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

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Vijinder Garg S/o Sh. Sohan Lal Garg, H.No. 1103, Sector 10, Panchkula (Haryana).

                   ---- Complainant

V E R S U S

1.       Star Health and Allied Insurance Company Limited, 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai – 600034.

2.       The Branch Manager, Star Health and Allied Insurance Co. Limited, SCO No. 257, 2^nd Floor, Sector 44, Chandigarh.

---- Opposite Parties

BEFORE:      SH. LAKSHMAN SHARMA                    PRESIDENT

MRS.MADHU MUTNEJA                       MEMBER

                   SH.JASWINDER SINGH SIDHU             MEMBER

Argued By:             Sh. Sukhdev S. Kanwal, Counsel for Complainant.

Sh. Gaurav Bhardwaj, Counsel for Opposite Parties.

PER JASWINDER SINGH SIDHU, MEMBER

1.                Briefly stated, the Complainant had taken a Health Insurance Policy No. 282550028914 (Gold Plan) from Reliance General Insurance Co., valid from 13.11.2007 to 12.11.2008, with a sum assured of Rs.2 lac, covering the Complainant along with his wife and two children were insured (Policy Annexure C-1).  The said policy was renewed for the period i.e. 18.11.2008 to 17.11.2008 vide Policy No. 282510346934 and thereafter vide Policy No. 2004792825003640, the policy was further renewed for next one year i.e. from 18.11.2009 to 17.11.2010 for the sum of Rs.2 lac on the same terms and conditions (Annexure C-2 & C-3).

                   It is averred that before the expiry of aforesaid policy, Complainant took a new family health insurance policy from Star Health & Allied Insurance Co. Ltd. All the insurance benefits available under previous insurance policies, issued by Reliance General Insurance Co., were rolled over to new insurance policy No. P/161113/01/2011/002087, issued by Star Health & Allied Insurance Co. Ltd. (Copy of Insurance Policy and Endorsement Schedule is at Annexure C-4 and C-5). As per terms and conditions of the insurance policy, there were certain exclusions laid down by the Company, wherein the company declared himself not liable to make any payments under the Policy in respect of any expenses whatsoever incurred by an insured person. As per clause 5 of said exclusions/ terms and conditions, it was declared that the exclusions 2, 3 and 4 shall not however apply in case of the insured persons/s having been covered under any insurance scheme with any of the Indian Insurance Companies for a continuous period of preceding 12 months/ 24 months respectively, without any break (Annexure C-6). Accordingly, the Opposite Parties with intention to give benefit of previous policies, waived off the first year exclusions, second years and 30 days waiting period (relevant extract of Endorsement Schedule to this effect stands reproduced by the Complainant in Para 3 of the complaint).

                   It is asserted that the wife of the Complainant namely Seema Garg, who was also insured under the aforesaid insurance policy issued by the Opposite Parties, suffered severe pain in abdomen on 3.1.2011 and for treatment she was admitted in Gokul Surgical Hospital, Sector 15, Panchkula. During treatment, multiple stones were found in the gall bladder therefore with surgical operation gall bladder was removed by the doctors. On 1.1.2011 i.e. two days before the day of operation, the Complainant intimated the Opposite Party for making cashless claim, vide Claim No. 81912, but the company denied the cashless claim on 3.1.2011 and advised to submit the claim after treatment. The Complainant again submitted his claim for Rs.79,941/- on 27.1.2011 to the Opposite Party (Annexure P-7). However, to his utter surprise, the claim was rejected by the Opposite Parties on 5.2.2011 saying that as per exclusion No.1 of policy, the company is not liable to make any payments under the policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of pre-existing disease as defined in the policy, until 48 months of continuous coverage have elapsed, since inception of the first policy with the company (copy of rejection letter is at Annexure P-8). The Complainant vide his letter dated 12.02.2011 (Annexure C-9), again requested the Opposite Parties to reconsider his claim because the company had already waived of first and second years exclusions along with 30 days waiting period and the claim of the Complainant does not fall under the category of pre-existing disease.  But when even after two months the Opposite Parties took no action, the Complainant brought the matter to the notice of Insurance Ombudsman vide his complaint Annexure C-10.  However, despite the best efforts, the Complainant could not gain anything there, as the Ombudsman is not holding his office for more than a year. Hence, this complaint.

                   The complaint of the Complainant is duly verified, and is supported by his detailed affidavit.

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

3.                Opposite Parties in their joint reply while admitting the factual matrix of the case, pleaded that the endorsement is with regard to the exclusion of the first year, second year and 30 days waiting period, but not with regard to the exclusion no.1 of the policy. No where it is mentioned that pre-existing disease shall be covered.  The wife of the Complainant visited the treating doctor on 25.12.2010 and the said doctor mentioned in the history that the patient is having abdominal pain for the last two months. It is admitted that the Complainant sent the pre-authorization form, but in the said form also, it is mentioned by the doctor that pain in abdomen two months (copy of doctors slip and pre-authorization form is at Annexures R-1 & R-2).

                   It is further pleaded that the claim was repudiated after due application of mind and as per terms and conditions of the policy. The claim was not verified from the panel doctor and the Complainant has not disclosed the pre-existing disease in the proposal form. A copy of the claim form and claim verification dated 2.2.2011 is at Annexure R-3 & R-4. The claim was reconsidered and the same was again got verified from another panel doctor on 23.3.2011 but the same was again repudiated vide letter dated 23.3.2011 as the exclusion no.1 was not waived off (copy of claim verification form & repudiation letter Annex. R-5 & R-6). The answering Opposite Parties even after repudiation of the claim, on receiving the representation of the complainant,  got the opinion of the expert for the said claim on 30.7.2011 and the rejection was upheld by the expert of the Opposite Parties (Annexure R-7).  Denying all other allegations and stating that there is no deficiency in service on their part, Opposite Parties have prayed for dismissal of the complaint with costs.  

                   The reply of Opposite Parties is not duly verified, but is supported by a detailed affidavit of Mr. P.C. Tripathy, Zonal Manager, Star Health & Allied Insurance Co. Ltd.

4.                Having gone through the entire complaint, version of the Opposite Parties, the evidence of the parties and with the able assistance of the learned counsel for the parties, we have come to the following conclusions.

5.                 The Complainant, who initially was a subscriber to a health insurance policy with Reliance General Insurance, in the year 2007, and subsequently, subscribed for another two policies continuously with the same Company, however, after a lapse of three years, the Complainant got himself insured, vide Family Health Optima Insurance Policy from the Opposite Parties on 16.11.2010 (Annexure C-4).  The Opposite Parties while offering this insurance cover, waived off few conditions, and the same are found quoted under the heading of endorsements, wherein the first & second year exclusions, along with thirty days waiting period stood waived off in the present policy. This option was made available to the Complainant, on the basis of his previous policy with Reliance G.I.C. Ltd. and all other terms & conditions/ warranties/ causes of the present policy remained unaltered.   The terms and conditions of the policy subscribed from the Opposite Parties are at Annexure C-6 with the complaint.

6.                The wife of the Complainant underwent treatment of Cholelithiasis (multiple stones in Gall Bladder) at Gokul Hospital and was charged Rs.79,941/-. The Complainant duly lodged a claim for indemnification of the amount paid for the aforesaid treatment of his wife, with the Opposite Parties.  However, the Opposite Parties refused the claim of the Complainant vide Claim repudiation letter Annexure P-8, wherein, it was stated that as per the Exclusion No.1 of the policy the Opposite Parties are not liable to make any payments in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of pre-existing disease, as defined in the Policy, until 48 months of continuous coverage has elapsed, since inception of the 1^st policy with the company.

7.                We have perused the Insurance Policy (Annexure C-4), wherein in the Column of Renewal Year it is mentioned as a New Policy. Meaning thereby, that the insurance policy subscribed by the Complainant from the Opposite Parties, was the first policy issued by this company, and the clause 1 of the Exclusions, as mentioned in the repudiation letter, reads as under:-

“The Company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by an insured person in connection with or in respect of:

1.       All diseases/ injuries which are Pre-Existing when the cover incepts for the first time.” 

                   A bare perusal of the aforesaid condition, along with the contents of the Medical Certificate, issued under the signatures of the treating doctor, which mentions under Clause 6(b) that the patient was suffering from the said symptoms since past two months. While relating this factor with the date of inception of the policy which is 16.11.2010, and the date of admission of the wife of the Complainant for treatment on 3.1.2011, the stand of the Opposite Parties that the wife of the Complainant was suffering from the symptoms of the disease for which she had been treated, were actually existing at the time of the inception of the policy of the opposite parties. Hence, the reason that the wife of the complainant was already suffering with the disease, for which the Opposite Parties had refused the claim to the Complainant, holds ground. 

8.                The Complainant has failed to satisfy us with regard to his claim of waiver of the condition of pre-existing disease, which he claims was part and parcel of the policy, which he had subscribed with the Opposite Parties, and under such waiver, he was entitled for indemnification of his claim lodged with the Opposite Parties.  We feel that as per clause 1 of the Exclusions, mentioned in Annexure C-6, is a valid ground for the repudiation of the claim of the Complainant.  The Complainant has himself received the terms and conditions of the and had at no point of time raised any objection to the Clause 1 of the Exclusions of the policy, thus having agreed to these conditions, he has failed to make out a case of deficiency in service against the Opposite Parties and present complaint being devoid of merits, deserves dismissal.

9.                In the light of above observations, we are of the concerted view that the present complaint deserves dismissal. Hence, the present complaint of the Complainant is dismissed. There is no order as to costs.         

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

Announced

28^th February, 2013.                                                                                         

Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

(MADHU MUTNEJA)

MEMBER

Sd/-

 (JASWINDER SINGH SIDHU)

MEMBER