of 02.01.2017 while in all the previous and further medial record the treatment was started from November, 2016. The doctor had specifically explained this mistake on a separate writing but the Ops have intentionally not honoured the claim. Due to this act and conduct of the Ops, the complainant has suffered harassment, pain and mental agony. This way, the Ops are deficient in providing service to the complainant.
2. On notice, the Ops appeared and filed their joint reply wherein it has been submitted that the insured had purchased Family Health Optima Insurance Plan, vide policy No.P/211121/01/2017/001100 for the period from 09.11.2016 to 08.11.2017 for sum assured of Rs.5 lakh covering Amrik Singh, complainant, Mrs.Parveen Kaur, Spouse, Baby Tavleen Kaur-dependent children. The terms and conditions were explained to the complainant at the time of proposing policy. The insured had submitted claim for reimbursement of medical expenses of Rs.16,161/- towards the treatment of B-Cell ALL in 48th day of policy. The insured patient, Baby Tavleen Kaur was hospitalized in PGI on 28.12.2016 for B-CELL ALL but on scrutiny of claim documents, it was observed that as per OPD sheet dated 02.01.2015, the insured patient was on chemotherapy for B-Cell acute lymphoblastic leukemia which confirms that the above disease was prior to inception of the policy and the insured had not disclosed the above said medical history/ health details in the proposal form which amounts to misrepresentation/ non-disclosure of material facts, therefore, the company is not liable to make any payment in respect of any claim as per condition No.8 of the policy. The said policy was issued for the period from 09.11.2016/08.11.2017 and the insured Tavleen fell ill on 15.11.2016 and was got admitted in PGI, Chandigarh on the same day and due to this reason the claim is also not payable as it falls within 30 days of waiting period. The claim has rightly been repudiated and the same was informed to the insured vide letter dated 21.10.2017. It has been further submitted as per Condition No.15, the policy is liable to be cancelled, if there is non-disclosure of material facts, thus the policy was cancelled and intimated to the insured. Objections about estoppal, cause of action, maintainability, concealment of material facts from this Forum and jurisdiction etc. have also been taken. Other contentions have been controverted and prayer for dismissal of the complaint has been made.
3. Thereafter, both the parties have led their respective evidence. The complainant produced documents Ex.C1 to Ex.C3. On the other hand, Ops have produced affidavit of Sh.Rajiv Jain Ex.RW1 and documents Ex.R1 to Ex.R6.
4. We have heard the complainant in person and learned counsel for the Ops and have perused the case file carefully.
5. The complainant in order to prove his case has furnished his affidavit wherein he has reiterated all the averments made in his complaint. The complainant has also placed on record copies of documents Ex.C1 to Ex.C3 as mentioned above. On the other hand, the opposite parties have furnished affidavit of Sh. Rajiv Jain, Chief Manager, as Ex.RW1 wherein he has reiterated the averments of the written statement. The OPs have also furnished copies of documents as Ex.R1 to Ex.R6.
6. As per averments made in the complaint, the complainant had got medical insurance for himself, his wife and his daughter Tavleen Kaur for a sum of Rs.5 lacs w.e.f. 09.11.2016 to 08.11.2017. On 15.11.2016, the daughter of the complainant namely Taveleen Kaur fell ill and she was got admitted in PGI, Chandigarh for treatment and during the treatment after 20 days, the doctor had declared that the patient is suffering from blood cancer and she is under treatment. Due intimation was given to the OP regarding the treatment being taken by the daughter of the complainant from a doctor of the PGI, Chandigarh, but however, the claim for the reimbursement of the expenses of the treatment was declined by the Op on the ground that the daughter of the complainant was suffering from pre-existing disease prior to the inception of the policy. However, as per the terms and conditions of the policy, no claim can be filed within 30 days of the issuance of the policy as the policy was taken by the complainant on 09.11.2016 and he got his daughter admitted in the PGI, Chandigarh on 15.11.2016. Learned counsel for the OP has relied upon the record of PGI, wherein at one place the doctor had written the date as 02.01.2015, though the treatment was taken on 09.11.2016, but however, the doctor has clarified the date vide his separate certificate issued in this regard, which is Ex.C2.
7. Admittedly, the policy was taken by the complainant on 09.11.2016, the copy of which is Ex.C3 for the period from 09.11.2016 to 08.11.2017 and as per the record of the PGI, the daughter of the complainant was admitted in hospital on 15.11.2016 and she was discharged on 19.11.2016, meaning thereby that she got the treatment within a period of 6 days. It is a settled principle of law that the parties to the insurance contract are bound by the terms and conditions of the insurance contract and as per the terms and conditions of the policy, no claim can be filed within 30 days from the issuance of the policy. Since the complainant got treatment of his daughter within a period of 6 days from the inception of the policy, which clearly debar the complainant from lodging the claim qua the reimbursement of the expenses spent by him on the treatment of his daughter.
8. So, in view of the above discussion, we are of the opinion that the complainant is not entitled for reimbursement of the expenses, which he has spent on the treatment of his daughter and complaint of the complainant appears to be devoid of any merits. Hence, the same is hereby dismissed with no order as to costs. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:27.03.2019. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member
DCDRF, Sirsa DCDRF, Sirsa
