Delhi

North East

RBT/CC/269/2022

RAHUL DAYAL - Complainant(s)

Versus

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

10 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

RBT/Complaint Case No.269/22

In the matter of:

 

	Sh. Rahul Dayal, S/o Sh. Prabhu Dayal, R/o H.No 425, Main Bus Stand, V.P.O. Darya Pur Kalan (NW) Bawana, Delhi	Complainant
	Versus
1.             2.	The Branch Manager/HOD Star Health And Allied Insurance Co. Ltd., 1st Floor, Himalaya House, 23, Kasturba Gandhi Marg, New Dehi 110001   The Chief Manager Star Health And Allied Insurance Co. Ltd., 1, New Tank Street, Valluvar High Road, Nungambakkam, Chennai 600034 Tamil Nadu	Opposite Parties

 

DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                         DATE OF ORDER  :

21.12.2018 02.08.2023 10.10.2023

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

ORDER

Surinder Kumar Sharma, President

The Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that on 12.08.2015, the Complainant had purchased a medi-claim/health policy from the Opposite Parties for a sum of Rs. 5 lacs. Opposite Parties assured the Complainant that the said policy would provide the cashless treatment to the Complainant.  Complainant paid Rs. 7,997/- as premium to the agent of the Opposite Parties. The period of the said policy was from 12.08.2015 to 11.08.2016. It is his case that he renewed the said policy for the next year i.e. 17.08.2016 to 16.08.2017 for an annual premium of Rs. 8,067/-. After that he again renewed the policy for the next year i.e. 17.08.2017 to 16.08.2018 for an annual premium of Rs. 8,277/-. After that again Complainant renewed the said policy for the next year i.e. 17.08.2018 to 16.08.2019 for an annual premium of Rs. 8,277/-. It is his case that in the month of August 2018, Complainant had some severe headache, nausea and vomiting and Complainant was taken to the Saroj Super Speciality Hospital, Rohini, Delhi, which comes under the panel of the Opposite Parties. Complainant requested to the Opposite Parties to provide the cashless treatment but Opposite Parties rejected the requisition of the Complainant vide letter dated 18.08.2018 by taking false view about the Complainant that the Complainant was suffering from Nephrotic syndrome in 2009 and the same was not disclosed by the Complainant while applying for the said policy.  It is his case that at the time of applying for the policy, the Complainant had clearly mentioned that he was not suffering from any kind of ailment. It is his case that he remained admitted in the hospital from 14.08.2018 to 18.08.2018 and the Complainant spent Rs. 1,06,034/- on the medical treatment and policy. It is his case that after getting discharged from the hospital, on 23.08.2018, Complainant filed an application for the claim amount of Rs. 1,06,034/- along with all the relevant documents. It is his case that Opposite Parties rejected the claim and the same was communicated vide letter dated 04.09.2018. Complainant had requested the Opposite Parties several times but they gave false assurance and avoided the same on one pretext or the other. It is his case that vide a letter dated 06.10.2018, Opposite Parties informed the Complainant about the cancellation of the said policy which was purchased by the Complainant for non disclosure of PED and also refunded the premium of Rs. 8,277/-. The Complainant had visited the office of Opposite Parties for the claim of the insurance amount but the Opposite Parties had not given any satisfactory feedback till date. On 15.10.2018, Complainant sent a legal notice to the Opposite Parties and Opposite Parties gave a false reply vide letter dated 02.11.2018. Hence, this shows the deficiency of service on the part of Opposite Parties. Complainant has prayed for Rs. 1,06,034/- as the medical expenses, Rs. 50,000/- on account of mental harassment and Rs. 21,000/- on account of litigation expenses.

  

Case of the Opposite Parties

2. The Opposite Parties contested the case and filed written statement. It is stated that the Complainant while purchasing the health insurance policy from the Opposite Parties had concealed about his past ailments. However, after admission in the hospital the previous history of the aliments of the Complainant were detected. It is stated that the Complainant was suffering from Nephrotic syndrome in 2009 and this ailment/disease was not disclosed by the Complainant. The Opposite Parties has stated that there was violation of the terms and conditions of the policy as the Complainant had not disclosed his past ailments. Therefore, the claim was rightly rejected by the Opposite Parties. It is prayed that the complaint be dismissed.

Rejoinder to the written statement of Opposite Parties

3. The Complainant filed rejoinder to the written statement of Opposite Parties, wherein the Complainant has denied the pleas raised by the Opposite Parties and has reiterated the assertion made in the complaint.

Evidence of the Complainant

4. The Complainant in support of his complaint filed his affidavit wherein he has supported the averments made in the complaint.

 

 

Evidence of the Opposite Parties

5. To support their case, Opposite Parties have filed affidavit of Sh. Rajiv Jain, Chief Manager, wherein, he has supported the case of the Opposite Parties as mentioned in the written statement.

Arguments & Conclusion

6. We have heard the Ld. Counsels for the Parties. We have also perused the file and written arguments filed by the Complainant and Opposite Parties. The case of the Complainant is that he had purchased the health insurance policy from the Opposite Parties. The Complainant was suffering from severe headache, vomiting etc. and he got himself admitted in Saroj Super Speciality Hospital from 14.08.2018 to 18.08.2018. His case is that he was denied the cashless treatment facility by the Opposite Parties. After his discharged from the hospital, he had submitted claim for reimbursement of medical bills etc. His claim was rejected by the Opposite Parties on the ground that the Complainant had concealed his previous disease as he was having some kidney related problem. It is the case of the Complainant that he was never suffering from the said disease and he had not concealed any fact from the Opposite Parties at the time of purchasing the health insurance policy. On the other hand, the case of the Opposite Parties is that the Complainant was a patient of kidney related disease i.e. Nephrotic syndrome and at the time of purchasing the policy, the Complainant had concealed this ailment. It is the case of the Opposite Parties that the concealment of previous ailment amounts to violation of the terms and conditions of the insurance policy and therefore, the claim of the Complainant was rejected rightly.
7. There is copy of initial assessment notes given by the Saroj Super Speciality Hospital. The perusal of the same reveals that it mentions about the Nephrotic syndrome as past history. Further, the said document does not anywhere mention about that at the relevant time the Complainant was admitted for treatment of kidney disease. At the relevant time the Complainant was admitted in the hospital for treatment of headache, vomiting etc. The perusal of the discharge card issued by the Saroj Super Speciality Hospital shows that diagnosis “Accelerated/Liabile HTN”.
8. Thus, it is very much clear from the discharge card of the Saroj Super Speciality Hospital that the Complainant was admitted for treatment of hypertension at the relevant time and not for kidney related disease. Therefore, in our opinion, the Complainant cannot be denied the reimbursement of medical treatment expenses as the expenses of the treatment in question are regarding hypertension and are unrelated to the kidney disease. The Complainant had submitted the final bill of the Saroj Super Speciality Hospital which shows that the Complainant has paid    Rs. 71,112/- to Saroj Super Speciality Hospital. The Complainant is also claiming the amount of the premium which he had paid to the Opposite Parties for purchasing the health insurance policy. The premium of the health insurance policy of the year 17.08.2018 to 16.08.2019 amounting to Rs. 8,277/- had been returned to the Complainant by the Opposite Parties. The premiums paid for earlier policies cannot be returned to the Complainant as the same were neither cancelled by the Opposite Parties nor any such request was made by the Complainant for cancellation of the said policies. Therefore, it is ordered that the Opposite Party No. 1 shall pay an amount of Rs. 71,112/- to the Complainant on account of medical treatment expenses along with interest @ 9 % p.a. from the date of filing the complaint till recovery. The Opposite Party No. 1 shall also pay an amount of Rs. 50,000/- to the Complainant on account of mental harassment and litigation expenses along with interest @ 9 % p.a. from the date of this order till recovery.
9. Order announced on 10.10.2023.

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Anil Kumar Bamba)		(Surinder Kumar Sharma)
(Member)		(President)