BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 216 of 2019
Date of Institution : 25.4.2019
Date of Decision : 08.01.2020.
Shimla Devi, aged 55 years wife of Shri Raj Kumar Soni, resident of Gali Khajanchian Wali, Tehsil and District Sirsa.
……Complainant.
Versus.
- Star Health & Allied Insurance Company Ltd., through its Branch Manager, Branch at Ground Floor Rathore Tower, Near Hotel Mehak, Dabwali Road, Sirsa, District Sirsa.
- Star Health & Allied Insurance Company Ltd., through its Branch authorized person/ signatory Regd. & Corporate Office at 1, New Tank Street, Valluvarkottam High Road, Nungambakkam, Chennai- 600034.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SMT. SUKHDEEP KAUR……………… MEMBER.
Present: Sh. R.D. Bishnoi, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
The case of the complainant, in brief, is that representative of the opposite parties approached husband of complainant and allured them to purchase the health insurance policy against one time premium amount of Rs.12,259/-. That before issuance of policy to the complainant and her husband, as per policy they had to undergo many tests to get themselves insured with ops from Sanjeevani Hospital, Sirsa and thereafter the ops issued policy No.P/211121/01/2018/000115 to them. It is further averred that later on complainant got the same renewed vide policy no.P/211121/01/2018/000253 which is valid w.e.f. 30.4.2018 to 29.4.2019 and also paid the premium thereon. It is further averred that in the month of May, 2018 complainant suffered with abdomen pain and she was taken to Janta Hospital, Sirsa for checkup on 4.5.2018 and the doctor advised her for ultrasound which was conducted on 5.5.2018 from Garg Diagnostic Centre, Sirsa. Thereafter, doctor advised the complainant to get checkup from Multi Specialty Hospital and then they went to Jindal Hospital, Hisar and she undergone lot of medical tests including MRI of lower abdomen and pelvis and the doctor disclosed the complainant that they have some doubts that there was a well defined lobulated solid mass lesion in right side of pelvis and also multiple intramural fibroids are seen in uterus and also urinary bladder is partially distended and reveal normal signal intensity on T1 & T2W images. After that complainant in order to get proper treatment went to BLK Super Specialty Hospoital, Delhi where the doctor after her thorough checkup disclosed the complainant that she is suffering from serious carcinoma ovary high grade and advised for admission in the hospital. The complainant was admitted in the hospital on 16.5.2018 and complainant handed over policy of ops to the hospital staff and as per terms and conditions of the insurance policy, the complainant also filled the TPA form and sent the same to the ops. It is further averred that complainant undergone long treatment including surgeries and remained admitted in the hospital from 16.5.2018 to 24.5.2018 and spent an amount of Rs.3,85,586/- on her treatment. The claim was lodged with the ops with all required documents and they were requested to pay the bills of the hospital and treatment but ops always lingered on the matter with one pretext or the other and complainant herself spent huge amount of treatment from her own pocket. That now in the first week of April, 2019, the complainant has received two letters from the ops whereby her claim has been repudiated on the ground of non disclosure of pre-existing disease which is wrong and incorrect because when complainant herself came to know about the disease in the month of May, 2018, how could she disclose the same to the ops. The complainant never undergone treatment from Medanta Hospital and the ops just in order to withheld/ grab the insured amount of complainant is taking such pleas. That ops have caused unnecessary harassment, deficiency in service and unfair trade practice towards the complainant. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement taking certain preliminary objections. It is submitted contents of purchasing of policy for sum insured of Rs.3,00,000/- for the period 19.4.,2017 to 18.4.2018 and 30.4.2018 to 29.4.2019 are admitted to be correct. It is further submitted that policy was issued believing that information provided by the insurer is true and correct. The policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of 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 the 2nd year of the inception of the policy. The insured was hospitalized in BLK Memorial Hospital, New Delhi on 16.5.2018 and was discharged on 24.5.2018 and as per discharge card, the insured patient was diagnosed with right sided high grade serous cystadenocarcinoma of ovary stage III B. It is further submitted that insured sought for approval of cashless treatment towards the above mentioned treatment. On scrutiny of claim documents, it is observed that insured was admitted for CA ovary, which falls under two years exclusion of the policy. Further, to ascertain the chronicity of the ailment, the histopathology report is necessary. Hence, the claim was denied vide letter dated 15.5.2018. Subsequently the insured submitted a claim for reimbursement of medical expenses for the above referred treatment for Rs.3,82,586/-. On scrutiny of claim documents, it is observed that :
a. As per the discharge summary, the insured was diagnosed with Rt sided high grade serous cystadenocarcinoma of ovary stage III B.
b. As per the claim verification report, it is noted that the insured patient has ovary cancer for the past two years which is prior to date of commencement of first year of policy.
c. Further as per the verification, the insured patient is on treatment at Medanta Hospital, Gurgaon. Inspite of our requested insured has not submitted treatment records taken at Medanta Hospital.
It is further submitted that from the above findings, it is noted that insured has pre existing disease and the same was not disclosed in the proposal form, which amounts to misrepresentation/ non disclosure of material facts making the contract of insurance voidable. Hence, the claim was rejected and same was communicated to the insured vide letter dated 26.3.2019 as per condition of the policy. Further, the policy was cancelled and same was informed to the insured as per condition of the policy. Lastly it is submitted that without conceding that company is liable to pay the claim in terms of contract of insurance issued to the claimant, the maximum quantum of liability under the terms of policy shall be Rs.3,24,116/-. 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 and have gone through the record carefully. During the course of arguments, learned counsel for complainant has also placed reliance on the judgment of Hon’ble Chandigarh State Commission (U.T) in case titled as Bharti Axa Life Ins. Co. Ltd. vs. Mamta Kumari, 2018 (3) CLT 208.
5. The complainant in order to prove her complaint has furnished her affidavit Ex.P1 in which she has deposed and reiterated all the averments made in the complaint. She has also furnished copy of policy Ex.P2 and treatment record and reputation letter as Ex.P3 to Ex.P18. 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.R11.
6. Admittedly, complainant and her husband purchased health insurance policy from the opposite parties on payment of premium of Rs.12,259/- and same was got renewed for the period 30.4.2018 to 29.4.2019. In the month of May, 2018, the complainant suffered abdomen pain and was taken to Janta Hospital, Sirsa. The doctor advised her for ultrasound which was got conducted on 5.5.2018 from Garg Diagnostic Centre, Sirsa. After getting report, doctor of Janta Hospital, Sirsa advised her to get checkup from Multi Specialty Hospital and then she approached Jindal Hospital, Hisar where she was medically examined and doctors opined that they have some doubts that there was a well defined lobulated solid mass lesion in right side of pelvis and also multiple intramural fibroids are seen in uterus and also urinary bladder is partially distended and reveal normal signal intensity on T1 & T2W images. Thereafter, she was taken to BLK Super Specialty Hospital, New Delhi where she was treated. The complainant has claimed a sum of Rs.3,85,586/- on account of treatment charges. Due intimation was given to the ops and claim was lodged, but however, same was repudiated vide letter Ex.R6 on the ground that “it is observed from the documents and information available with them, the insured patient has ovary cancer for the past two years which is prior to date of commencement of first year policy. The insured patient is on treatment at Medanta Hospital, Gurgaon. Inspire of our request insured has not submitted treatment records taken at Medanta Hospital which confirm that insured patient has carcinoma ovary present prior to date of commencement of first year policy. At the time of inception of policy which is from 19.4.2017 to 18.4.2018, you have 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.” The ops in order to prove their defence plea have furnished affidavit of Sh. Rajiv Jain, Chief Manager as Ex.RW1/A and have tendered documents Ex.R1 to Ex.R11.
7. The ops have not placed on record any affidavit of doctor who examined the treatment papers of the complainant and recommended to the insurance company that complainant was having a pre-existing disease of cancer. The ops have only alleged that complainant was taking treatment from Medanta Hospital prior to her treatment from above mentioned hospital. The ops have relied upon investigation report Ex.R7 of Indu Singh, Director IP Assure Services Private Limited, but however, ops have not placed on record any affidavit of Indu Singh in support of their plea. Indu Singh in the report Ex.R7 has reported that during visit at her residence, Dr. Pradeep Kumar, B.M.S who has a clinic nearby her house shared that he knows her family very well for last 10 years and she used to come there for regular routine check-ups then he got to know that she had ovary cancer for last two years for which she has been consulting many clinics and hospitals and she was admitted in Medanta Hospital, Gurgaon as well for the treatment and Video and audio of Dr. Pradeep attached. But however, ops have not placed on record any statement of Dr. Pradeep or the affidavit of Dr. Pradeep in support of this investigation report.
8. The perusal of discharge summary of BLK Hospital reveals that treating doctor has not mentioned anything that patient was having pre-existing disease of ovary cancer for the last two years. So, it appears that ops have failed to prove their defence plea by leading cogent and convincing evidence and non payment of claim amount to the complainant clearly amounts to deficiency in service on their part.
9. In view of our above discussion, we allow this complaint and direct the opposite parties to settle and pay the claim within 45 days from the date of receipt of copy of this order, failing which the ops will be liable to pay interest @7% per annum on the claim amount from the date of order till actual payment. We further direct the ops to pay a sum of Rs.10,000/- as compensation for harassment and Rs.5000/- 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. President,
Dated:08.01.2020. Member District Consumer Disputes
Redressal Forum, Sirsa.
