BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.75 of 2017
Date of Instt. 20.03.2017
Date of Decision: 15.01.2019
Kavita Gupta Age 60 years W/o Late Naval Kishore Gupta R/o H. No.557, Guru Gobind Singh Avenue, Opp. I. O. C., Near Trinity College, Jalandhar.
..........Complainant
Versus
1. Star Health and Allied Insurance Company Ltd., Branch Office- EH-198, 2nd Floor, Nirmal Complex, G. T. Road, Jalandhar Through its Manager/Business Head/Authorized Representative.
2. Star Health and Allied Insurance Company Ltd., Corporate Office-1-New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034 Through its M. D./C.E.O./Authorized Representative.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna Thatai (Member)
Present: Sh. A. S. Sohal, Adv Counsel for the Complainant.
Sh. A. K. Arora, Adv Counsel for the OPs No.1 and 2.
Order
Karnail Singh (President)
1. Brief facts of the complaint are that the OPs are engaged in providing health insurance in the name of Star Health and Allied Insurance to the general public, against the charges. The complainant took the health insurance policy by paying premium of Rs.17,837/- from the OPs and the OPs issued the cashless Mediclassic Individual Health Insurance Policy No.P/161125/2015/002239 on dated 24.01.2015 for sum insurance of Rs.5,00,000/- of the complainant. The complainant is a consumer and the OPs are the service provider to the complainant. Thus, there is a relationship of consumer and service provider between the parties.
2. That the OPs sent the complainant to their Doctor i.e. Dr. Rajesh Arora C/o Balaji Hospital, Dyal Nagar, Jalandhar for the complete medical examination of the complainant before issuance of the policy. The complainant was examined by the Dr. Rajesh Arora and the complainant disclosed everything about her pre-existing disease related to the pancreatic enzyme supplements to the agent doctor of the OPs and it also comes into the scanning done by the said doctor and after complete examination, the aforesaid policy was issued to the complainant.
3. The complainant never claimed in the policy year 2015-16 and she again renew her policy within time by paying a premium of Rs.18,177/- for the year 2016-17 to the OPs and the OPs renew the policy of the complainant with Mediclassic Individual-revised for sum insurance of Rs.5,00,000/- along with no claim bonus of Rs.25,000/-, vide cashless policy No.P/161125/01/2016/002459 and it is valid from 24.01.2016 to 23.01.2017. The OPs insist the complainant for taking the top-up policy, which was newly launched by the OPs for a sum insurance of Rs.10,00,000/- and the complainant took the top-up policy No.P/161125/01/2016/002460 for the period 31.12.2015 to 30.12.2016, but unfortunately, the complainant admitted in the PGI Premier Gastroenterology Institute on 24.08.2016 to 27.08.2016 due to viral infection and she informed the OPs within 24 hours for her problem and admission in above said hospital. One of the agent of the OPs came to the hospital and collected all the documents of the policy and medical reports and it was utter surprised that he said that the claim will pass within 15 days instead of cashless treatment and he gave the claim No.CLMGI/2017/161125/0030846 to the complainant. After discharge and clearance of the hospital bill, the complainant approached the office of the OP No.1 on 18.11.2016 regarding the claim and OP No.1 gave an assurance to the complainant that the claim will be cleared soon, but all in vain, then complainant again approached OP No.1 on 25.11.2016, but OP No.1 again lingering on the matter on one pretext or the other. The medical claim of Rs.21,743/- was submitted by the complainant, but the same was rejected by the OP, vide letter dated 22.12.2016 on the plea that there was a pre-existing disease to the complainant, which was not disclosed by the complainant at the time of filling the document. The act and conduct of the OPs is tantamount to negligent and deficient for providing proper services to the complainant, which gave rise to file the instant complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pass the claim amount of Rs.21,743/- with interest @ 12% per annum and renew the policy from 24.01.2017 for the year 2017-18 with 2 years benefits as the OPs already received the premium on 27.02.2017 for renewal of the original policy after issuing the cancellation of the policy and further OPs be directed to compensate the complainant by paying a sum of Rs.60,000/- for causing mental harassment and agony to the complainant and further OPs be directed to pay litigation expenses of Rs.11,000/-.
4. Notice of the complaint was given to the OPs, who appeared and filed joint reply and contested the complaint by taking preliminary objections that no cause of action has arisen in favour of the complainant to file the present case. It is further submitted that the OPs has acted strictly on the basis of the terms and conditions contained in the policy. The present case is pre-mature as the complainant had not submitted the required document for the purpose of claim despite of repeated requests by the answering OPs, the complaint has been filed by the complainant with malafide intention and further to grab the public money. Hence, the complaint is liable to be dismissed and further averred that the complainant is bound by the terms and conditions of the policy and further submitted that the complainant has concealed the material facts from the Forum, therefore, the complainant is not entitled for the discretionary relief. On merits, the factum in regard to purchase of the insurance policy by the complainant is admitted, but the other allegations as made in the complaint are categorically denied and further alleged that the policy was purchased by the complainant as per her own requirement and desire, specially after fully understanding the terms and conditions of the policy and further submitted that the insured was admitted at Jalandhar Nursing Home Maternity Hospital on 24.08.2016 for the treatment of Chest Infection and submitted pre-authorization request for cashless treatment and on perusal of the claim records, the answering OPs have called some documents, which are mandatory to process the claim, vide letter dated 27.08.2016, but the insured has not submitted the required documents to enable the OP to process the claim and further alleged that the complainant cannot compel the answering OPs to pass her claim, which is beyond the terms and conditions of the policy and the claim of the complainant was rejected because the complainant has concealed the previous ailment and further submitted that as per condition No.13 of the policy, the company may cancel the insurance policy on grounds of misrepresentation/non-disclosure of material facts as declared in the proposal form at the time of claim and hence, this policy was cancelled and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.
5. In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavits of the complainant Ex.CA and Ex.CB along with some documents Ex.C-1 to Ex.C-26 and closed the evidence.
6. Similarly, counsel for the OPs tendered into evidence affidavit Ex.OP1/A along with some documents Ex.OP-1 to Ex.OP-11 and closed the evidence.
7. We bestowed our thoughtful consideration to the submissions made by learned counsel for the respective parties and also gone through the case file very minutely.
8. From the pleading, it reveals that the case of the complainant in regard to purchasing of insurance policy thricely i.e. for the year 2015-16, 2016-17 and then from 2017-18, is admitted and further, there is also no dispute that the complainant got treatment from Premier Gastroenterology Institute and where remained admitted 24.08.2016 to 27.08.2016 and cashless treatment was not allowed to the complainant and thereafter, the complainant submitted the medical treatment bill to the OPs, but the said claim was rejected by the OPs, vide letter Ex.C-18 dated 22.12.2016 on the ground of pre-existing disease, which was not disclosed by the complainant at the time of inception of the policy and in support of these versions, counsel for the OPs referred some material documents issued by the hospital, which are Ex.OP5, Ex.OP7 & Ex.OP11, wherein chronic pancreatitis disease is mentioned, the said disease was in existence to the complainant since the year 2014, but at the time of filling of Proposal Form, the complainant did not disclose the said disease and counsel for the OPs also referred the Proposal Form Ex.OP-3 and further made reliance upon some judgments in order to give strength to his argument, the judgments referred by the learned counsel for the OP are cited in 2015(2) CLT 422, titled as “Star Health and Allied Insurance Company Ltd. and Others Vs. Gurbax Singh and Others”, further made reliance upon a judgment of Hon'ble Apex Court, cited in 2013(3) CPR 664 SC, titled as “Satwant Kaur Sandhu Vs. New India Assurance Company Ltd.” and then referred an other pronouncement of Hon'ble National Commission, cited in 2009(1) CPJ 117, titled as “Diwan Surender Lal Vs. Oriental Insurance Co. Ltd. and Another”.
9. We have gone through the documents referred by learned counsel for the OP as well as counsel for the complainant and also scanned the judgments (Supra) referred by learned counsel for the OPs and find that the OP has wrongly interpreting its own documents. First of all, if we talk about the Proposal Form Ex.OP-3, wherein on third page in column no.3, the complainant has given reply that she is a patient of Diabetes for the last six year and in reply to 3(b), the complainant gave reply that she is a patient of High BP and Cholesterol for the last three years, but these replies of the insured was not taken into consideration at the time of considering the medi-claim of the complainant.
10. From the above Proposal Form, it is clear that the complainant has not concealed any previous ailment rather she disclosed the same. The OP has brought on the file some documents of the hospital, where-from it is clear that the complainant having some pancreatitis problem and we find that the pancreatitis problem is co-related problem of the diabetic and again we reverting back to the documents of the OP i.e. Insurance Policy, which are Ex.C-1 for the period 2015-16 and in this insurance policy one head is made as under:-
'PED' means “Pre-Existing Disease”
and against this word PED, it is clearly mentioned by the complainant that she is a patient of Diabetes and Hypertension and their complications including target organ damage. We are of the opinion that the peoples become very aware about their health and everybody know that the co-related problem as well as target organ are which one, hypertension can create problem to brain, heart and similarly diabetes can create problem for pancreatitis. So, the copy of the insurance policies Ex.C-1, Ex.C-3 and Ex.C-19 itself again established that an immunity was given to the complainant from the disease of diabetes and hypertension. Further, there is an other letter produced on the file by the complainant, which is Ex.C-2 dated 24.09.2010, which was sent to Divisional Manager of the Insurance Company i.e. OP by the complainant and in this letter, the complainant has also disclosed the disease problems related to pancreatitis, diabetes and high BP and we think that in response to the rejection letter, the above discussion is sufficient and no further question is required to discuss and ultimately, we find that there is no concealment on the part of the OP and the rulings referred by the learned counsel for the OPs are not applicable in the present case because the OPs itself miserably failed to prove any concealment and wrong information submitted by the complainant and thus, the claim of the complainant has been wrongly and illegally rejected by the OPs and even the insurance policy for the year 2017-18 has been also wrongly cancelled by the OPs without any solid reason and rhyme.
11. Further, we have also considered the plea taken by the OP in its written reply that the present complaint is pre-mature as the complainant has not submitted the required documents for the purpose of the claim despite of repeated request of the OP. This plea has been simply taken by the OPs in its written reply, but no documentary proof in the shape of letter has been produced and proved on the file, whereby the said document was ever demanded by the OPs from the complainant. So, this plea of the OP is seemed to furtile plea, taken by the OPs and the same having no solid substances.
12. From the above detailed discussion, we came to conclusion that the complainant is entitled for the relief claimed and accordingly, the complaint of the complainant is partly accepted and OPs are directed to reimburse the medical claim amount of Rs.21,743/- to the complainant along with interest @ 12% per annum from the date of repudiation of the claim i.e. 22.12.2016, till its realization and further OPs are directed to refund the premium amount of the insurance policy, which had been wrongly cancelled by the OPs. The said premium be paid to the complainant along with interest @ 12% per annum from the date of deposit, till realization and further OPs are directed to compensate the complainant by paying damages for causing mental harassment and agony to the complainant, to the tune of Rs.35,000/- and further OPs are also directed to pay Rs.10,000/- as litigation expenses. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Thatai Karnail Singh
15.01.2019 Member President
