Chandigarh

DF-I

CC/1042/2016

Lakhpat Rai - Complainant(s)

Versus

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

Sourabh Goel

23 Aug 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

                               

Consumer Complaint No.	:	CC/1042/2016
Date of Institution	:	01/12/2016
Date of Decision	:	23/08/2018

 

Lakhpat Rai s/o Lt. Sh. Nanu Ram r/o H.No.10, Alankar Apartments, Sector-14, Panchkula, Haryana.

… Complainant

V E R S U S

1.     Star Health and Allied Insurance Company, SCO 130-131, 4^th Floor, Sector 34-A, Chandigarh through its Branch Manager.

2.     Alchemist Hospital Limited, Sector 21, Panchkula through its Managing Director.

3.     Dr. Arvind Kaul, MD/DM Cardiology, Senior Consultant c/o Alchemist Hospital Limited, Sector 21, Panchkula.

4.     United India Insurance Company Limited, Polytechnic Chowk, Bal Bhawan Road, Ambala City through its Branch Manager.

5.     Sh. Krishan Kumar Garg, r/o H.No.878, Sector 10, Panchkula.

6.     Max Super Specialty Hospital, Mohali Near Civil Hospital, Phase-6, SAS Nagar, Mohali through its authorised representative. 

… Opposite Parties

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

                                                                     

ARGUED BY	:	Sh. Sourabh Goel, Counsel for complainant
	:	Sh. Guarav Bhardwaj, Counsel for OP-1
	:	Sh. Gunjan Rishi, Counsel for OPs 2 & 3
	:	Sh. Satpal Dhamija, Counsel for OP-4
	:	OP-5 ex-parte.
	:	None for OP-6.

 

Per Rattan Singh Thakur, President

1.         The summary of allegations are, complainant had purchased policy (Annexure C-1) from OP-1 which was valid from 23.12.2014 to 22.12.2015.  On expiry of the said policy, OP-5/agent of OP-1 obtained a cheque for renewal of the policy of the amount of Rs.19,047/-and it was renewed vide policy which was valid for the period from 31.12.2015 to 30.12.2016 (Annexure C-2).  It is the case, complainant was not suffering from any disease nor any pre-existing disease was mentioned related to cardio vascular system or neurological system and the note to this on the policy is devoid of any basis.  On 11.6.2016, the complainant suffered heart attack and was taken to OP-2 hospital where he underwent coronary angiography and coronary angioplasty single vessel. He was discharged on 14.6.2016. Intimation for preauthorization was sent through OP-2, but, it was rejected by OP-1 citing the reason he was suffering from PED which is not admissible until completion of 48 months from the date of inception of the policy. The complainant had paid Rs.1,51,700/- to OP-2.  Maintained, on 14.6.2016, complainant was again admitted with OP-2.  Angioplasty was conducted by OP-3 and was charged Rs.94,350/-.  He was again admitted on 23.6.2016 and was charged Rs.23,031/-.  Maintained, OP-3 had wrongly mentioned complainant had past history of hypertension for 15 years and suffering from diabetes for four years.  The complainant had incurred expenses from 11.6.2016 to 25.6.2016 which comes out to Rs.2,69,081/-, but, the claim was wrongly rejected by OP-1. It is also the case, complainant had purchased insurance policies from OP-4 since 2010 and on the asking of OP-5 (agent of OP-4), complainant had ported his policy from OP-4 to OP-1.  Later on the complainant was operated upon in OP-6/hospital on 3.8.2016 and was charged Rs.2,54,910/-.  The policy cover issued by OP-1 was for Rs.3,00,000/- + Rs.75,000/-.  Hence, the present consumer complaint praying for payment of claim of Rs.3,75,000/- alongwith compensation for mental and physical harassment alongwith costs of litigation.
2.         OP-1 filed written statement and claimed the complainant had pre-existing disease of CAD and as per the terms and conditions of the policy, indemnification of the heart disease was to be reimbursed to the complainant on completion of 48 months w.e.f. 23.12.2015 which had not expired.  As such, the claim was rightly rejected. On these lines, the cause is sought to be defended.
3.         OPs 2 & 3 in their joint written reply admitted that the complainant was treated at the OP hospital from 11.6.2016 to 14.6.2016.  Maintained, complainant was suffering from diabetes Mellitus-II.  On these lines, the cause is sought to be defended.
4.         The stand taken by OP-4 is, details of the previous insurance policies from 2010 to 2014 not mentioned, therefore, no reply could be furnished.
5.         Initially OP-5 appeared in person and the case was adjourned for filing reply and evidence.  However, on 20.4.2017 neither the reply and evidence were filed nor anybody put in appearance on behalf of OP-5, therefore, he was proceeded ex-parte.
6.         Reply of OP-6 is bypass surgery (CAG) was performed and total sum of Rs.2,54,910/- was charged by it.
7.         Replication to the written statement of  OP-1 was filed and averments made in the consumer complaint were reiterated.
8.         Parties led evidence by way of affidavits and documents.
9.         We have heard the learned counsels for the parties and gone through the record of the case.  After scrutiny of record, our findings are as under:-
10.         Per pleadings of the parties and the documents annexed therewith, the claim of complainant is, the policies he had purchased from the previous insurer (OP-4) since the year 2010 were to be tacked/combined with the present policy issued by OP-1 in the year 2015, therefore, the period of 48 months had expired.  As such, even as per the terms and conditions of the policy, reimbursement/ indemnification of the CAD was part of the policy.  However, the complainant has not annexed the copies of health insurance policies issued by OP-4 from the year 2010 to 2014 so as to apply the doctrine of tacking/combining for the purpose of reckoning of 48 months making him entitled to the reimbursement/ indemnification of the treatment and surgery of heart disease. Merely making a reference or disclosing in his declaration form will not in any way link up the period of continued policy till the year 2014-15.  This link is missing and it remained a mere pleading that this period was to be combined or to say linked up with the present policy.  Suffice it to say, 48 months had not yet expired even from the year 2014.
11.         The foundation of the claim of the complainant is, the insurance policy issued from 31.12.2015 to 30.12.2016 (Annexure C-2).  The terms and conditions scribed thereon binds both the parties.  These are accepted terms and conditions.  The complainant cannot wriggle out from the same.  Admittedly, there is reference in the insurance policy of pre-existing disease relating to treatment of cardio vascular system and neurological diseases and its complication.  It is part and parcel of the policy. The terms and conditions were, with regard to the indemnification of cardio vascular system disease, 48 months from the date of inception of the policy i.e. 31.12.2015 ought to have expired while in the present case, the complainant was admitted, treated and operated in the year 2016.  As such, said period of 48 months had not expired.  Now it does not lie in the mouth of the complainant to assert, he was not suffering from cardio vascular disease particularly so when the basic foundation of the claim of the complainant is the health policy (Annexure C-2). The complainant has himself created an estoppel because the basic document on the basis of which the claim is preferred is Annexure C-2.
12.         A perusal of the record further shows, there is a consent letter on which the complainant had appended his signatures whereby he had consented, the cardio vascular disease treatment claim had to be excluded till the period of four years expired from the date of inception of the policy.  The consent letter is Annexure R-1/1. There is no denial of his signatures on this consent letter.  Again the complainant is estopped to deny the terms and conditions i.e. pre-existing disease claim was not liable till 48 months had expired.  The previous insurance policies purchased from OP-4 could not be combined or say tacked with the present policy unless the said policies were produced on record.  However, except for mere pleadings, no other documents produced on record i.e. to say copies of the previous insurance policies and OP-4 had denied the issuance of said policies unless the full particulars of those policies were mentioned.
13.         The attack of the learned counsel for the complainant is, medical health check-up conducted by OP-4 at the time of issuance of the policy in the year 2015 had declared the complainant medically fit, therefore, the said terms and conditions could not have been scribed in the policy beyond medical record.  This was the mere satisfaction of the insurer i.e. to say OP-1.  The terms and conditions were finalized by way of policy document which is conclusive and medical cannot override the terms and conditions of the policies.  This records in itself that on the date of issuance of the policies the complainant was a patient of cardio vascular system and neurological disease and its complications and this was so mentioned in the policy and this was not admissible till the period of 48 months had expired.  Thus, we safely land to a conclusion that the complainant cannot go beyond the terms and conditions which were accepted by him and were never objected till his claim was repudiated by the insurer.  Hence, the complainant has not been able to prove any deficiency in service or unfair trade practice on the part of the OPs.
14.         In view of the above discussion, we are of the opinion, there is no merit in the present consumer complaint and the same is accordingly dismissed, leaving the parties to bear their own costs.
15.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
23/08/2018	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	Member	President