Haryana

StateCommission

A/528/2018

MADHU JALAN - Complainant(s)

Versus

STAR HEALTH AND ALLIED INSURANCE CO. - Opp.Party(s)

RAMENDER CHAUHAN

30 Aug 2018

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA, PANCHKULA

                                                First Appeal No.           :         528 of 2018

                                                Date of Institution        :         16.04.2018

                                                Date of Decision                   :         30.08.2018

 

 

Smt. Madhu Jalan aged about 40 years wife of Sh. Bajrang Jalan, resident of Gali Aalmal, Prathan Pana, Bhiwani, Tehsil and Distt. Bhiwani.

 

          …… Appellant.

 

Versus

1. Branch Manager, Star Health and Allied Insurance Co. Ltd., Ashoka Plaza 3^rd Floor, Delhi Road, Rohtak.
2. Senior Manager, Start Health and Allied Insurance Co. Ltd. 1^st Floor, Himalaya House, 23, Kasturba Gandhi Marg, New Delhi.

 

……. Respondents.

 

CORAM:             Shri Diwan Singh Chauhan, Presiding Member.

 

Present:              Mr. Ramender Chauhan, counsel for the appellant.

                             Mr. Ravinder Arora, counsel for the respondents.

 

O R D E R

 

 

DIWAN SINGH CHAUHAN, PRESIDING MEMBER

 

 

                             The present appeal has been decided by me in view of the order passed by Hon’ble President of the State Commission conveyed to me vide Endst. No. 195 dated 25.01.2018 whereby I have been authorized to decide the cases singly in Additional Bench-II.

                             This appeal has been preferred against the order dated 27.02.2018 passed by the District Consumer Forum, Bhiwani (for short ‘District Forum’) whereby complaint filed by appellant/complainant against the respondents/OPs has been allowed.  It was observed by the Learned District Forum as under:-                    

“Taking into account each and every aspect of the case, we partly allow the complaint of the complainant against the OPs.  The OPs are directed to pay Rs. 12,234/- alongwith interest at the rate of 8 per cent per annum from the date of institution of the present complaint till the date of payment.”

                             The brief facts of the case are that complainant alongwith her other family members had taken a Family Health Optima Insurance Plan from the OPs vide policy no. P/211118/01/2015/001321 for a sum assured Rs. 300000/- effective from 12.1.2015 to 11.1.2016 covering the mediclaim risk of person insured at a yearly premium 11950/-.  It is alleged that the complainant was suffered from enteric ferver, cough & difficulty in breathing.  It is alleged that the complainant on the medical advice was admitted for treatment in Jeevan Nursing Home, Bhiwani from 31.5.2015 to 5.5.2015 and subsequently the complainant was admitted for treatment in OP Jindal Institute of Cancer & Cardiac Research, Hisar from 1.7.2015 to 5.7.2015 and complainant during the both treatment had incurred expenses to the tune of Rs. 42085/- on the treatments in cash.  The complainant lodged a claim with the OP for the reimbursement of expenses alongwith original bills and other connected documents in respect of the treatment on 10.6.2015 and 16.7.2015.  It is alleged that first claim of the complainant was rejected by the OPs vide letter dated 25.7.2015 on the ground that the different date of discharge shown in discharge summary was mentioned as 5.5.2015 and this was wrongly written by the staff of concerned doctor as 5.5.2015 instead of 5.6.2015, later on the correction letter of doctor was given despite the fact the respondent rejected the claim.  It is further alleged that second claim of the complainant was also rejected by the OP vide their letter dated 3.7.2015 on the ground that we are unable to ascertain the duration of the presenting complaints.  The complainant further alleged that due to the act and conduct of the respondents, he had to suffer mental agony, harassment and litigation expenses. This act of the Ops amount to deficiency in service on its part.

                             Upon notice OPs filed written statement and took preliminary objections and denied the allegations of the complainant. It is submitted that the complainant was suffering from the disease in question prior to the inception of insurance policy but the said fact was not disclosed by the insured.  It is submitted that the complainant has submitted the claim form alongwith medical documents seeking reimbursement of medical expenses for the treatment of COAD on 16.7.2015 on scrutiny of the claim records.  It is submitted that at the time of inception of the first policy which is from 12.1.2015, the insured had not disclosed the above mentioned medical history of the insured person in the proposal form which amounts to misrepresentation of material facts.  Hence, in view of the facts and circumstances mentioned above, there is no deficiency in service on the part of OPs and complaint of the complainant is liable to be dismissed with costs.  

                             Both the parties led evidence in support of their respective claims.

                             On appraisal of the pleadings of the parties and evidence adduced on record, the District Forum accepted the complaint and granted relief as noticed in the opening para of this order.

                             Aggrieved with the impugned order, appellant-complainant has come up in appeal.  Hence this appeal.

                             I have heard the learned counsel for both the parties and perused the case file thoroughly.

The learned counsel for appellant/complainant has contended that District Forum Bhiwani assessed the total bill amount of Rs.12,234/- instead of 42,085/- without any basis whereas the bill submitted by the appellant/complainant. The amount of bill of Rs.12,234/- in place of Rs.42,085/- awarded by the District Forum is on the lower side and nothing has been granted towards harassment, mental agony and litigation expenses etc. The counsel for the appellant/complainant further contended that there is no evidence produced by the insurance company to indicate that complainant/appellant had any pre-existing disease at the time of purchasing the policy.

On the other hand learned counsel for the respondents/OPs has contended that complainant had taken a Family Health Optima Insurance Plan from OPs for his family members for a sum assured of Rs. 3 lakh effective from 12.1.2015 to 11.1.2016.  The complainant fell ill and he taken a treatment from Jeevan Nursing Home, Dadri Road, Bhiwani from 31.1.2015 to 5.5.2015 (but the complainant in his complaint has mentioned the wrong dates) and thereafter the complainant was admitted for treatment in OP Jindal Institute of Cancer & Cardiac Research, Model Town, Hisar from 1.7.2015 to 5.7.2015.  The counsel for the respondents/OPs further contended that Complainant was suffering from COAD/AN from the last one year as per the history and OPs has rightly repudiated the claim of the complainant/appellant.

I have gone through the impugned order and taken into consideration facts and circumstances of the case. There is no evidence produced by the Insurance Company to indicate that any such disease existed at the time of purchasing of policy and it was pre-existing. It is clear that respondents/Ops have committed deficiency in services.  The respondents/OPs has not produced any evidence regarding the pre-existing disease of the appellant/complainant. It is settled law that the onus to prove that the insured had a pre-existing disease was on the Insurance Company which as stated above, has failed to do so. Thus, in the absence of any credible evidence, the Insurance Company cannot escape its liability to pay the claim of the complainant/appellant.

Such a controversy has been decided by this Commission in First Appeal No. 668 of 2015 titled The Oriental Insurance Company Ltd. and another versus Ravi Shankar and others decided on 06.01.2016.

In view of the above, this appeal is accepted and the impugned order is modified with the direction to the opposite parties/respondents to pay Rs.42,085/- (after deducting the amount of Rs.12,234/- if paid to the appellant/complainant) along with interest @8% per annum from the date of filing of complaint till its realization and Rs.5000/- for harassment, mental agony and litigation expenses to the complainant.

The impugned order is modified on the terms indicated above.

With this modification, the appeal is disposed of.

                                      

Announced                                                                                 Diwan Singh Chauhan,

30.08.2018                                                                      Presiding Member

                                                                                 Addl. Bench-IInd