BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 302 of 2018
Date of Institution : 10.12.2018
Date of Decision : 29.07.2019
Ashok Kumar, aged 49 years son of Shri Anjani Kumar, resident of Near Idea Tower, Ward No.5, Ellenabad, Tehsil Ellenabad, District Sirsa.
……Complainant.
Versus.
- Star Health and Allied Insurance Company Ltd., Branch Office: Ground Floor, Opp. Shakti Motors, Near IDBI Bank, Sirsa, Tehsil and District Sirsa through its Branch Manager.
- Star Health and Allied Insurance Company Ltd., Regd. office: 1, New Tank Street, Valluyer Kottam High Road, Nungmbakkam, Chennai- 600 034, through its authorized signatory.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA………………. ……PRESIDENT.
MRS. SUKHDEEP KAUR……………..MEMBER.
Present: Sh. JBL Garg, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
The case of the complainant, in brief, is that the complainant purchased a Family Health Optima Insurance Plan from the opposite parties vide policy No.P/211121/ 01/2017/001031 for the period 24.10.2016 to 23.10.2017 and got insured himself, his wife Smt. Sarla Devi, daughter Riya and son Himanshu for the basic floater sum insured of Rs.10,00,000/- and paid a sum of Rs.21,735/- as insurance premium for the same. Before issuance of said policy, the ops had got the complainant medically checked up from their approved doctor. It is further averred that in January, 2017, the complainant suffered heart ailment and he was got medically checked up at Medanta the Medicity Hospital, Sukhrali (CT) where he remained admitted as an indoor patient w.e.f. 27.1.2017 to 4.2.2017 and was operated upon for the heart ailment. A sum of Rs.5,51,000/- was incurred by the complainant on his operation and treatment etc. That when the complainant was under treatment, officials of the ops visited the hospital and obtained the signatures of the complainant on certain papers on the pretext of lodging and settlement of claim on behalf of complainant. It is further averred that complainant after recovering from ailment, supplied all the required documents and information and also observed all the required formalities for the settlement of the claim. But however, the ops repudiated the claim of the complainant on the ground that “As per exclusion no.1 of the policy issued to the complainant, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/ condition, until 48 months of continuous coverage has elapsed, since inception of the policy i.e. from 24.10.2016.” That the complainant was shocked to know the repudiation of his claim due to above imaginary reason developed by the ops, because the complainant had no pre-existing history of the heart ailment and the ops have also not furnished any proof in this regard. That the ops by their such act and conduct have been indulged in unfair trade practice and have committed gross deficiency in service towards the complainant. The complainant approached the ops on many occasions and requested them to settle his claim but they did not pay heed to the same. The complainant also got served a legal notice upon the ops on 17.5.2017 and the ops gave reply to the notice on 24.6.2017 and refused to admit the claim of complainant. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement taking certain preliminary objections. It is submitted that claim was reported in the 3rd month of inception of the policy and an amount of Rs.5,15,000/- was claimed. The complainant/ insured patient Mr. Ashok Kumar was admitted in Medanta The Medicity on 27.1.2017 and was discharged on 4.2.2017 and insured has submitted pre authorization request for cashless treatment. On perusal of the documents submitted by the treating hospital, it is observed that Echo shows evidence of concentric LVH (Left ventricle hypertrophy) indicating long standing hypertension and the onset of the illness cannot be ascertained with the available records. Hence, the cashless authorization was denied and requested the insured to submit the documents for reimbursement of medical expenses vide letter dated 2.2.2017. The insured submitted claim records for reimbursement of medical expenses. On scrutiny of the claim records, it is observed that as per discharge summary, the insured patient was 47 years old hypertensive diabetic male, presented with complaints of breathlessness on exertion since 10-15 days associated with headache since 10 days and as per the findings noted in discharge summary, the echo report evident of congenital bicuspid aortic valve and biopsy report suggestive of myxoid degeneration of aorta. As per the field visit report of their doctor, which is also signed by the insured patient, the duration of present illness i.e. heart disease is 10 to 12 years which is prior to inception of the medical insurance policy. It is further submitted that in order to verify the exact duration of the heart disease, hypertension and diabetes mellitus, the claim was entrusted for investigation. The statement of Dr. Madan Jain states that the insured was taking treatment of hypertension and consulting the doctor on and off since two years, the statement of owner of Ashish Laboratory & X-ray centre dated 8.3.2017 states that the insured used to take investigation in his Lab. since 4-5 years and under regular treatment with Dr. Madan Jain. It is further submitted that from the above findings, it is observed that the present admission and treatment of the insured patient is for the pre existing disease which is long standing prior to inception of insurance policy. Thus, the claim was repudiated on the ground of pre existing disease which is exclusion and is not covered for 48 months from the inception of the policy. It is further submitted that also the claim was repudiated on the ground of two years exclusion as the insured patient has undergone treatment primarily for disease due to bicuspid aortic valve i.e. for Congenital Internal Disease which is not payable during the two years of continuous coverage for insurance policy as per exclusion no.3 of above policy. It is further submitted that as a general underwriting safeguard, the persons aged above 50 years are put to pre medical examination. In the instant case, the insured was aged 47 years and 8 months. Hence, based on the declaration made in the proposal form, without any pre medical screening, the policy was issued to the insured. It is further submitted that complainant has no locus standi to claim any alleged sum assured, as the insurance policy was obtained by the insurer by misrepresenting the material facts in order to defraud the op and as such the contract of insurance is void and not tenable in the eyes of law. Lastly, it is submitted that if the op is held liable to pay the claims of the complainant, the liability of the op as per terms and conditions shall be limited to Rs.4,62,283/-. Remaining contents of complaint are denied and prayer for dismissal of complaint made.
3. The parties then led their respective evidence.
4. We have heard learned counsel for the parties and have gone through the case file carefully.
5. The complainant in order to prove his complaint has furnished his affidavit Ex.CW1/A in which he has reiterated all the averments made in the complaint. He has also placed on record copy of insurance plan Ex.C1, copy of letter dated 9.2.2017 Ex.C2, copies of claim form Ex.C3, Ex.C4, copy of letter Ex.C5, copy of discharge summary Ex.C6 and copy of status of intimation Ex.C7, copy of letter dated 24.6.2017 Ex.C8, copy of customer identity card Ex.C9, copy of legal notice Ex.C10, postal receipts Ex.C11, Ex.C12, copies of treatment record and bills Ex.C13 to Ex.C16, copy of declaration regarding queries Ex.C17, copy of queries Ex.C18, copy of query on pre authorization Ex.C19, copy of x-ray report Ex.C20, copy of hospital bill Ex.C21, copy of insurance policy Ex.C22, copy of insurance plan Ex.C23 and copies of treatment records and copies of emails etc. Ex.C24 to Ex.C59 and copy of application to issue indoor case papers Ex.C60. On the other hand, the ops have furnished affidavit of Sh. Rajiv Jain, Chief Manager as Ex.RW1/A in which he has reiterated all the averments made in the written statement. The ops have also placed on record copy of insurance policy Ex.R1, copy of proposal form Ex.R2, copy of policy schedule Ex.R3, copy of query on pre authorization Ex.R4, copy of denial letter dated 2.2.2017 Ex.R5, copy of claim form Ex.R6, copies of letters, treatment record and bills etc. Ex.R7 to Ex.R13.
6. Admittedly the complainant had purchased a family health optima insurance plan from the ops vide policy No. No.P/211121/ 01/2017/001031 for the period 24.10.2016 to 23.10.2017 and got insured himself, his wife Smt. Sarla Devi, daughter Riya and son Himanshu for the basic floater sum insured of Rs.10,00,000/- and paid a sum of Rs.21,735/- as insurance premium for the same. In January, 2017, the complainant suffered heart ailment and he was got medically checked up at Medanta the Medicity Hospital, Sukhrali (CT) where he remained admitted as an indoor patient w.e.f. 27.1.2017 to 4.2.2017 and was operated upon for the heart ailment. According to the complainant, a sum of Rs.5,51,000/- was incurred by the complainant on his operation and treatment etc. Due intimation was given to the ops and claim was lodged, but however, the claim of complainant was repudiated on the ground that as per exclusion clause No. 1 of the policy, the company is not liable to make any payment in respect of expenses of the treatment for pre-existing disease/ ailment until 48 months of continuous coverage has elapsed, since inception of the policy i.e. from 24.10.2016. No doubt, this policy was purchased by the complainant for the period 24.10.2016 to 23.10.2017 and complainant suffered heart ailment in January 2017 and period of 48 months had not elapsed since the inception of the policy. The perusal of the written reply of the ops reveals that it has been submitted by the ops that as per discharge summary, the insured patient was 47 years old hypertensive diabetic male, presented with complaints of breathlessness on exertion since 10-15 days associated with headache since 10 days and as per the findings noted in Discharge summary, the echo report evident of congenital bicuspid aortic valve & biopsy report suggestive of myxoid degeneration of aorta and as per the field visit report of their doctor which is also signed by the insured patient, the duration of present illness i.e. heart disease is 10 to 12 years which is prior to inception of the medical insurance policy. It has further been submitted that in order to verify the exact duration of the heart disease, hypertension and diabetes mellitus, the claim was entrusted for investigation and the findings of the investigation are as follows “The statement of Dr. Madan Jain states that the insured was taking treatment of hypertension and consulting the Doctor on and off since 2 years and the statement of owner of the Ashish Laboratory & X-ray Centre dated 8.3.2017 states that the insured used to take investigation in his Lab since 4-5 years and under regular treatment with Dr. Madan Jain.” On the basis of discharge summary and investigation, the ops formed the opinion that complainant was suffering from pre-existing disease of heart ailment prior to inception of the policy.
7. The perusal of the evidence of ops reveals that they have not furnished affidavit of Dr. Madan Jain who was allegedly giving treatment of heart ailment to the complainant. Nor the ops have furnished affidavit of any other expert doctor and investigator who gave such observation that complainant was suffering from heart ailment from the last number of years prior to inception of the policy. So, it appears from the evidence of the ops that ops have repudiated the claim of complainant in a very casual and ordinary manner and same is hereby set aside.
8. In view of our above discussion, we allow this complaint and direct the opposite party to settle and pay the claim of the complainant within a period of 45 days from the date of receipt of copy of this order, failing which the complainant will be entitled to interest @7% per annum on the claim amount from the date of this order till actual payment. We further direct the ops to pay a sum of Rs.5000/- as compensation for harassment and Rs.2000/- as litigation expenses to the complainant. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. Member President,
Dated:29.07.2019. District Consumer Disputes
Redressal Forum, Sirsa
