Haryana

Karnal

CC/230/2019

Bharat Singh - Complainant(s)

Versus

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

Kuldeep Singh Tarar

06 Mar 2020

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 230 of 2019

                                                          Date of instt.26.04.2019

                                                          Date of Decision 06.03.2020

 

Bharat Singh son of Shri Ajmet Singh resident of village Chogawan Tehsil Indri, District Karnal, Mobile no.9813220201.

                                                 …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Company Ltd. SCO 130-131,4^th floor, sector 34, Chandigarh, through its Manager.

2.  Star Health and Allied Insurance Company Ltd. having its Branch office SCO 242, 1^st floor, Sector 12, Karnal through its 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 Kuldeep Singh Advocate for complainant.

                   Shri Naveen Khaterpal Advocate for opposite party.

                                              

                   (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 has got the insurance under the Star Health and Allied Insurance Company Ltd. on 08.03.2018, vide policy no.P/161113/01/2018/004602, previous no.P/161113/01/2017/005075 in the name of complainant alongwith his family members and also paid the amount as per the direction of OPs and the said policy is valid 06.03.2018 to 05.03.2019. At the time of issuance of the said policy, the OPs assured the complainant that the company of OPs will giving a best service to complainant and the other official of OPs also assured the complainant by saying that if any problem arose to complainant and his family members regarding the health in future, thereafter, the complainant will have not paid any money in this regard.  On 17.11.2018 the son of complainant namely Rudra Mandhan has been admitted in the Penal Hospital New Delhi due to some illness and also conducted all necessary reports by the hospitalities and the complainant spent approximately Rs.4,00,000/- on the treatment of his son and during the treatment of his son, the complainant intimated the whole story regarding the health policy to the Director/Senior Doctor of Sir Ganga Ram Hospital but the Director/Senior Doctor of Sir Ganga Ram Hospital did not listen the genuine request of complainant. Complainant spent Rs.4,00,000/- on the treatment of his son. Complainant approached the agent of the OPs and requested for reimbursement of the said amount but the OPs and its agent refused to pay the same. Then complainant served a legal notice dated 24.12.2018 upon the OPs in this regard but it 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 maintainability; jurisdiction; cause of action and concealment of true and material facts. On merits, it is pleaded that the insured availed Family Health Optima Insurance plan vide policy no. no.P/161113/01/2018/004602 for the period of 20.07.2018 to 19.07.2019 covering Mr. Bharat Singh self, Mrs. Reetu Rani- Spouse and Mr. Haven-Dependent child for the sum insured of Rs.5,00,000/- and Baby Rudra Mandhan was incorporated in the policy. The baby Rudra Mandhan was covered in the policy from 15.10.2018 and only 10% of the sum insured is only available to the new born baby, since we are providing coverage without premium. As per coverage clause K. Hospitalization expenses for treatment of New Born Baby: The coverage for new born baby starts from the 16^th day after its birth till the expiry date of the policy and is subject to a limit of 10% of the sum insured or Rs.50,000/-whichever is less, subject to the availability of the sum insured, provided the mother is insured under the policy for a continuous period of 12 months without break. Intimation about the birth of the New Born Baby should be given to the company and policy has to be endorsed for this cover to commence. Waiting periods as stated under 3(i) shall not apply for the New Born Baby. All other terms, conditions and exclusions shall apply for the new born baby. The insured submitted claim in the 2^nd month of the policy. The insured submitted claim for Rs.3,40,355/-. The insured baby was hospitalized in Sir Ganga Ram Hospital on 16.11.2018 and discharged on 12.12.2018 towards the treatment of Hydrocephalus with Right Sided VP Shunt in Situ. The insured sought for pre authorization request towards the above mentioned treatment. The same was denied since there is a non disclosure of material facts vide letter dated 19.11.2018. Subsequently, the insured submitted claim documents alongwith claim form for reimbursement of the medical expenses for Rs.3,40,355/-. On scrutiny of claim documents, it is observed that

. The Discharge summary for the period from 08.09.2018 to 03.10.2018 of the Radhakishan Hospital submitted during cashless processing that the insured patient is diagnosed with prematurity with respiratory distress with sepsis with seizure and had increase in head size-occipitofrontal circumference (38cm).

The insured has not provided the abovementioned birth summary at the time of inception of baby in the policy. It is submitted that at the time of inclusion of the child in the policy which is from 15.10.2018, the insured has 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. As per condition no.6 of the policy, ‘if there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim.”

Thus, the claim of the complainant is not maintainable, as per terms and conditions of the policy, the claim was repudiated and same was informed to the complainant vide letter dated 23.02.2019. So, 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.C3 and closed the evidence on 06.12.2019.

4.             On the other hand, OP tendered into evidence affidavit of Rajiv Jain Ex.RW1/A and documents Ex.R1 to Ex.R21 and closed the evidence on 14.01.2020.

5.             We have heard the learned counsel of both the parties and perused the case file carefully and have also gone through the evidence led by the parties.

6.             The case of the complainant, in brief, is that he availed Family Health Optima Insurance plan vide policy no. no.P/161113/01/2018/004602 for the period of 20.07.2018 to 19.07.2019. On 17.11.2018 the son of complainant namely Rudra Mandhan has been admitted in the Penal Hospital New Delhi due to some illness and complainant spent approximately Rs.4,00,000/- on the treatment of his son. Complainant approached  the OPs and requested for reimbursement of the said amount but the OPs refused to pay the same.

7.             On the other hand, the case of the OP, in brief, is that the insured availed Family Health Optima Insurance plan vide policy no. no.P/161113/01/2018/004602 for the period of 20.07.2018 to 19.07.2019 covering Mr. Bharat Singh self, Mrs. Reetu Rani- Spouse and Mr. Haven-Dependent child for the sum insured of Rs.5,00,000/- and Baby Rudra Mandhan was incorporated in the policy. The baby Rudra Mandhan was covered in the policy from 15.10.2018 and only 10% of the sum insured is only available to the new born baby, since we are providing coverage without premium. As per coverage clause K. Hospitalization expenses for treatment of New Born Baby: The coverage for new born baby starts from the 16^th day after its birth till the expiry date of the policy and is subject to a limit of 10% of the sum insured or Rs.50,000/-whichever is less, subject to the availability of the sum insured. The insured baby was hospitalized in Sir Ganga Ram Hospital on 16.11.2018 and discharged on 12.12.2018 towards the treatment of Hydrocephalus with Right Sided VP Shunt in Situ. The insured sought for pre authorization request towards the above mentioned treatment. The same was denied since there is a non disclosure of material facts vide letter dated 19.11.2018. Subsequently, the insured submitted claim documents alongwith claim form for reimbursement of the medical expenses for Rs.3,40,355/-. The Discharge summary for the period from 08.09.2018 to 03.10.2018 of the Radhakishan Hospital submitted during cashless processing that the insured patient is diagnosed with prematurity with respiratory distress with sepsis with seizure and had increase in head size-occipitofrontal circumference (38cm). The insured has not provided the abovementioned birth summary at the time of inception of baby in the policy which amounts to misrepresentation/non disclosure of material facts. Thus, the claim of the complainant is not maintainable, as per terms and conditions of the policy, the claim was repudiated and same was informed to the complainant vide letter dated 23.02.2019.

8.             Admittedly, complainant purchased family health policy from the OPs which was valid from 20.07.2018 to 19.07.2019. Minor son of complainant namely Rudra Mandhan had taken the treatment from Sir Ganga Ram Hospital, New Delhi and spent Rs.3,40,355/-. This fact has been proved from the medical record and medical bills Ex.C15 to Ex.C24. Treatment was taken by minor son of the complainant during subsistence of the insurance policy.

9.             Claim of the complainant was repudiated by the OP, vide repudiation letter Ex.R21, on the ground that at the time of inclusion of the child in the policy which is from 15.10.2018, the insured has not disclosed the medical history/health details of the insured person in the proposal form which amounts to misrepresentation/non disclosure of material facts. The onus was upon the OPs to prove their stand but OPs failed to produce any cogent, convincing and concrete evidence to prove the same. Thus, the repudiation of the claim done by the OPs is held to be unjustified and amounts to deficiency in service and unfair trade practice.

10.            Complainant claimed Rs.3,40,355/- from the OPs but on perusal of the Clause K of the policy document Ex.R3, baby Rudra Mandhan was covered in the policy from 15.10.2018 and only 10% of the sum insured is available to the new born baby. Said facility has been provide by the OP, without premium. The Cause k of the policy reads as under:-

“Hospitalization expenses for treatment of New Born Baby: The coverage for new born baby starts from the 16^th day after its birth till the expiry date of the policy and is subject to a limit of 10% of the sum insured or Rs.50,000/-whichever is less, subject to the availability of the sum insured, provided the mother is insured under the policy for a continuous period of 12 months without break.”

 The sum insured is Rs.5,00,000/- and its 10% come out Rs.50,000/-. So, the complainant is entitled for the amount of Rs.50,000/- alongwith compensation for harassment and litigation expenses.

11.            Thus, as a sequel to abovesaid discussion, we allow the present complaint partly and direct the OPs to pay Rs.50,000/- to the complainant with interest @ 9% per annum from the date of repudiation till its realization. We further direct the OPs to pay Rs.15,000/- to  the complainant on account of mental agony and harassment suffered by him and Rs.5500/- for the litigation expenses. This order shall be complied with within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:06.03.2020                                                                       

                                                                      President,

                                                              District Consumer Disputes

                                                               Redressal Forum, Karnal.      

 

 

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                           Member