BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KAITHAL.

                                                     Complaint Case No.223 of 2018.

                                                     Date of institution: 27.08.2018.

                                                     Date of decision:03.05.2019.

Sunil Kumar age 42 years, son of Sh. Kishori Lal, resident of Ward No.2, Mohalla Shadion Street Wala, Habri Road, Pundri, Tehsil Pundri, District Kaithal.

                                                                        …Complainant.

                        Versus

Star Health and Allied Insurance Company Ltd., No.15, SRI Bala Ji Complex, Ist Floor Whites Lane, Royapettah, Channai-6000014, through its authorized signatory.

….Respondent.

Before:      Sh. D.N.Arora, President.

                Sh. Rajbir Singh, Member.

                Smt. Suman Rana, Member.

Present:     Sh. Rajiv Goswami, Advocate, for the complainant.   

                Sh. Ranvir Parashar, Advocate for the OP.

ORDER

D.N.ARORA, PRESIDENT

                The complainant has filed the present complaint under Section 12 of Consumer Protection Act, 1986, with the averments that the Op-insurance company called the complainant several times and introduced the complainant with Star Health Policy and on the advice and induce of the insurance company-Op, the complainant purchased a Senior Citizen Red Carpet Health Policy bearing No.P/700001/01/2018/014301 for the period valid w.e.f. 06.12.2017 to 05.12.2018 and paid the premium amount of Rs.9978/- through online.  It is alleged that the father of complainant namely Sh. Kishori Lal was also fully covered for a sum of Rs.2 lacs in the said policy.  Unfortunately, the father of complainant started feeling uneasy in the month of February, 2018 and as such, the complainant alongwith his father got examined by the doctors who advised for treatment AC.LVF/AF+FVR.  The father of complainant was admitted in Cygnus Super Specialty Hospital, Kaithal on 23.02.2018 and discharged on 28.02.2018 where the complainant incurred/spent Rs.43,012/- from 23.02.2018 to 28.02.2018 at Cygnus Super Specialty Hospital, Kaithal.  The complainant immediately informed the insurance company-Op and also submitted all the required documents but the Op repudiated the claim of complainant vide letter dt. 17.07.2018 on the ground that “the patient has chronic long standing heart disease prior to date of commencement of first year policy”, whereas the father of complainant was hale and health before taking the policy in question.  The said repudiation of claim is wrong and illegal.  So, it is a clear cut case of deficiency in service on the part of Op and prayed for acceptance of complaint.  Hence, this complaint.     

2.            Upon notice, the OP appeared before this Forum and contested the complaint by filing their reply raising preliminary objections with regard to locus-standi; maintainability; cause of action; that this Forum has no jurisdiction to entertain and try the present complaint because the policy in question was issued by the Head Office of the answering Op situated at Chennai and the answering Op has no branch office at Kaithal; that the complainant has concealed the true and material facts from this Forum.  The true facts are that the complainant had purchased the policy in question for the sum assured of Rs.2,00,000/- and at the time of availing the policy, the complainant was supplied with the terms and conditions of the policy.  As per terms and conditions of the policy, only those pre-existing diseases which are specifically declared by the proposer in the proposal form are covered under the policy.  The answering Op received intimation regarding hospitalization of father of complainant and accordingly sent a query on pre-authorization to the Cygnus Hospital on 24.02.2018 raising demand of necessary documents but the answering Op has not received any previous treatment record of the insured and accordingly, the pre-authorization for cashless treatment was denied vide letters dt. 24.02.2018 and 26.02.2018 respectively.  It is submitted that the insured was chronic patient of long standing heart disease prior to date of commencement of first year of policy, so, the claim of complainant was rightly repudiated by the Op vide letter dt. 17.07.2018.  Therefore, invoking condition No.13 of the policy, the policy in respect of Kishori Lal stands cancelled w.e.f. 06.09.2018 due to non-disclosure of PED-CARDIAC DISEASE and further hospitalization being within two months of the issuance of the insurance policy and in consequence thereof, a refund of premium amounting to Rs.9978/- Premium of Rs.8456/-+S.T. Rs.1522/-) was allowed to the insured.  There is no deficiency in service on the part of Op.  On merits, the objections raised in the preliminary objections are reiterated and so, prayed for dismissal of complaint.

3.             The complainant tendered into evidence affidavit, Ex.CW1/A and documents Annexure-C1 to Annexure-C17 and thereafter, closed the evidence.

4.           On the other hand, the Op tendered into evidence affidavit, Ex.RW1/A and documents Annexure-R1 to Annexure-R22 and thereafter, closed the evidence.

5.             We have heard the learned Counsel for both the parties and perused the record carefully.

6.             Undisputedly, the complainant purchased a Senior Citizen Red Carpet Health Policy bearing No.P/700001/01/2018/014301 for the period valid w.e.f. 06.12.2017 to 05.12.2018 and paid the premium amount of Rs.9978/- through online and the father of complainant namely Sh. Kishori Lal was also fully covered for a sum of Rs.2 lacs in the said policy.  The complainant contended that his father was admitted in Cygnus Super Specialty Hospital, Kaithal on 23.02.2018 and discharged on 28.02.2018 where the complainant incurred/spent Rs.43,012/- from 23.02.2018 to 28.02.2018 at Cygnus Super Specialty Hospital, Kaithal.  The grievance of the complainant is that he submitted the bills of Rs.43,012/- with the Op but the Op repudiated the claim of complainant vide letter dt. 17.07.2018 on the ground that the patient has chronic long standing heart disease prior to date of commencement of first year policy.  The said repudiation of claim is wrong and illegal.  The complainant has placed reliance upon the case law cited in 2018(3) CLT page 289 titled as LIC of India Vs. P.R.Sumanagala (NC); 2018(3) CLT page 187 titled as Rajinder Singh Vs. NIA (SC Haryana) and 2018(2) CLT page 205 titled as Manish Goyal Vs. Max Bupa Health Insurance Co. Ltd. and others.  The complainant has also placed reliance upon copy of order dt. 05.11.2014 passed by Hon’ble National Commission in case titled as ICICI Prudential Life Insurance Company Ltd. Vs. Veena Sharma.

                   On the other hand, ld. counsel for the Op contended that the as per terms and conditions of the policy, only those pre-existing diseases which are specifically declared by the proposer in the proposal form are covered under the policy.  He further contended that the insured was chronic patient of long standing heart disease prior to date of commencement of first year of policy, so, the claim of complainant was rightly repudiated by the Op vide letter dt. 17.07.2018.

                We have considered the rival contentions of both the parties and perused all the record available on the file.  On careful perusal of record, we find that there is nothing on record which could prove that the father of complainant was suffering from pre-existing disease relating to heart because the Op has not placed on file any treatment record regarding heart disease of father of complainant which could prove that the insured was suffering from heart disease prior to date of commencement of first year of policy.  The Op has placed on record only ECHO CARDIOGRAPHY & COLOR DOPPLER REPORT, Ex.R6 and from perusal of above-said report, the right ventricle was found normal and right atrium was found normal and no pericardial effusion.  Only mentioned in the above-said report in the column of comments that severe: LV Systolic Dyfunction, GlobaL: Hypokinesia of LV, Global LVEF:22% but above-said report does not co-relate with the previous history of disease.   Even otherwise, there is no previous history mentioned in the above-said report.  So, the contention of Op that the complainant has not disclosed the medical history of the insured person in the proposal form has no force.  Moreover, the onus to prove that the deceased had obtained policy by suppressing facts relating to his illness was on the Insurance Company/Corporation, but no tangible evidence was produced on its behalf to prove that the deceased was suffering from serious liver ailment at the time of taking policy and he had deliberately suppressed the facts.  Undisputedly, the policy in question was issued on 05.12.2017 and the father of complainant must have filled the proforma some time prior to that date.  Therefore, the Corporation ought to have produced evidence to prove that as on the date of filing the proforma, the deceased was suffering from any identified ailment and he had intentionally written no against item Nos.(a) to (d) of clause 11.  This the Corporation had failed to do.  In this regard, we can rely upon the case titled as ICICI Prudential Life Insurance Company Ltd. Vs. Veena Sharma (supra), which is fully applicable to the facts of instant case.  Hence, in the facts and circumstances of the case, we are of the considered view that the Op has wrongly repudiated the claim of complainant and this act of Op amounts to gross deficiency in service on their part and they have adopted the unfair trade practice.  The complainant has placed on file the bills Annexure-C1 to Annexure C8 total amounting to Rs.43,012/-, so, the complainant is entitled to the amount of Rs.43,012/- from the Op. 

7.             Thus, as a sequel of above discussion, we allow the complaint and direct the Op to pay the amount of Rs.43,012/- to the complainant alongwith interest @ 9% p.a. from the date of filing of present complaint till its realization and further to pay Rs.5,000/- as lump sum compensation on account of harassment, mental agony and costs of litigation charges.  Let the order be complied with within 30 days from the date of preparation of copy of this order.  A copy of said order be supplied to the parties free of costs.  File be consigned to record-room after due compliance.     

Announced in open court:

Dt.:03.05.2019.  

                                                                        (D.N.Arora)

                                                                        President.

(Suman Rana),           (Rajbir Singh)         

Member                             Member.