Chandigarh

DF-II

CC/869/2017

Mulakh Raj Gaba - Complainant(s)

Versus

Star Health and allied Insurance Company Limited - Opp.Party(s)

Rishi Karan Kakar Adv.

27 Feb 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	869/2017
Date of Institution	:	08.11.2017
Date of Decision	:	27.02.2019

 

                                       

                                               

Mulakh Raj Gaba r/o H.no.3510, Sector 32-D, Chandigarh.

                                ...  Complainant.

Versus

1.     Star Health and Allied Insurance Co. Ltd.,  Registered and Corporate Office 1, new Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034 through its Manager Director.

 

2.     Star Health and Allied Insurance Co. Ltd.,  Branch Office SCO no.130-131, 4^th Floor, Sector 34-A, Chandigarh -160022 through its Office Manager.

…. Opposite Parties.

 

BEFORE: SHRI RAJAN DEWAN, PRESIDENT

SMT.PRITI MALHOTRA, MEMBER

SHRI RAVINDER SINGH, MEMBER

 

Argued by :Sh.Rishi Karan Kakkar, Adv. for the complainant.

                Sh.Gaurav Bhardwaj, Adv. for the  OPs.     

 

 

PER RAJAN DEWAN, PRESIDENT

1.         Briefly stated, the complainant purchased Senior Citizens Red Carpet Health Insurance Policy for himself and got the same renewed over 4 years and at present  the said policy was renewed for the period from 26.08.2015 to 25.08.2016 (Annexure C-1). He got admitted in the hospital and had to be administered three stunts due to heart problem.  It has further been averred that the insurance cover was supposed to be cash less but the claim was refused on the ground that the disease was pre-existing one.  However, he paid the amount to the hospital after availing the financial help from his friends and family.  Subsequently, he received a letter in the month of November, 2016 that the insurance cover was cancelled as the disease was pre-existing one and that he had mis-represented the facts.  It has further been averred that he approached the OPs for his valid claim but to no effect.  Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the OPs, the complainant has filed the instant complaint.
2.         In their written statement, the OPs, while admitting the factual matrix of the case, have pleaded that the complainant was admitted at Ace Heart and Vascular Institute, Mohali on 27.08.2016 for the treatment of ACC, HTN, DM and submitted pre-authorization request form for cashless authorization and the same was denied vide letter dated 29.08.2016 stating that the patient is k/c/o of CAD since 2009 and he had taken the treatment for the same and remained hospitalization but he failed to disclose the said fact at the time of inception of the policy and as such the cashless was denied.  It has further been pleaded that as per Clause 9 of the policy there is any mis-representation/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 and the claim was rightly repudiated.  The remaining allegations have been denied, being false. Pleading that there is no deficiency in service on its part, a prayer for dismissal of the complaint has been made.
3.         The complainant filed rejoinder to the written reply of the Opposite Parties controverting their stand and reiterating his own.
4.         We have heard the learned counsel for the parties and have gone through the documents on record.
5.         It is an admitted fact that the complainant is obtaining the Medical Health Policy i.e. Senior Citizens Red Carpet Health Insurance Policy in question for the last four years from the Opposite Parties and in the present complaint,  he has sought the reimbursement of the treatment under the policy which was renewed for the period from 26.08.2016 to 25.08.2017 (Annexure C-1) for sum assured of Rs.2 lacs. 
6.         Admittedly, the complainant was operated for heart and administered three stunts in ACE Heart & Vascular Institute, Mohali  and he alleged to have incurred a sum of Rs.9.40 lacs on his treatment.  The claim lodged by the complainant with the Opposite Parties under the policy for cashless authorization was rejected on the ground that the complainant was a known case of CAD since 2009 and he had taken treatment for the same and remained hospitalized but he failed to disclose the same at the time of inception of the policy.
7.         In the backdrop of above evident facts, we have to see whether the repudiation done by the OPs is justified or not?  For such decision, it is pertinent to look into the reason quoted for the repudiation of the claim by the OPs.  The record reveals that it is so submitted by the OPs that during the investigation, while processing the claim lodged by the complainant, it was revealed that he was a known case of CAD since 2009 and he had taken treatment for the same and remained hospitalized but he failed to disclose the same at the time of inception of the policy and, therefore, the cashless facility request was denied following the same the reimbursement claim was also denied.
8.         In view of the terms & conditions of the Policy, we have to see whether the complainant had suppressed any fact required to be disclosed at the time of inception of the policy.  The record before us divulge that no suppression has been made by the complainant as he was not under obligation to disclose about any illness/injury suffered by him next before the period of 48 months from the date of policy inception.  As per the terms and conditions of the policy in question, the pre-existing disease means any condition, ailment or injury or related condition(s)  for which the insured person had signs or symptoms and/or were diagnosed and/or received medical advice/treatment within 48 months prior to the insured person’s first policy with any Indian insurer.  In the instant case, as per the version of the OPs themselves, the complainant had taken the treatment for the heart in the year 2009 i.e. 9 years prior to the taking the Insurance Policy in question. There is no record to show that the complainant had ever taken any treatment for the same within the period of 48 months prior to inception of the policy in question. So in our considered opinion, the case of the complainant definitely does not fall under the category of suppression of fact as alleged by the OPs. Reiterated that no independent evidence has been brought forward by the Opposite Parties to establish that the complainant has ever taken any treatment during the 48 months period prior to inception of the policy in question. 
9.         In the instant case, the complainant has claimed a sum of Rs.9.40 lacs towards the reimbursement of the claim, however, the policy in question was issued for sum assured of Rs.2 lacs.  Moreover, the OP-Company’s liability for cardio vascular treatment under the policy is limited to Rs.1.50 lacs and as such the complainant is entitled to  that amount only.    
10.         From the above discussion, it is held that the Opposite Parties have wrongly & illegally rejected the claim of the complainant, which clearly amounts to gross deficiency in service and unfair trade practice on their part.  Therefore, the present complaint is allowed against the Opposite Parties with following directions:-

1. To reimburse the claim amount of Rs.1,50,000/- to the complainant;
2. To pay an amount of Rs.7,000/- as compensation for causing harassment & mental agony to the complainant;
3. To pay an amount of Rs.5,500/- towards litigation expenses.

11.           This order be complied with by the opposite parties, within 45 days from the date of receipt of its certified copy, failing which the amount at Sr.No.(i)  & (ii) shall carry interest @ 9% per annum from the date of this order till actual payment, besides payment of litigation costs.
12.         Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Sd/-                         sd/-                 sd/-

ANNOUNCED	[RAVINDER SINGH]	[RAJAN DEWAN]	(PRITI MALHOTRA)
27.02.2019	MEMBER	PRESIDENT	MEMBER