BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 134 of 2019
Date of Institution : 13.03.2019
Date of Decision : 15.10.2019
Kamla Devi aged about 59 years wife of Shri Dilbag, resident of village Daulatpur, Tehsil and District Hisar.
……Complainant.
Versus.
- Star Health and Allied Insurance Company Ltd., Ground Floor, Rathore Tower, Near Hotel Mehak, Dabwali Road, Sirsa through its Branch Manager/ Authorized Signatory.
- Star Health and Allied Insurance Company Ltd., office at SCO 130-131 4th Floor, Sector 34A Chandigarh through its AGM/ Authorized Signatory.
- Star Health and Allied Insurance Company Ltd., Grievance Department No.1, New Tank Street, Valluvar Kottam High Road, Vungam Bakkam Chennai- 600034 through its Managing Director.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L. AHUJA……………………PRESIDENT.
SH. ISSAM SINGH SAGWAL…….MEMBER
Present: Sh. Puneet Narang, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
The case of the complainant, in brief, is that on 23.10.2017, the complainant and her husband namely Dilbag had jointly purchased a health care insurance policy namely “Family Health Optima Insurance Plan” bearing No.P/211121/01/2018/001920 from op no.1. The said policy was valid for a period of one year w.e.f. 23.10.2017 to 22.10.2018. An amount of Rs.24,142/- was got deposited by op no.1 from the complainant being premium amount and sum assured was Rs.5,00,000/-. That unfortunately after the purchase of the policy, the husband of complainant felt problem in breathing and he immediately got the same checked medically from Adhar Health Institute Hisar and he remained under treatment there from 18.1.2018 till 20.1.2018 and he was diagnosed with acute asthmatic bronchitis. During this period, he undergone various tests and took costly drugs but as no improvement was seen, therefore, he got himself discharged from the said hospital and thereafter, he remained admitted in Jindal Hospital, Hisar from 31.1.2018 to 2.2.2018. It is further averred that vide cytopathology report dated 2.2.2018, he was found to be suffered with stained smears are moderately cellular and show presence of clusters and groups of tumor cells. The individual tumor cells show high N.C. Ratio, hyper chromatic` nuclear, irregular nuclear membrane, prominent nucleoli and scant to moderate amount of cytoplasm and advised to biopsy for further evaluation. The husband of complainant was found declared to be suffered from lungs disease and he remained under treatment in Jindal Hospital up to 15.9.2018 on which date he expired on account of said disease. It is further averred that an amount of Rs.2,33,042/- was incurred upon his treatment including hospitalization, various tests, medicines and life saving drugs etc. That as per terms and conditions of the policy, the complainant was/is entitled to get indemnified her claim under the aforesaid policy and in order to get the same indemnified, the complainant lodged her claim through toll free number with the ops and requested ops to indemnify her claim, on which she was required to submit some requisite documents with the ops and was assured that her claim is under process and will be indemnified. It is further averred that requisite and required documents were got submitted by the complainant with the ops but on 22.3.2018, the op no.3 issued a repudiation letter vide which her claim has been rejected by them stating that husband of complainant suffered with the said disease prior to the purchase of the policy and stated that he had long standing lung disease prior to inspection of the medical insurance. On 22.3.2018, the ops cancelled her policy without any reason and without her knowledge whereas at the time of issuing the policy, the complainant and her husband were got medically examined by the ops and after their entire satisfaction and finding them to be physically fit, the policy was issued to them and thus the repudiation letter issued by the ops is nothing but it arbitrary and unlawful and is liable to be ignored and withdrawn. That Dr. Vikas Sheoran had opined that patient had no past history of bronchitis in his report. Due to lack of money, the ops are solely responsible for the death of husband of complainant. That such act and conduct on the part of ops amounts to deficiency in service and unfair trade practice on account of which the complainant has suffered unnecessary harassment and mental tension. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement raising certain preliminary objections. It is submitted that policy was issued believing that the information provided by the insurer is true and correct. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and same was served to the complainant alongwith the policy schedule. Moreover, it is clearly stated in the policy schedule that the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. It is further submitted that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. The claim was reported in 3rd month of the inception of the policy and claimed an amount of Rs.18,733/-. The insured was hospitalized in Aadhar Health Institute on 18.1.2018 and discharged on 20.1.2019 and as per discharge summary, the insured was diagnosed with acute asthmatic bronchitis. It is further submitted that the insured sought for approval of cashless treatment towards the above mentioned treatment. On scrutiny of the pre-authorization documents, it is observed that the details of the claim cannot be ascertained in the cashless level. Thus, the answering op has called for the insured to submit claim for reimbursement vide letter dated 20.1.2018. Subsequently, the insured submitted claim for reimbursement of medical expenses for Rs.18,733/-. On scrutiny of the same, it is observed that CT chest report dated 1.2.2018 shows bilateral emphysematous lungs, large soft tissue mass lesion in left hilar region infiltrating lower lobe bronchus with resultant collapse of left lower pulmonary lobe, few calcific density foci seen with associated loculated left pleural effusion and few calcified mediastinal lymph nodes are seen. It is further submitted that at the time of inception of policy which is from 23.10.2017 to 22.10.2018, the insured has not disclosed the above mentioned medical history/ health details of the insured person in the proposal form which amounts to misrepresentation/ non disclosure of material facts. As per condition no.6, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim. Hence, the claim was rejected and the same was informed to the insured/ complainant vide letter dated 22.3.2018. With these averments, dismissal of complaint prayed for.
3. The parties then led their respective evidence.
4. We have heard learned counsel for the parties.
5. Learned counsel for complainant has contended that it is proved case of complainant that complainant had purchased a health insurance policy for herself and her husband Dilbag Singh on payment of premium of Rs.24,142/- for a period of one year w.e.f. 23.10.2017 to 22.10.2018. It is also proved fact on record that husband of complainant Dilbag Singh felt some problem in breathing and he was taken to Adhar Health Institute, Hisar and he remained there from 18.1.2018 to 20.1.2018. He was diagnosed with acute asthmatic bronchitis. Thereafter, again he remained admitted in Jindal Hospital, Hisar from 31.1.2018 to 2.2.2018 and later on he was diagnosed to be suffering from lungs disease. In this way, they have spent an amount of Rs.2,33,042/- on his treatment. Claim was lodged with the ops alongwith all the requisite documents, but however, ops have repudiated the claim in a very arbitrary and illegal manner and even cancelled the policy without any rhyme and reason. Unfortunately Dilbag Singh husband of complainant lost his life on 15.9.2018. The ops have no right to cancel the policy or to repudiate the claim of complainant rather liable to pay the claim amount to the complainant. The policy as issued after medical examination of both the insured and fulfilling all the required formalities. Learned counsel for complainant has also relied upon judgment of the Hon’ble State Consumer Disputes Redressal Commission, UT Chandigarh in case titled as Bharti Axa Life Ins. Co. Ltd. and others vs. Mamta Kumari, 2018 (3) CLT 208.
6. On the other hand, learned counsel for ops has strongly opposed the contentions of learned counsel for complainant. It has been contended that husband of complainant namely Dilbag Singh was already a patient of chronic lung disease before inception of the policy and this fact was concealed by the insured at the time of filing the proposal form. The policy was got issued by way of misrepresentation and same was liable to be cancelled under the terms and conditions of the policy. The insured Dilbag Singh was got admitted in the hospital for his treatment even within three months of the inception of the policy, as such the ops are not liable to reimburse the expenses of treatment of Dilbag Singh. The ops have rightly cancelled the policy and repudiated the claim.
7. We have considered the rival contentions of the parties and have gone through the record as well as judgment relied upon by learned counsel for complainant carefully.
8. The perusal of the record reveals that there are specific allegations of complainant that she and her husband Dilbag Singh were got insured for health purposes vide policy in question for a period of one year i.e. from 23.10.2017 to 22.10.2018. Her husband suffered some problem in the chest and was admitted in Adhar Health Institute Hisar and thereafter he remained admitted in Jindal Hospital, Hisar and spent more than Rs. two lacs on his treatment. In order to prove her allegations in the complaint, the complainant has tendered her affidavit Ex./CW1/A in which she has deposed and reiterated all the averments made in the complaint and has also tendered copy of letter Ex.C1, copies of policy documents Ex.C2 to Ex.C4, copy of repudiation letter dated 22.3.2018 Ex.C5, copies of treatment record, death certificate and bills etc. Ex.C6 to Ex.C63 and insurance plan Ex.C64. On the other hand, ops have furnished affidavit of Sh. Rajiv Jain Chief Manager as Ex.RW1/A and copies of documents Ex.R1 to Ex.R12 in order to prove their defence plea.
9. Undisputedly, husband of complainant namely Dilbag Singh was insured with the ops for the period 23.10.2017 to 22.10.2018 vide health insurance policy in question and within three months of inception of the policy he suffered some breathing problem and was taken to Adhar Health Institute, Hisar and remained admitted there for three days and thereafter he remained admitted in Jindal Hospital, Hisar from 31.1.2018 to 2.2.2018 and spent Rs.2,33,042/- on his treatment. Claim was lodged with the ops, but however, same was repudiated and even policy was cancelled by ops on the ground that husband of complainant was suffering from pre-existing disease of lungs and he had misrepresented the fact that he is not suffering from any disease in the proposal form. The complainant has taken specific plea in her complaint that before inception of the policy, both the insured were got medically examined by the ops and this fact also finds corroboration from the covering letter Ex.C1 which was issued alongwith the policy and this letter finds mention the fact that “ the said policy has been prepared based on the details furnished by you in the proposal form (copy enclosed) and the medical reports wherever applicable” meaning thereby that before issuance of the policy, the ops had got medical reports regarding the status of the health of the insured. Now, the ops are estopped by their own act and conduct from taking this plea that deceased Dilbag Singh was suffering from some pre-existing disease prior to inception of the policy.
10. The second plea of the ops qua suffering of the deceased Dilbag Singh from some pre-existing disease of lungs also found to be devoid of any merit as ops have not led any cogent and convincing evidence in order to prove this plea. Though, repudiation letter Ex.C5 finds mention that “it is observed that the CT chest report dated 1.2.2018 submitted vide our claim No.0573774 shows bilateral emphysematous lungs, large soft tissue mass lesion in left hilar region infiltrating lower lobe bronchus with resultant collapse of left lower pulmonary lobe, few calcific density foci seen with associated loculated left pleural effusion and few calcified mediastinal lymphnodes are seen. Based on these findings, our medical team is of the opinion that the insured patient has chronic, longstanding lung disease prior to inception of the medical insurance policy.” This letter was issued on the opinion of the medical team of the ops, but however, ops have not disclosed the name of those medical experts who were members of the medical team and formed their opinion that insured patient had chronic, longstanding lung disease prior to inception of the insurance policy and they have not furnished any affidavit in support of their opinion before this Forum in order to support defence plea of the ops. Further, the ops have not placed on record any report of the expert on the basis of which claim of complainant has been repudiated and policy has been cancelled. So, it appears that ops have acted in a very casual and haste manner while repudiated the claim of complainant and cancelling the policy in question, which clearly amounts to deficiency of service and unfair trade practice on the part of ops.
11. In view of our above discussion, we hereby allow the present complaint and set aside the order of repudiation and cancellation of the policy in question and direct the opposite parties to settle and pay the claim of complainant as per terms and conditions of the policy within 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 order till actual payment. We further direct the opposite parties to pay Rs.10,000/- as compensation for harassment and Rs.2,000/- 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:15.10.2019. District Consumer Disputes
Redressal Forum, Sirsa.
