Haryana

Karnal

CC/102/2018

Anil Raheja - Complainant(s)

Versus

Star Health And Allied Insurance Company Limited - Opp.Party(s)

Narinder Sharma

01 Jul 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 102 of 2018

                                                          Date of instt. 03.05.2018

                                                          Date of Decision 01.07.2019

 

Anil Raheja son of Shri Brij Lal resident of village Nighdu District Karnal (Haryana)

                                                                       …….Complainant

                                        Versus

 

1. Star Health and allied Insurance Co. Ltd. Registered and Corporate office 1, New Tank Street, Valluvar Kottam High Road, Nugambakkam, Chennai through its Managing Director.

2. Star Health and allied Insurance Co. Ltd. SCO no.242, 1^st floor Sector-12, opp. Mini Sectt. Karnal through its Branch Manager.

                                                                                                                                                                            …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

      Dr. Rekha Chaudhary…….Member

            

 

 Present:  Shri Narender Sharma Advocate for complainant.

                  Shri Naveen Khatterpal Advocate for opposite parties.

 

                   (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant is consumer of OPs as he is having Medi-claim policy of his family consisting of his wife Rajni Rani, son Nitin Kumar and daughter Kairen Raheja vide policy no.P/211114/01/2016/001417. The said policy was valid upto 18.8.2016. The complainant is continuous consumer of the OPs, since 19.08.2013. The son of the complainant namely Nitin had gone to Australia on 10.07.2014 and returned back to India on 19.05.2016. When he was in Australia he suffered from Dengu fever and there his illness could not be cured hence, he returned to India. On 26.05.2016 he was admitted in Indraprastha Apollo Hospital, New Delhi for his treatment and complainant immediate gave due information to Delhi office as well as Karnal office of OPs. Complainant spent Rs.133502/- on treatment of his son and when the Hospital authorities sent the bills to OPs for payment then OPs refused to make payment of medical bills without any valid reason and sufficient cause. Thereafter, complainant approached the OPs on number of times and requested for reimbursement of the amount, but OPs did not make the payment and put off the matter on one pretext or the other. To the utter surprise of the complainant, OPs sent a letter dated 15.07.2016, vide which name of his son was deleted from policy and a refund cheque of Rs.486/- was issued to the complainant. The son of the complainant was having insurance policy since August, 2013 which was continuing and had never lapsed. It is pertinent to mention here that the illness for which the son of complainant was treated is covered under said policy and OPs are legally liable to pay the amount of policy. Son of complainant was not having any kind of pre-existing diseases as alleged which is very much evident that when he went to Australia he was thoroughly medically examined by the Super Specialist doctors. The complainant visited the office of OPs, number of times and requested for reimbursement of the amount but OPs did not pay any heed to his requests. Then complainant sent a legal notice dated 5.8.2016 to the OPs in this regard but this also did not yield any result. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written version raising preliminary objections with regard to cause of action; mis-joinder and non-joinder of necessary parties; complainant is estopped by his own act and conduct from filing the present complaint and concealment of true and material facts. On merits, it is pleaded that the insured availed Family Health Optima Insurance Policy covering Anil Raheja-self, Rajni Rani-spouse, Kairen Raheja & Nitin Kumar–dependant children for the sum insured of Rs.3,00,000/-, vide policy no.P/211114/01/2016/001417 for the period 19.08.2015 to 18.08.2016. The insured patent was admitted on 27.05.2016 in Indraprastha Apollo Hospital in the 3^rd year of the policy and raised a pre-authorization for cashless treatment of ITP(Idiopathic Thrombocytopenic Purpura). On perusal of the documents submitted by the treating hospital, it is observed that:

        As per Pre Auth Form, the insured was under the treatment of cancer. Hence OPs have called for the following documents, vide letter dated 26.05.2016 in order to process the claim.

1. First Consultation, Treatment Records of Cancer & Discharge Summary.

2. All investigation taken (ITP), exact duration and ICP.

From the documents submitted by the treating hospital in response to OP query dated 06.05.2016, it is observed that:

As per Discharge summary dated 23.08.2008 (prior to policy inception) the insured patient was admitted for Chronic Immune thrombocytopenic Purpura, which is prior to inception of policy.

        As per Discharge summary dated 15.09.2012 (prior to policy inception), the insured patient was again admitted for Chronic Immune thrombocytopenia and in the history column it is noted that “Mr. Nitin Kumar, 17 years old male is a follow-up case of chronic ITP diagnosed since 2007. He initially showed excellent to steroids but his disease recurred and then went on to receive 2 doses of anti D immunoglobin in the post. Recently he has been also given Eltrombopag for 15 days from outside but showed no response. This time he presented with marked reduction in platelet count i.e. 3000/cumm and was admitted for further management”.

Based on the above findings, it is noted that the insured patient has the disease i.e. chronic ITP prior to policy. At the time of inception of the policy which is from 19.08.2013 to 18.08.2014, the insured did not disclose the above mentioned medical history/health details in the proposal form which amounts to misrepresentation/non-disclosure of material facts. It is further pleaded that in Pre-Authorization Form submitted by the treating hospital it is mentioned that the insured patient is undergoing treatment for Cancer and the same was also not disclosed while availing the policy. Hence the pre-authorization request was rejected and the same was informed to complainant and the treating hospital vide letter dated 27.05.2016. Hence there is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C53 and closed the evidence on 12.03.2019.

4.             On the other hand, OPs tendered into evidence affidavit of Rajiv Jain Ex.RW1/A and documents Ex.R1 to Ex.R21 and closed the evidence on 29.05.2019.

5.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

6.             The case of the complainant is that his son namely Nitin Kumar was suffering from Dengu fever. On 26.05.2016 he was admitted in Inderprath Apollo Hospital, New Delhi for his treatment and complainant sent the intimation in this regard to the OPs. Complainant spent Rs.133502/- on treatment of his son and when the Hospital authorities sent the bills to OPs for payment then OPs refused to make payment of medical bills without any sufficient cause. Thereafter, complainant approached the OPs a number of times and requested for reimbursement of the amount but OPs did not make the payment and postponed the matter on one pretext or the other. Further, OPs also sent a letter dated 15.07.2016, vide which name of his son has been deleted from policy and a refund cheque of Rs.486/- has been issued to the complainant.  The son of the complainant is having insurance policy since August, 2013 which is continuously going on and has never been lapsed. Hence the illness for which the son of complainant was treated is covered under said policy and OPs are legally liable to pay the amount of policy. Son of complainant was not having any kind of pre-existing diseases as alleged.

7.             On the other hand, the case of the OPs is that insured patent was admitted on 27.05.2016 in Indraprastha Apollo Hospital in the 3^rd year of the policy and raised a pre-authorization for cashless treatment of ITP(Idiopathic Thrombocytopenic Purpura). On perusal of the documents submitted by the treating hospital, it is observed that:

        As per Pre Auth Form, the insured was under the treatment of cancer. Hence OPs have called for the following documents, vide letter dated 26.05.2016 in order to process the claim.

1. First Consultation, Treatment Records of Cancer & Discharge Summary.

2. All investigation taken (ITP), exact duration and ICP.

From the documents submitted by the treating hospital in response to OP query dated 06.05.2016, it is observed that:

As per Discharge summary dated 23.08.2008 (prior to policy inception) the insured patient was admitted for Chronic Immune thrombocytopenic Purpura, which is prior to inception of policy.

        As per Discharge summary dated 15.09.2012 (prior to policy inception), the insured patient was again admitted for Chronic Immune thrombocytopenia and in the history column it is noted that “Mr. Nitin Kumar, 17 years old male is a follow-up case of chronic ITP diagnosed since 2007. He initially showed excellent to steroids but his disease recurred and then went on to receive 2 doses of anti D immunoglobin in the post. Recently he has been also given Eltrombopag for 15 days from outside but showed no response. This time he presented with marked reduction in platelet count i.e. 3000/cumm and was admitted for further management”.

Based on the above findings, it is noted that the insured patient has the disease i.e. chronic ITP prior to policy. At the time of inception of the policy which is from 19.08.2013 to 18.08.2014, the insured did not disclose the above mentioned medical history/health details in the proposal form which amounts to misrepresentation/non-disclosure of material facts. Further, in Pre-Authorization Form submitted by the treating hospital it is mentioned that the insured patient is undergoing treatment for Cancer and the same was also not disclosed while availing the policy. Hence the pre-authorization request was rejected and the same was informed to complainant and the treating hospital vide letter dated 27.05.2016.

8.             Admittedly, the complainant has purchased the Medi-claim policy of his family consisting of his wife Rajni Rani, son Nitin Kumar and daughter Kairen Raheja vide policy no.P/211114/01/2016/001417. The said policy valid upto 18.8.2016. The complainant is continuous consumer of the OPs since 19.08.2013. It is not admitted by the OPs that the son of complainant Nitin Kumar was suffering from Dengu Fever, infact, as per pre-Auth Form, h e was under the treatment of cancer and treated for  this ailment from Indraprastha Apollo Hospital, New Delhi. The complainant spent Rs.133502/- on the treatment of his son.

9.             The complainant filed the claim with the OPs for reimbursement of the claim but the claim of the complainant was rejected by the OPs on the ground that the insured patient has suffering from Cancer prior to inception of the policy and this fact was not disclosed by the complainant at the time of inception of the policy. To prove his stand OPs placed on record prescription slip dated 21.05.2007 Ex.R1, prescription slip dated 29.05.2007 Ex.R2, prescription slip dated 9.7.2007 Ex.R3, prescription slip dated 22.05.2008 Ex.R4. OPs further relied upon  the discharge summary dated 23.08.2008, 15.09.2012, 22.09.2012 and 29.09.2012 (Ex.R5 to Ex.R8). A perusal of the above documents it is clear that the son of complainant under the treatment of Chronic ITP disease since 2007 and taken the treatment regularly. Hence it is clear that insured patient was suffering chronic disease prior to inception of the policy. Thus, there is no deficiency in service on the part of the OPs in repudiating the claim of the complainant.

10.            It is settled principle of insurance law that contract of insurance is a contract uberrima fides and utmost faith must be observed by the contracting parties. Every material fact must be disclosed, otherwise there is good ground for rescission of contract. If, there are misstatements or suppression of material facts, the policy can be called into question. In this regard reference may be made to the judgment of the Hon’ble Supreme Court in case titled Satwant Kaur Sandhu Versus New India Assurance Co. IV( 2009) CPJ 8 (SC) and judgment of Hon’ble National Commission in case Life Insurance Corporation of India and another Versus Bimla Devi Revision Petition no.3806 of 2009 decided on 12.8.2015.

11.            Thus, as a sequel to abovesaid discussion and in view of law cited above, we do not find any merits in the complaint and the same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:01.07.2019                                                                       

                                                                      President,

                                                              District Consumer Disputes

                                                               Redressal Forum, Karnal.      

 

 

                (Vineet Kaushik)          (Dr. Rekha Chaudhary)

                 Member                            Member