Chandigarh

DF-II

CC/542/2017

Sunil Kumar - Complainant(s)

Versus

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

Atul Goyal Adv.

23 Mar 2018

ORDER

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

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Consumer Complaint  No	:	542 of 2017
Date  of  Institution	:	17.07.2017
Date   of   Decision	:	23.03.2018

 

 

 

 

Sunil Kumar s/o Sh.Ramchander Bansal, R/o House No.395, Ground Floor, Sector 32-A, Chandigarh.    

             …..Complainant

 

Versus

Star Health and Allied Insurance Company Limited, SCO 130-131, 4^th Floor, Sector 34-A, Chandigarh 160022 through its authorised representative.  

    ….. Opposite Party 

 

BEFORE:  SH.RAJAN DEWAN             PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER 

                               

 

 

Argued by :- Sh.Atul Goyal, Adv. for complainant

  Sh.Puneet Jain and Amit Gupta, Adv. for OP

 

 

PER PRITI MALHOTRA, MEMBER

 

         Briefly stated, the complainant subscribed for ‘Family Health Optima Insurance Plan’ from Opposite Party by paying premium of Rs.11,828/-, which was effective from 8.12.2015 to 7.12.2016 covering complainant, his wife, his daughter and son for sum insured of Rs.5 lacs (Ann.C-1).  It is averred that the complainant in June, 2016 faced some problem of chest discomfort and as such was admitted to Max Super Speciality Hospital, Mohali where he was operated and treated for Coronary Angioplasty (PTCA).  It is also averred that the complainant was finally discharged and was made to make the payment of Rs.2,39,478/- for his treatment expenses, in addition to Rs.1134/- incurred towards post-surgery medicines (Ann.C-2).  Thereafter, the complainant lodged claim with the Opposite Party, which vide letter dated 2.8.2016 repudiated the claim on the ground of pre-existing disease i.e. diabetes mellitus.  However, even after rejection of the claim, the policy of the complainant was renewed for further period from 8.12.2016 to 7.12.2017 (Ann.C-5).  Alleging the said repudiation of claim as illegal and deficiency in service, hence this complaint has been filed.

 

2]       The Opposite Party has filed reply and while admitting the factual matrix of the case, stated that from the medical record submitted by the complainant, it is observed that the insured patient has undergone treatment for the complication of diabetes mellitus and the same was included in the Policy as Pre Existing Disease which is not payable for 48 months of continuous coverage has elapsed. It is stated that the complainant has categorically answered in the affirmative to the question regarding the status of the disease and therefore there is no question of non-mentioning of the same in the proposal form. It is submitted that the claim of the complainant has been rightly repudiated on the ground of Exclusion clause for the pre-existing disease i.e. D.M. Pleading no deficiency in service and denying rest of the allegations, the Opposite Party has prayed for dismissal of the complaint.

 

3]       Replication has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of the Opposite Party.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the entire record.

 

6]       It is an admitted case that the complainant opted for Family Health Optima Insurance Plan from Opposite Party which was effective from 8.12.2015 to 7.12.2016 (Ann.C-1) and that during the coverage of the policy, the complainant suffered chest discomfort and admitted to Max Super Speciality Hospital, Mohali where he was operated & treated for Coronary Angioplasty.  The lodging of the claim for reimbursement of the medical expenses by the complainant with the Opposite Party and its repudiation, is the moot question before this Forum to decide.

 

7]       After giving due consideration to the reply filed by the Opposite Party and after perusing the record, in particular the repudiation letter, it reveals that the claim of the complainant has been declined stating that the complainant suffered from pre-existing disease and as per the policy terms & conditions, the same is excluded for 4 years.  Further, the Opposite Party claimed that the ailment with which the complainant suffered during the coverage period, is the complication of his pre-existing disease i.e. Diabetes Mellitus and thus the claim is not covered as per Exclusion No.1 of the policy terms & conditions.

 

8]       In our considered opinion, the reasons given in the repudiation letter for repudiating the claim of the complainant are unjustified and not legal.  A thorough perusal of the record reveals that the complainant while opting for the policy in question duly filled the proposal form wherein he categorically declared against a proper column that he is suffering from sugar/diabetes since 2007 and on Metformin, Glimepiride.  It is evident fact that on the basis of said proposal form, the complainant was issued policy from 8.12.2015 to 7.12.2016 wherein the Opposite Party considered and mentioned as “Treatment related to previous Fractures and their sequelae” as pre-existing disease and not mentioned about the second problem i.e. sugar/diabetes, which has been declared by the complainant in the proposal form. From this, it divulge that the Opposite Party considered the ailment  of Fractures and their sequelae as pre-existing disease and left the ailment of sugar/diabetes to be considered/mentioned as pre-existing disease in the policy though mentioned in the proposal form by the complainant.  From this, an inference can be drawn that the complainant cannot be denied the benefit under the policy.   It is apt to mention that no cogent evidence is brought forward by the Opposite Party, which shows that the ailment suffered by the complainant during the coverage period is the complication of diabetes mellitus. Thus, the rejection of the claim on that a ground is highly unjustified.     

 

9]       One thing, which is interesting to mention over here is that the Opposite Party very smartly while renewing the policy in question for further period from 8.12.2016 to 7.12.2017 (Ann.C-5) also added  Diabetes Mellitus as pre-existing disease, which they earlier voluntarily did not mention in the previous policy valid from 8.12.2015 to 7.12.2016 (Ann.C-1) despite being mentioned in the proposal form.  This draws an inference about unfair practice resorted by the Opposite Party. Undoubtedly the Opposite Party in the present complaint not only remained deficient in their service but also resorted to unfair practice.

 

10]      Taking into account the foregoing findings, the complaint is allowed with directions to the Opposite Party to reimburse an amount of Rs.2,40,612/- to the complainant along with interest @9% p.a. from the date of repudiation of claim i.e. 2.8.2016 till realization and also to pay compensation of Rs.10,000/- with ligation cost of Rs.7000/-, within a period of 30 days from the date of receipt of copy of this order.

         In case the Opposite Party failed to comply with the order within the above stipulated period, then it shall also be liable to pay an additional compensatory cost of Rs.10,000/- apart from the above relief.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

23^rd March,  2018                                                                                                                                                           Sd/-

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER