BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.            

                                                          Consumer Complaint no. 191 of 2018                                                               

                                                           Date of Institution         :    26.06.2018

                                                          Date of Decision   :    28.08.2019.

Rajiv Kumar(aged about 52 years) son of Sh. Tara Chand, resident of House No.125/B, B-Block, Sirsa.

                      ……Complainant.

                             Versus.

1.  Star Health and Allied Insurance Company Ltd., 1-New Tank Street, Valluvar Kottam High Road Nungambakkam, Chennai-600034 through its Senior Manager/Incharge Customer Care.
2. Vishal Taneja Branch Manager, Star Health and Allied Insurance Company Ltd. Ground Floor, Rathore Tower, Near Hotel Mehak, Dabwali Road, Sirsa.
3. Gulshan Kumar Mehta, authorized agent vide code no.BA0000261298,Star Health and Allied Insurance Company Ltd. Ground Floor, Rathore Tower, Near Hotel Mehak, Dabwali Road, Sirsa.
4. Sanjay Jindal, SM, (SMcode:SH29601) Star Health and Allied Insurance Company Ltd. Ground Floor, Rathore Tower, Near Hotel Mehak, Dabwali Road, Sirsa.

…….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. Ravinder Monga,  Advocate for the complainant.

                   Sh. M.K. Saini, Advocate for opposite parties no.1&2.

                   Opposite parties no.3&4 exparte.

ORDER

                   In brief, the case of the complainant is that complainant purchased health policy No.P/211121/01/2018/001148 from opposite party no.1 on the asking of ops no.2 to 4 for the period 5.8.2017 to 4.8.2018 after completing all the formalities. The complainant paid premium amount of Rs.24379/- through cheque and the complainant alongwith his family members i.e Neeraj Arora wife and Hardik and Arpit Chaudhary sons were insured under the said policy. The limit of coverage was given of Rs.five lacs under the scheme description 2A + 2C. It is further averred that ops no.2 to 4 also explained that they are having paneled doctors in Sanjivani Hospital who will examine all the insured persons. After physical verification etc,  the ops issued customer identity card under the IRDL instruction no.129. That in the last week of September, 2017, the younger son of complainant namely Arpit Chaudhary felt some trouble in abdomen and at that wife of complainant provided some domestic treatment and he felt comfortable. Then suddenly on 6.10.2017, he again felt severe pain and was admitted to Dayal Nursing Home, Sirsa without any delay and doctor P. Dayal after examination advised for regular tests for investigation purpose and after receiving the test report, the doctor disclosed that there is stomach infection and started diagnose. The son of complainant remained admitted in the said hospital from 6.10.2017 to 11.10.2017 and doctor charged Rs.11,500/- as hospital charges and besides this complainant spent Rs.5399/- on medicines and laboratory tests. It is further averred that again son of complainant felt infection and was admitted in Dayal Hospital from 6.11.2017 to 9.11.2017 and doctor charged Rs.7100/- as hospital charges and complainant also spent Rs.4775/- on medicines and tests. In this manner, the complainant has spent total amount of Rs.28,783/- on the treatment of his son. Due intimation was given to the ops and as the Dayal Nursing Home is not in the list of doctors provided by the ops, so ops no.2 to 4 advised to pay the entire amount to the doctor and to submit the treatment record and bills of all the expenses. The complainant submitted all the bills in the office of op no.2 in the presence of ops no.2 and 4 and they assured that claim shall be released within 15/20 days but then the ops postponed the matter on one pretext or the other and caused delay after giving assurances. That when inquired about the status of his claim vide email on 20.2.2018, he received a mail dated 22.2.2018 whereby it was informed that his claim has been rejected as per condition no.3 for want of documents. Then the complainant wrote a letter to the ops on 6.3.2018 with the request that as alleged in mail dated 22.2.2018 he has not received any letter from the company requiring any information from the complainant. Then as per the admission of the ops in the mail, it is established that on 16.3.2018 they have received the claim documents of the complainant. It is further averred that thereafter in response to his mail dated 19.3.2018 and letter dated 4.4.2018 regarding status of his claim, he received a shocking letter dated 20.5.2018, the contents of which are self explanatory about the unfair trade practice by the company and negligence, deficiency in service on the part of its official. The last height crossed by the ops when the complainant received a Whats-app letter 30.3.2018 from his friend in regards to his claim wherein the ops have repudiated the claim with the reference of condition no.3 and 12 of the policy, which is bad in the eyes of law and the ops have no legal right to decline the claim of complainant. The ops by showing their negligence, deficiency and unfair trade practice, illegally and unauthorisedly wrote a letter dated 5.5.2018 with the observation “We referred to the repudiation of claim from our claims department Corporative Office Chennai, due to non-disclosure of material facts i.e. about the existence of pre-existing disease, based upon the above individual is belated to whom is PED is found out and new policy coverage have been provided for the rest of the person with same terms and conditions, therefore, the difference in premium is refunded by way of cheque therewith”. The said action taken by the ops is liable to be set aside forthwith. Hence, this complaint.

2.                On notice, opposite parties no.1 and 2 appeared and filed written statement raising certain preliminary objections. It is submitted that policy was issued as per the terms and conditions of the insurance policy 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 and it was clearly stated in the same that insurance under the policy is subject to conditions, clauses, warranties, exclusions etc. The insured claimed an amount of Rs.16,673/- towards the hospitalization dated 6.10.2017 and Rs.11,885/- towards the hospitalization dated 6.11.2017 in the second month of the issuance of policy.  It is further submitted that insured patient Mr. Arpit Chaudhary, was admitted at Dayal Nursing Home on 06.10.2017 to 11.10.2017 and 06.11.2017 to 09.11.2017 for the treatment of chronic Colitis with IBD, on scrutiny of the same, it is observed that:

         As per the discharge summary for the period 06.10.2017 to 11.10.2017, the insured has a history of pain in abdomen for the last few weeks. Therefore, the answering ops have called for the following vide letter dated 21.01.2018:-

        Letter from treating doctor stating exact duration of chronic colitis with IBD and history of bleeding per rectum,  Colonoscopy with biopsy reports, any medications taken for IBD and all previous hospitalization records taken prior to this admission.

         But the insured has only submitted a treating doctor certificate and has not submitted any previous hospitalization record. The claim is reported in the 2^nd month of the policy and the insured was symptomatic few weeks prior to the admission. Therefore, the answering ops have called for the previous treatment details, whereas even after repeated reminders, the insured has not submitted the same. It is further submitted that in the absence of the above documents/details, answering ops are not able to process the claim. As per condition no.3 of the above policy, the insured person has to submit all the required documents and details called for by insurance company. Hence, the claim of the complainant was repudiated and the same was communicated to the insured vide letter dated 20.02.2018 and 29.03.2018. As per the condition No.12, the policy is also liable to be cancelled, if there is any non disclosure or non cooperation. Thus, the policy in question was cancelled and was duly communicated to the complainant. Remaining contents of the complaint are also denied and prayer for dismissal of the complaint made.

3.                Opposite parties no.3 and 4 did not appear despite notice and were proceeded against exparte.

4.                The complainant as well as ops no.1 and 2 then led their respective evidence.

5.                We have heard learned counsel for the parties and have perused the case file carefully.

6.                The complainant in order to prove his complaint has furnished his affidavit Ex.CW1/A in which he has deposed and reiterated all the averments made in the complaint. He has also furnished documents i.e. copies of letters, treatment record, bills, policy documents and email as Ex.C1 to Ex.C60. On the other hand, ops no.1 and 2 have furnished affidavit of Sh. Rajiv Jain, Chief Manager as Ex.RW1/A in which he has deposed and reiterated the averments made in the written statement. They have also furnished copies of policy documents and treatment record and copies of letters as Ex.R1 to Ex.R11.

7.                Undisputedly, the complainant had purchased health policy No.P/211121/01/2018/001148 for the period 5.8.2017 to 4.8.2018 for himself and his family members i.e. wife and two sons. The son of complainant namely Arpit Chaudhary felt some problem in his abdomen in the last week of September, 2017 and he remained admitted in the hospital from 6.10.2017 to 11.10.2017 and from 6.11.2017 to 9.11.2017 and complainant spent total amount of Rs.28,783/- on the treatment of his son. Due intimation was given to the ops and claim was lodged with the ops, but however, same was repudiated and not paid after making reference of condition no.3 and 12 of the policy on the ground of non disclosure of material facts of pre-existing disease, based upon the above individual is belated to whom PED is found out and new policy coverage have been provided for the rest of the persons with same terms and conditions, therefore, the difference in premium is refunded by way of cheque.

8.                It is legal obligation of the ops to prove pre-existing disease on the basis of which they have repudiated the claim of the complainant qua treatment of his Arpit Chaudhary. The ops no.1 and 2 in order to prove their plea have furnished affidavit of Sh. Rajiv Jain, Chief Manager Star Health and Allied Insurance Company ltd. who has deposed and reiterated the averments made in the written statement. He has deposed that insured patient Arpit Chaudhary was admitted at Dayal Nursing Home from 6.10.2017 to 11.10.2017 and from 6.11.2017 to 9.11.2017 but the insured has only submitted a treating doctor certificate and has not submitted any previous hospitalization record. The claim is reported in the 2^nd month of the policy and the insured was symptomatic few weeks prior to the admission. Therefore, they called for previous treatment details and even after repeated reminders, the insured has not submitted the same. He has further deposed that as per condition No.3 of the policy, the insured has to submit all the required documents and details called for by insurance company and as per condition no.12, the policy is also liable to be cancelled, if there is any non disclosure or non cooperation. The ops have not furnished any opinion of the expert who examined the documents submitted by the complainant alongwith claim for settlement of the same, but however, it is the duty of the complainant to submit all the required documents which are necessary for the settlement of the claim. But the ops cannot repudiate the claim and cannot cancel the policy without going through the proper record. On one side they have called for documents and on the other side the ops have passed order of cancellation of the policy and have refunded amount of premium. It will be in the fitness of things, if a direction is given to the complainant to submit the documents as per letter dated 21.1.2018 i.e. Letter from treating doctor stating exact duration of chronic colitis with IBD and history of bleeding per rectum, colonoscopy with biopsy reports, any medications taken for IBD and all previous hospitalization records taken prior to that admission and the thereafter the ops are directed to examine the documents and to settle and pay the claim of complainant as per terms and conditions of the policy. The order of repudiation as well as cancellation of policy are set aside.  

9.                In view of above discussion, we partly allow the present complaint and direct the complainant to submit the documents detailed above within 15 days from the date of receipt of copy of this order and thereafter ops are directed to re-open the claim file and consider the documents submitted by complainant and thereafter pass a fresh order and to settle and pay the claim of the complainant as per terms and conditions of the policy within further period of 30 days. No order as to costs. A copy of this order be sent to both the parties free of costs. File be consigned to the record room.

Announced in open Forum.     Member Member        President,

Dated:28.08.2019.                                                          District Consumer Disputes

                                                                             Redressal Forum, Sirsa.