Order by:
Smt.Priti Malhotra, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant availed health insurance policy bearing no.P/211222/01/2023/001945 valid from 31.05.2022 to 30.05.2025 from Opposite Parties. Unfortunately, complainant suffered with problem of SAIO on 02.07.2022 and got admitted in Sidhu Hospital and Diagnostic Centre, Moga for the period 02.07.2022 to 07.07.2022 and thereafter complainant was referred to DMCH, Ludhiana vide discharge cum summary card dated 07.07.2022. The complainant spent Rs.48,828/- on his treatment at Sidhu Hopsital and Diagnostic Centre, Moga The complainant approached the Opposite Parties and lodged the claim of medical reimbursement alongwith original medical record and bills with them, but the Opposite Parties vide letter dated 30.08.2022 repudiate the claim of the complainant. The complainant also served a legal notice dated 23.11.2022 to Opposite Parties to settle the claim, but to no effect. To the surprise of the complainant, the Opposite Parties vide letter dated 13.10.2022 informed the complainant that they are going to cancel the policy w.e.f 22.11.2022. Due to such act and conduct of the Opposite Parties, the complainant suffered mental tension and harassment. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite parties may be directed to pay Rs.48,828/- with regard to the his mediclaim alongwith interest @ 12% p.a. from the date of filing of present complaint till its realization and to restore the above said policy which was cancelled by them w.e.f 22.11.2022 vide its letter dated 13.10.2022.
b) To pay an amount of Rs.50,000/- as compensation on account of damages, mental tension and harassment.
c) To pay an amount of Rs.5500/- as cost of the complaint.
2. Opposite parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in summary procedure under C.P. Act and appropriate remedy, if any, lies only in the Civil Court; the complainant has concealed material facts and documents from this Commission as well as from the opposite parties, therefore, the complainant is not entitled to any relief. Further averred that complainant availed the ‘Star Health Assure Insurance Policy No.P/211222/01 /2023/001945 for the period 31.05.2022 to 30.05.2025 and under this policy, the complainant was insured for an amount of Rs.10,00,000/-. Further submitted that the Policy is contractual in nature and the claims arising therein are subject to terms and conditions forming part of the policy. Averred further that the complainant has accepted the Policy agreeing and being fully aware of such terms and conditions. Averred that the claim in dispute got reported within 30 days from the commencement of the policy and the claim was registered vide no.CIR/2023/211222/0642007. Further it is averred that after receiving of the claim form and supporting documents in the present case, the same were perused by the medical team of the Opposite Parties which is of the opinion that ‘the insured patient was Syomptomatic of the disease during the first 30 days from the date of commencement of the policy and as per exclusion no.3 of the policy under the terms and conditions of the policy, expenses related to the policy within 30 days of policy commencement shall be excluded except the claims arising due to accident provided the same are covered.’ So, the claim was repudiated vide letter dated 30.08.2022 and the complainant was duly informed about the same. The complainant is not the consumer of the Opposite Parties; the complainant has no locus standi or cause of action to file the present complaint against the Opposite Parties; the complaint is not maintainable in the present form; the complainant has violated the terms and conditions of the policy. Hence, the Opposite Parties are not liable to pay any claim. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. In order to prove his case, the complainant has tendered into evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C30.
4. To rebut the evidence of complainant, ld. counsel for the Opposite Parties has tendered into evidence affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OPs/1 alongwith copies of documents Ex.OPs/2 to Ex.OPs/13.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. It is well proved on record that complainant availed ‘Star Health Assure Insurance Policy’ bearing no.P/21122/01/2023/001945 for the period 31.05.2022 to 30.05.2025 for a term of 3 years for a sum of Rs.10,00,000/- from the Opposite Parties and during the policy coverage complainant namely Darshan Lal Grover suffered from SAIO and got admitted in Sidhu Hospital and Diagnostic Centre, Moga on 02.07.2022 and after being treated got discharged on 07.07.2022. However, the grievance of the complainant is that claim lodged by him for the reimbursement of the expenses incurred on the treatment with the Opposite Parties was repudiated vide letter dated 30.08.2022 and the said repudiation of the claim of the complainant has been challenged through this complaint.
7. Thorough perusal of the record further reveals that Opposite Parties repudiated the claim of the complainant vide repudiation letter dated 30.08.2022, the contents of the repudiation letter are reproduced as under:-
“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of coronary artery disease/CABG/done Coronary artery bypass graft done/sub acute intestinal obstruction.
It is observed from the submitted medical records that the insured patient is symptomatic of the above disease during the first 30 days from the date of commencement of the policy
As per 3. Exclusions No.3, 30 days waiting period- Code Excl. 03 (A) of the above policy, expenses related to treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered.
The above ground so taken by the Opposite Parties for the repudiation of the claim of the complainant is not genuine. Record available is evident of the fact that complainant remained admitted in Sidhu Hospital and Diagnostic Centre for the period 02.07.2022 to 07.07.2022 for his treatment and the policy in question was obtained on 31.05.2022 and the policy coverage started from 31.05.2022. Thus, it is well clear that complainant got treatment beyond 30 days period from the date of policy inception, so the ground of repudiation of the claim in question is unjustified and non sustainable in the eyes of law and the Exclusion Clause No.3-30 days waiting period on the basis of which repudiation is made not applicable in the present case.
8. Perusal of the record further reveals that after repudiation of the claim of the complainant, vide letter dated 13.10.2022 Opposite Parties also cancelled the policy in question w.e.f 22.11.2022 on ground of non disclosure of material fact or non co-operation by the insured person. Perusal of the record reveals that the complainant approached Sidhu Hospital and Diagnostic Centre on 02.07.2022 and after proper diagnoses, it came to the knowledge of the complainant that he is suffering from CAD/Post CABG/SAIO. There is no record to show that complainant was having any past history of his ailment or he was ever treated for the same or was aware about his ailment before issuing of the policy. Moreover, the onus of proving the fact that the insured had prior knowledge that he was suffering from the said disease and he deliberately suppressed these material facts at the time of filling up the proposal form was on the insurance co. For the opinion above, we are guided by the judgement of Hon’ble National Consumer Disputes Redressal Commission, New Delhi in case LIC of India Versus Mamta Sipani, Revision Petition no.1033 of 2008 decided on 2nd March, 2022, in which, it has been held as under:-
“However, in the instant case, the onus of establishing the fact that there was deliberate suppression of material facts was on the insurance co., which onus it failed to discharge by adducing the adequate evidence to substantiate such contention. The revision petition, being sans merit, is dismissed.
In the present complaint, Opposite Parties have failed to discharge their burden and thus the cancellation of the policy in question is also unjustified and illegal on the part of the Opposite Parties.
9. Furthermore, the policy document placed on record by Opposite Parties vide Ex.OPs/3 reveals that at the time of obtaining the policy, the life assured has duly mentioned his age as 74, which is more than 45 years, so it was the bounden duty of the Opposite Parties-Insurance Company to get the life assured medically examined before issuing the policy as per I.R.D.A.I Rules and Instructions. However, the Opposite Parties-Insurance Company has not placed on record any evidence that before issuing the policy they ever got medically examined the insured.
10. In view of the above discussion, we are of the opinion that the Opposite Parties have wrongly and illegally repudiated the claim of the complainant and also unjustifiably cancelled the policy in question.
11. Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant claimed the amount of Rs.48,828/- spent at Sidhu Hospital and Diagnostic Centre, Moga, which is duly proved on record vide medical bills Ex.C6 to Ex.C21. Hence we allow the same.
12. From the above discussion, we partly allow the complaint of the complainant and direct the Opposite Party to pay an amount of Rs.48,828/- (Rupees Forty Eight Thousand Eight Hundred Twenty Eight only) to the complainant. Further Opposite Parties are directed to pay compository costs of Rs.10,000/-(Rupees Ten Thousand only) for deficiency in service and litigation expenses to the complainant. Opposite Parties are also directed to restore/revive the policy in question from the date it has been cancelled. The Opposite Parties have not placed on record any document revealing that after cancellation of the policy, the amount of premium was refunded or not? However, even if they have already refunded the amount of premium on pro rata basis to the complainant after cancellation of the policy, then in that case complainant is at liberty to get the policy in question revived after paying the requisite premium amount. The pending application (s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 30 days from the date of receipt of copy of this order, failing which, the Opposite Parties are further burdened with additional cost of Rs.10,000/-(Rupees Ten Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission
