DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Murari Lal Sharma s/o Late Sh. Tulsi Ram Sharma, R/o Main Bazar, Rajgarh, District Sirmour, Himachal Pradesh.

                   --- Complainant

V E R S U S

1]      Star Health and Allied Insurance Co. Limited, Branch Office: SCO No.257, 2^nd Floor, Sector 44-C, Chandigarh – 160047, through its Branch Manager.

2]      Star Health and Allied Insurance Co. Limited, Registered Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai – 600034, through its Managing Director.

---- Opposite Parties.

BEFORE:      MRS.MADHU MUTNEJA                       PRESIDING MEMBER

                   SH.JASWINDER SINGH SIDHU             MEMBER

Argued By:             Sh. Gurditt Singh Saini, Counsel for Complainant.

Sh. Gaurav Bhardwaj, Counsel for Opposite Parties.

PER JASWINDER SINGH SIDHU, MEMBER

1.                     Briefly stated, on being duly medically examined at Fortis Hospital, in the presence of agent of Opposite Party, the Complainant was provided with “Family Health Optima Insurance Policy” No.P/161113/01/2009/00853, for the period 27.2.2009 to 26.2.2010 by the Opposite Parties at the annual premium of Rs.11,593/- and in the column of pre-existing disease it was mentioned that Complainant was having chest problem as per medical record. The said policy was renewed from time to time and lastly it was renewed for the period 27.2.2012 to 26.2.2013. As per policy Complainant and his wife namely Urmila Sharma were provided medi-claim policy for Rs.4.00 lac by the Opposite Parties (Insurance Policy, premium payment receipt, 3^rd year renewal policy certificate & premium payment receipt are Annexure C-1 to C-4). During the subsistence of aforesaid policy, Complainant was admitted at Fortis Hospital, Mohali on 21.05.2012 for treatment of inferior wall myocardial infraction single vessel disease. Percutaneous transluminal coronary angioplasty (PTCA) treatment was done on Complainant and a stent to RCA was fixed to him and he was discharged on 23.5.2012 (Treatment record & medical bills at Annexure C-5 & C-6). The Complainant being medically insured with Opposite Parties raised medical claim for hospitalization for treatment of inferior wall myocardial infraction and single vessel disease amounting to Rs.2,40,153/-, but the Opposite Parties repudiated the genuine claim of the Complainant on imaginery and false grounds of misrepresentation/non-disclosure of material facts, vide letter dated 20.6.2012 (Annexure C-7). The Complainant claims that at the time of making proposal of insurance, he disclosed the insurance agent of Opposite Parties that he was having heart problem as he went through Percutaneous transluminal coronary angioplasty (PTCA) treatment in the year 2004 at Fortis Hospital Mohali and as such a stent to RCA was fixed. The insurance agent of Opposite Parties assured the Complainant that the PTCA treatment is no way relevant with the taking of “Family Health Optima Insurance Policy”. Hence, this complaint.

2.                     Notice of the complaint was sent to Opposite Parties seeking their version of the case.  

3.                     Opposite Parties in their joint reply, while contesting the claim of the Complainant, has pleaded that the Complainant never disclosed the pre-existing disease or about the treatment taken for the ailment to them. However, a careful scrutiny of the proposal form submitted at inception of the policy reveals that the insured has not disclosed the history of old IWMI in 2000 and surgery (PTCA) in 2004. The policy was issued to the Complainant based upon the proposal form filled by him (Annexure R-1) and all the terms & conditions were explained to him. It is asserted that the policy was issued as per terms and conditions and exclusions mentioned therein (Annexure R-2 colly). It has been averred that on scrutiny of the discharge summary and medical records, the in house medical expert opined that the Complainant is a known case of hypertension admitted with the history of DOE (Dyspnoea On Exertion) Grade II CAG done on 21.5.2012 revealed SVD. He underwent successful PTCA with stent to RCA. Hence, the claim was rightly repudiated as per condition no.7 of the policy. However, the said conclusion was arrived at after scrutinizing the pre-authorization request form received from the treating hospital (Annexure R-3). As per column 3 of the table provided in the said form it was mentioned that the Complainant was suffering from heart disease for the last 12 years but he had not disclosed the said fact in his proposal form. The Complainant has suppressed the material information with regard to his health and has not disclosed the disease suffered by him prior to the taking of the policy. While pleading that the claim has been repudiated after due application of mind and as per terms & conditions of the Policy, and denying all other allegations of the Complainant, prayer has been made for dismissal of the complaint with costs.    

4.                     Parties were permitted to place their respective evidence on record in support of their contentions.

5.                     We have heard the learned counsel for the parties and have perused the record.

6.                     The complainant subscribed for a health policy for himself and his wife in the year 2009 by filling up the proposal form No.488774 dated 19.2.2009 (R-1) and thereafter continued to renew the same by paying regular premiums.  At the time of subscription of the first policy, the complainant had submitted a medical report which clearly showed him to be suffering with a chest problem.  This fact, with regard to his status of previous disease, is found mentioned in the column of the insurance policy but, at the same time, under the clause of pre-existing disease the word “N/A” is found mentioned.  On being pointed out, the counsel for the opposite parties admitted that this abbreviation (N/A) means “Not Applicable”.

7.                     This aspect is also found mentioned in the proposal form (Annexure R-1) wherein five different points are mentioned which were necessary for the issuance of the policy and under Sr.No.3 of these notings, exclusion of chest problem as per report is found mentioned meaning thereby the submission of report is admitted by the opposite parties and even the exclusion of chest problem, being not applicable, is also endorsed when the policy was issued to the complainant.  

8.                     The complainant suffered a mild discomfort in the fourth policy year and was hospitalized.  The complainant submitted all the required documents to lay claim for the reimbursement of the expenses incurred by him on his treatment but the opposite parties denied the claim citing reasons that the complainant was suffering from the chest problem at the time of subscribing the policy and not having disclosed this aspect has breached the terms and conditions of the policy on account of non disclosure of the material facts.  To our mind, the complainant on his part having tendered a medical report, which is very much found mentioned in the proposal form, as well as the policy document,  has not faulted in suppressing any such information which was material and relevant at the time of subscription of the policy.  The opposite parties, having full knowledge of the chest problem of the complainant, which was disclosed while filling up the proposal form by the complainant, and thereafter issuing a health policy, wherein the chest problem was declared to be not applicable, for the purpose of pre-existing disease, have themselves allowed the complainant the future benefits arising out of the said policy.  Hence, the opposite parties, after a passage of nearly 3½ years, cannot be allowed to change their stance, after having received four consecutive premiums from the complainant.  The act of the opposite parties in now denying the rightful claim of the complainant, therefore, amounts to deficiency in service on their part.   

9.                     In view of the above discussion, the present complaint of the Complainant deserves to succeed against the Opposite Parties, and the same is allowed, qua them. The Opposite Parties are, jointly and severally, directed:-

[i]      To pay the amount payable to the complainant as per his entitlement on the basis of the policy.

[ii]     To pay Rs.15,000/- on account of deficiency in service and causing mental and physical harassment to the Complainant; 

[iii]    To pay Rs.10,000/- as cost of litigation;

10.                  This order be complied with by the opposite parties, within 45 days from the date of receipt of its certified copy, failing which the amounts at Sr.No.(i) &(ii) shall carry interest @18% per annum from the date of this order till actual payment besides payment of litigation costs.

11.                  Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

27^th  May, 2013.                                                   

Sd/-

(MADHU MUTNEJA)

PRESIDING MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER