Haryana

Karnal

CC/228/2019

Sudesh Rani - Complainant(s)

Versus

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

08 Apr 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL  COMMISSION, KARNAL.

 

                                                          Complaint No. 228 of 2019

                                                          Date of instt.26.04.2019

                                                          Date of Decision 08.04.2021

 

Sudesh Rani wife of Shri Sharvan Kumar resident of village and post office, Ranwar, District Karnal. Mobile no.9896964986.

 

                                         …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Co. Ltd., near Kalra Sweets, Main Market, sector-13, Karnal.

2. Star Health and Allied Insurance Co. Ltd., Registered corporate office:1, New street Valluar, Kottam High Road, Nungambakkam Chennai-600034.

 

                                                                …..Opposite Parties.

 

       Complaint u/s 12 of the Consumer Protection Act, 1986.      

 

Before   Sh. Jaswant Singh……President.       

      Sh.Vineet Kaushik ………..Member

              Dr. Rekha Chaudhary…….Member

 

 Present: Shri Jitender Sharma counsel for complainant.

                Shri Naveen Khetarpal counsel 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 the three years ago husband of complainant obtained a Health Insurance Policy bearing no.P/211114/01/2017/004290 from the opposite parties (hereinafter referred to as OPs) through an agent Vikas. Through this policy husband of complainant himself, complainant and her son Deepak was insured. At the time of purchasing the policy husband of complainant paid Rs.18,000/- as premium and the same was renewed vide policy no.P/21114/01/2018/005422 on 19.11.2017 and paid the premium, the limit of coverage of Rs.5,00,000/-. At the time of renewal of the policy, the agent of the insurance company told the husband of complainant that he and his family members if any fell ill then the OPs will pay all the expenses of the treatment. In the first year of policy complainant and his family members have claimed no claim but in the next year September, 2018 complainant fell ill and she was taken to Amritdhara hospital, Karnal for taking medical treatment. After examination, doctor told the complainant that she is suffering from acute febrile illness, thrombocytopenia, hypothyroidism, morbid obesity (BMI-43) and advice her to admit in the hospital. Then she got admitted in the said hospital on 17.09.2018 and after giving treatment she was discharged by the doctor on 20.09.2018. On her treatment complainant spent approximately Rs.30,000/-. Thereafter, complainant visited the office of OPs so many times and requested to reimburse the said amount but OPs did not pay any heed to the request of complainant and lastly repudiated the claim of complainant on the unreasonable ground of misrepresentation regarding the heavy weight. 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; cause of action and concealment of true and material facts. On merits, it is pleaded that the insured availed Family Health Optima Insurance Plan covering Sharvan Kuamr-self, Sudesh Rani-spouse, Deepak Kumar-dependent child for the sum insured of Rs.5,00,000/-, vide policy no.P/211114/01/2018/005422, valid from 19.11.2017 to 18.11.2018 and earlier policy no.P/211114/01/2018/005422, valid from 19.11.2016 to 18.11.2017. The claim was reported in the 2^nd year of the policy. Claimed amount is Rs.13,300/-. The insured Sudesh Rani was admitted at Amritdhara Hospital, Karnal on 17.09.2018 for the treatment of AFI/ Hypothyroidism/morbid Obesity/Thrombocyfopenia and submitted claim records towards reimbursement of medical expenses, on scrutiny of the claim records, it is observed that:

As per Discharge Summary,

a) The insured was admitted on 17.09.2018 and discharged on 20.09.2018

b) Diagnosed: Acute Febrile Illness Thromocytopenia Hypothyroidism Morbid Obesity (BMI-43).

 It is observed from the discharge summary of the above hospital that the insured patient’s BMI mentioned as 43; but as per the declaration given by the insured through the telephonic conversation, the patient’s weight is 80 kgs and height 5 feet 6 inches which confirms BMI to be 28.7. Thus, there is discrepancy regarding the BMI of the patient which amounts to misrepresentation. As per condition no.6 of the policy issued to you, if there is any misrepresentation 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, hence, the claim was repudiated and the same was communicated to the insured, vide letter dated 23.11.2018. 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 her affidavit Ex.CW1/A, medical bills Ex.C2 to Ex.C19, insurance policy Ex.C20 and repudiation letter dated 20.12.2018 Ex.C21 and closed the evidence on 27.01.2020 by suffering separate statement.

4.             On the other hand, OP tendered into evidence affidavit of Rajiv Jain Ex.RW1/A, claim form Ex.R1, clinical pathology Ex.R2, discharge summary Ex.R3, bill Ex.R4, letter dated 19.11.2016 Ex.R5, letter dated 21.11.2018 Ex.R6, repudiation letter dated 23.11.2018 and 20.12.2018 Ex.R7 and Ex.R8, request letter Ex.R9 calculation sheet Ex.R10, proposal form Ex.R11, policy Ex.R12 and Ex.R13, terms and conditions Ex.R14 and closed the evidence on 21.01.2021 by suffering separate statement.

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.             Learned counsel for complainant argued that the complainant has purchased an health insurance policy from the OPs and during the subsistence of the policy, the complainant fell ill and got admitted in Amritdhara Hospital, Karnal on 17.09.2018 and discharged on 20.09.2018. During the treatment, the complainant spent approximately Rs.30,000/- and thereafter, lodged her claim with the OPs but the OPs repudiated the claim of the complainant without any reason and rhyme, hence, prayed for allowing the complaint. 

7.             Per-contra, learned counsel for OPs argued that from the discharge summary it is clear that the BMI of the complainant is 43 but as per the declaration given by the insured through telephonic conversation, the patient’s weight is 80 Kgs and height 5’6” which confirms BMI to be 28.7 thus, there was discrepancy regarding the BMI of the patient which amounts to misrepresentation, hence, the claim of the complainant was rightly repudiated and prayed for dismissal of complaint. 

8.             Admittedly, the complainant purchased an insurance policy from the OPs and during subsistence of the policy, the complainant fell ill and got submitted medical bills with the OPs for reimbursement of the claim and the OPs repudiated the claim of the complainant vide repudiation letter Ex.C21 on the following ground:- 

“Our medical team has perused your representation and the medical records referred above and has noted the contents. The team which re-examined the claim records has observed that as per discharge summary of the above hospital it is noted that the insured patient’s BMI is mentioned as 43; but as per the declaration given by the insured through the telephonic conversation, the patient’s weight is 80 kgs and height 5’6” inches which confirms BMI to be 28.7. Thus, there is discrepancy regarding the BMI of the patient which amounts to misrepresentation. Hence, the claim is not payable as per policy terms and conditions. Clarification letter from the treating doctor is not acceptable.”

 

9.             The claim of the complainant has been repudiated that at the time of applying for the policy the BMI of the complainant was 28.7 and at the time of lodging of claim it was 43 BMI. It is an admitted fact that the claim lodged by the complainant was in the second year after obtaining the policy in question. It is a common knowledge that the weight of any person may be increased or decreased in a month but in the present case there is a gap of approximately 1 ½ years between applying in the policy as well as in raising the claim. Moreover, the version of the OP is based upon the telephonic conversion but there is no proof on file that such type of alleged conversation had taken place between the complainant and the OP. The reason behind repudiating the claim of complainant by OP is not justified as it is a common observation that the weight of any person never remains the same and in the present case complainant has gone for her treatment where she is declared as a patient of morbid obesity (BMI-43). In such type of disease the possibility of BMI cannot be ruled out. Hence, the act of the OPs amount to deficiency in service while repudiating the claim of the complainant. 

11.             The complainant claimed for Rs.30,000/- for her treatment but she placed on record bills Ex.C1 to Ex.C19 which comes out only Rs.23684/-. Thus, she is entitled only Rs.23,684/- alongwith interest, compensation and litigation expenses.

12.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.23,684/- to the complainant alongwith interest @ 9% from the date of repudiation of claim till its realization. We further direct the OP to pay Rs.20,000/- to the complainant on account of mental agony and harassment suffered by her and Rs.5500/- for the litigation expenses. This order shall be complied within 45 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: 08.04.2021                                                                    

                                                                      President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

 (Vineet Kaushik)               (Dr. Rekha Chaudhary)

      Member                               Member