Haryana

Ambala

CC/184/2020

Deepak - Complainant(s)

Versus

Star Health and Allied Insurance Co Ltd - Opp.Party(s)

Tarun Kumar Kalra

20 Jul 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

 

Complaint case no.	:	184 of 2020
Date of Institution	:	09.09.2020
Date of decision	:	20.07.2022

 

Sh. Deepak Son of Sh. Rattan Lal, age about 53 years, Resident of House No.1091, Housing Board Colony, Sector-8. Ambala City.

          ……. Complainant.

                                                Versus

1. Star Health and Allied Insurance Company Limited, Branch Office, 3^rd  floor, 180-1 to 3, Minerva Complex, Rai Market, Ambala Cantt. (Haryana) through its Branch Manager/Concerned Officer.
2. Star Health and Allied Insurance Company Limited, Branch Office, SCO No. 5-A, 2^nd  Floor, Madhya Marg, Sector-7C, Chandigarh through its concerned person/Officer
3. Star Health and Allied Insurance Company Limited, Registered and Corporate Office:1, New Tank Street, Valluvar Kottam, High Road, Nungambakkam, Chennai-600034, through its Director/Managing Director or Concerned Person/officer.

2nd Address: Star Health and Allied Insurance Company Limited, SRI BALAJI COMPLEX, 15, WHITES ROAD, CHENNAI-600014 through its concerned person/officer.

                                                                                   ….…. Opposite Parties.

 

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member,

Shri Vinod Kumar Sharma, Member.         

                            

Present:       Shri Tarun Kalra, Advocate, counsel for the complainant.

                        Shri Mohinder Bindal, Advocate, counsel for the OPs.

 

Order:        Smt. Neena Sandhu, President

Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

(i) To pay Rs.Four Lakh Twenty Seven thousand five Hundred and  seventy two only (Rs.4,27,572/-), as reimbursement of medical expenses.

(ii) To pay Rs.5,00,000/- as damages/compensation for the agony suffered by the complainant.

(iii) To pay Rs.5,000/- as cost of legal notice served upon all the Opposite Parties.

(iv) To pay Rs.10,000/- as litigation costs.

                                    Or 

Grant any other relief which this Hon’ble Commission may deem fit.

2.             Brief facts of the case are that the complainant had purchased a health insurance policy i.e. "Family Health Optima Insurance Plan" from the opposite parties vide policy Number P/161113/01/2017/001722, which was valid from 16.08.2016 to 15.08.2017, on making payment of premium of Rs.24,995/- for himself and his family members i.e. for his wife Smt. Gagandeep and his three dependent children namely Master Jatin, Miss Manvi and Vansh. The sum assured of this policy was 10,00,000/-. Complainant got renewed the above-mentioned policy for the period from 16.08.2017 to 15.08.2018 vide policy Number P/161113/01/2018/001734, by paying total premium of Rs.33966/- and the sum assured was Rs.10,00,000/- and Rs. 2,50,000/- as BONUS. He again got renewed the above-mentioned policy from 12.09.2018 to 11.09.2019 vide RENEWAL Number P/161113/01/2019/002262 by paying total premium of Rs. 31937/- and the sum assured was Rs.5,00,000/- PLUS Bonus Rs.3,00,000/-. The complainant never claimed any amount for his or his family member’s treatment in above all three health insurance policies. The complainant again renewed the above-mentioned policy from 05.11.2019 to 04.11.2020 vide RENEWAL ENDORSEMENT Number P/161113/01/2020/003616 by paying total premium of Rs.31937/- and the sum assured was Rs.5,00,000/- PLUS Bonus Rs.3,50,000/- within grace period for renewal of policy i.e. within 120 days. It is worth mentioning here that this policy was not a fresh policy but was issued for renewal of the previous policy within grace period and endorsement number was also issued RENEWAL ENDORSEMENT Number P/161113/01/2020/003616. However, thereafter, during subsistence of this last insurance  policy, the complainant was treated and operated in MAX HOSPITAL, Mohali, for which he applied for cashless treatment with the opposite parties, but the same was rejected vide letter dated 08.11.2019, by the OPs on the ground that "The above insurance policy is renewed after a break period from 12.09.2019 to 04.11.2019" and it is observed from color Doppler ECHO report dated 04/11/2-19 that the onset of the above disease is during the break period of insurance and this was not disclosed at the time of renewal of this Policy. Hence the claim is not admissible." After rejection of cashless treatment by the OPs, the complainant was under impression that any sudden expenses of treatment up to Rs8,50,000/- shall be borne by OPs. The complainant then remained admitted in Max Super Specialty Hospital from 08.11.2019 to 18.11.2019 and spent Rs.4,27,572/-, on his admission, operation, medicines etc. during the period of his admission in hospital. After discharge from the Hospital, when he claimed the amount spent on his treatment from the OPs, his claim was repudiated by them vide letter dated 04.03.2020 on the ground that "The above Policy is renewed after a break period of 54 days i.e. from 12.09.2019 to 04.11.2019. It is observed from the submitted discharge summary of the above hospital that the insured patient has complaints of breathlessness on walking long distance and climbing 3-4 steps for the past 1 month and the patient has undergone color Doppler ECHO on 04.11.2019, which confirmed that the onset of the above disease is during the break in policy period and the insured patient is treated subsequently". The complainant then submitted a representation the higher officials of the OPs for reconsideration and allowing the reimbursement of the treatment expenses, but the same was also rejected vide reply of email dated June 18, 2020. When his grievance was not redressed, the complainant issued Legal Notice dated 14.08.2020  upon OPs No.2 and 3 but to no avail. By not reimbursing the claim amount, the OPs have committed deficiency in service. Hence, the present complaint.
3.           Upon notice, the OPs appeared and filed written version raised preliminary objections with regard to maintainability, jurisdiction, cause of action, not come with clean hands and suppressed the material facts etc. On merits, it is stated that complainant initially availed one Family Health Optima Insurance policy no. P/161113/01/2017/001722 for the period from 16.08.2016 to 15.08.2017 which was renewed on different dates from 16.08.2017 to 15.08.2018, 12.09.2018 to 11.09.2019 and lastly from 05.11.2019 to 06.11.2020, for himself alongwith his wife Smt. Gagandeep, his sons Jatin, Vansh and daughter Manvi. However, the insurance policy for the period from 12.09.2018 to 11.09.2019 was renewed for basic floater sum of Rs.5,00,000/- and later for the period from 05.11.2019 to 04.11.2020 similarly for the same amount of Rs.5,00,000/- and this last insurance policy for the period from 05.11.2019 to 04.11.2020, relevant to the facts of this case, was renewed by the complainant on 05.11.2019 i.e. after a gap of 54 days from the expiry of his earlier insurance policy which had expired on 11.09.2019. As such, the said policy was issued subject to terms and conditions of the insurance policy.  Complainant preferred a claim in the said insurance policy valid for the period from 05.11.2019 to 06.11.2020 with regard to his treatment at Max Super Specialty Hospital, Mohali, where he remained under treatment from 12.11.2019 to 18.11.2019 as a case of Coronary Artery Disease Triple Vessel Disease and was operated upon. Request for cashless authorization for the treatment of Severe LV Dysfunction was received on 08.11.2019 and the same was rejected, since the onset of ailment falls under the break in period. However, it came to the knowledge of the OPs that the complainant was diagnosed for the disease on 04.11.2019, which is evident from the ECHO report dated 04.11.2019, issued by Mehra Hospital, Ambala City i.e. he was having complaint of breathlessness on walking long distance and climbing 3-4 steps for the last 1 month when he reported in Max Hospital. The Color Doppler ECHO report dated 04.11.2019 (prior to the renewal of policy) shows LVEF as 25 to 30% which confirms heart failure and thus the onset of the above disease was during the break period of insurance which infact was not disclosed by the complainant while getting the renewal of his insurance policy on the next day on 05.11.2019. Thus, his claim was found not maintainable as per Condition no. 7 of the insurance policy. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant alongwith the policy schedule. Moreover, it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC. ATTACHED." Rest of the averments of the complainant were denied by the answering OPs and prayed for dismissal of the present complaint with costs.
4.           Learned counsel for the complainant tendered affidavit of complainant as Annexure CX alongwith documents as Annexure C-1 to C-36 and closed the evidence on behalf of complainant. On the other hand, learned counsel for the OPs tendered affidavit of Sh.Rajiv Jain, Chief Manager, Star Health and Allied Insurance Co. Ltd., 1^st Floor, Himalaya House, 23, Kasturba Gandhi Marg, New Delhi-110001 as Annexure OP-A alongwith documents Annexure OP-1 to OP-14 and closed the evidence on behalf of OPs.
5.           We have heard the learned counsel for the parties and OPs and carefully gone through the case file and also gone through the written arguments filed by the learned counsel for the OPs.
6.           Learned counsel for the complainant has submitted that neither any wrong information was provided by the complainant with regard to his health at the time of filling up of the proposal form nor he was suffering from any pre-existing disease, and at the same time, the policy in question was a not  fresh one, but on the other hand, it was renewed by the OPs with the grace period, in continuation of the original insurance policy purchased in the year 2016 onwards, yet, his genuine claim has been repudiated by the OPs, which act amounts to deficiency in providing service, negligence and adoption of unfair trade practice on their part. 
7.           On the contrary, the learned counsel for the OPs has submitted that though the policy in dispute was renewed by the OPs, within a grace period of 120 days, yet, because since there was a gap of 54 days in obtaining the said policy and at the same time, the complainant was diagnosed from the disease i.e Symmetrical Global Hypokinesia LVEF as 25-30%, vide report dated 04.11.2019 i.e. the date when there was no insurance policy in force, as such, his claim was rightly rejected by the OPs, strictly as per condition no.7 of the insurance policy, which says that in case the insured suffers any  disease/illness during the grace period, in which the premium has not been paid, shall be considered as pre-existing disease and his claim will be considered accordingly.
8.           First coming to the objection taken by the OPs that as the dispute allegedly involves the determination of complex and number of complicated issues, laws and facts that cannot be decided in the absence of expert and huge evidence, as such only the civil court has jurisdiction in the matter, it is submitted that it is a simple case of repudiation of claim of the complainant by the OPs, and the only question which is to be decided by this Commission is as to whether the said repudiation is justified or not. Thus, objection taken by the OPs being devoid of merit is rejected.
9.           As far as objection regarding impleading of Director/Managing Director as necessary party to this complaint is concerned, we are of the considered view that the company being a juristic person/artificial legal person created by law, it is necessary to act only through the agency of natural persons. It can only act through human beings, and they are the Managing Director/Directors through whom mainly the company acts. So, it is the Director or group of Directors, who administers controls or directs the day-to-day affairs of the company. The Managing Director/Directors, in our considered opinion, are holding such important positions in the Company, where they are directly involved with the decision-making process in the Company and will be jointly and severally liable alongwith the Company, for all the acts done. Similar view was expressed by the Hon’ble National Commission, in M/s. India Bulls Real Estate & Wholesale Services Ltd. & Ors, Vs. Vemparala Srikant & Anr., First Appeal No. 797 of 2017, decided on 16 Aug 2017. Thus, this objection taken by the OPs also being devoid of merit is rejected.
10.           Now coming to the merits of this case, it is an admitted fact that the complainant had purchased a health insurance policy i.e. "Family Health Optima Insurance Plan" from the OPs vide policy Number P/161113/01/2017/001722, which was valid from 16.08.2016 to 15.08.2017, on making premium of Rs.24995/- for himself and his family members i.e. for his wife Smt. Gagandeep and his three dependent children namely Master Jatin, Miss Manvi and Vansh, for sum assured to Rs.10,00,000/-. It is also not disputed that the said policy was got renewed from time to time on making payment of premiums i.e.  16.08.2017 to 15.08.2018 vide policy Number P/161113/01/2018/001734, 12.09.2018 to 11.09.2019 vide RENEWAL Number P/161113/01/2019/002262.
11.           However, the last policy, which is in dispute, was got renewed only for the period from 05.11.2019 to 04.11.2020 vide RENEWAL ENDORSEMENT Number P/161113/01/2020/003616 by paying total premium of Rs.31937/- and the sum assured was Rs.5,00,000/- PLUS Bonus Rs.3,50,000/-. It is also not in dispute that while referring condition no.7 of the insurance policy, the claim of the complainant was repudiated by the OPs vide letter dated 04.03.2020, Annexure OP-14, on the ground that the treatment of the disease for which the complainant had undergone in the hospital had been diagnosed 04.11.2019, and as such, the onset of the above disease was during the break period of insurance  cover, as the said policy was issued after a break of 54 days but his earlier insurance had expired on 11.09.2019. Under these circumstances, the question which arises here is as to whether, the OPs were justified in repudiating the claim of the complainant or not? For answering this question, we need to refer condition no.7 of the insurance policy, which reads as under:-

“……7. Renewal. The policy will be renewed except on grounds of misrepresentation/Non-disclosure of material fact as declared in the proposal form and at the time of claim, fraud committed/moral hazard non cooperation of the insured. A grace period up to 120 days from the date of expiry of the policy is available for renewal. If renewal is made within this 120 days period, the continuity of benefits with reference waiting periods stated will be available. Any Disease/illness contracted or injury sustained during the grace period will be deemed as Pre existing and will be subject to waiting period as stated under 3iii..…..”

 

12.           Bare perusal of the condition no.7 makes it very clear that though it has been clearly mentioned therein that a grace period up to 120 days from the date of expiry of the policy is available for renewal and if renewal is made within the said 120 days period, the continuity of benefits with reference waiting periods will be available but at the same time, it has also been mentioned that in case, any disease/illness contracted or injury sustained during the grace period, will be deemed as Pre existing and will be subject to waiting period. It is clearly evident from ECHO report dated 04.11.2019, Annexure OP12 issued by Mehra Hospital, Ambala City that the complainant was diagnosed Symmetrical Global Hypokinesia LVEF as 25-30%. Thus, in our considered opinion, the onset of the above disease was during the break period of insurance which fact was not disclosed by the complainant, while getting the renewal of his insurance policy on 05.11.2019. It may be stated here that the insurance policy between the  insurer and the insured represents a contract between the parties and the insured cannot claim  anything more than what is covered by the insurance policy. The Hon’ble Supreme Court of India in Oriental Insurance Co. Ltd Vs Sony Cherian (II 1999 CPJ 13 SC) has held that- ― “..The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy. That being so, the insured has also to act strictly in accordance with the statutory limitations or terms of the policy expressly set out therein…”. Thus in our considered opinion, irrespective of the fact that the treatment of the said disease was got done for the period from 08.11.2019 to 18.11.2019, yet, admittedly, as stated above, the said disease of the complainant was diagnosed on 04.11.2019 i.e. one day before inception of the renewal policy, though within the grace period,  the OPs have rightly repudiated the claim of the complainant, as per condition no.7 of the insurance policy and, as such, in no way they can be held deficient in providing service on this count.
13.           In view of peculiar facts and circumstances of this case, it is held that because the complainant has failed to prove his case, therefore, no relief can be given to him. Resultantly, this complaint stands dismissed with no order as to costs. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on: 20.07.2022.

 

          (Vinod Kumar Sharma)        (Ruby Sharma)                   (Neena Sandhu)

              Member                             Member                            President