District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.182/2022.
Date of Institution: 04.04.2022.
Date of Order: 19.12.2022.
Akhilesh son of Shri Ram Khilwan, resident of village Etora Doripur Tehsil Ghosi P.O.Kopaganj Distt. Mau (U.P) at present resident of House NO. 1085, Gal No. 322, Sanjay Colony, Sector-23, Faridabad.
…….Complainant……..
Versus
1. Star Health and Allied Insurance Company Limited Unit No. 213-214 2nd floor, Tribhuvan Complex, Ishwar Nagar Mathura Road, New Delhi – 110 020 through its authorized person.
2. Star Health and Allied Insurance Company Limited, Regd. & Corporate office 1, New Tank Street Valuvar Kottam High Road, Nungambakkam Chennai 600 034 through its authorized person.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Rajesh Ahlawat, counsel for the complainant.
Sh. O.P.Gaur, counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant had obtained mediclaim policy bearing No. P/161124/01/2021/009951 valid from 21.12.2020 to 20.12.2021. During the mediclaim policy, the son of the complainant namely Master Akash was admitted in Fortis Escorts Hospital, Faridabad on 11.12.2021 for the treatment and the doctor observed and diagnosed that Master Akash was suffering from status Epilepticus and there was no history for the same disease and the son of the complainant was discharge don 16.12.2021 after its treatment and the hospital had raised the bill amount of Rs.1,03,901/- but the opposite parties not paid the bill amount and the complainant had to pay the said bill amount from his own pocket and in this regard the complainant intimated to the representative of the opposite parties to make the said amount but the representative of the opposite parties ignored the legitimate request of the complainant and rejected the claim on 10.01.2022 by making the false & concocted story. Later on the complainant had sent all related documents regarding the treatment of the complainant as well as bill for getting the imbursement of the mediclaim amount but no fruitful result came out. The complainant sent legal notice dated 02.08.18.01.2022 through registered A.D. post to the opposite parties but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) make the mediclaim amount of Rs.1,03,901/- alongwith interest @ 18% which was paid by the complainant from his own pocket during the mediclaim insurance period and the said policy was the cashless policy.
b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 22,000 /-as litigation expenses.
2. Opposite parties Nos.1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties Nos. 1 & 2 refuted claim of the complainant and submitted that the complainant had obtained the medi insurance policy with M/s. Star Health & Allied Insurance Company Ltd. Vide “Family Health Optima Insurance Policy” No. P/161124/01/2021/009951 for the period 21.12.2020 to 20.12.2021. However, previously the complainant had ported the medi insurance policy from M/s. Cigna TTK Insurance Company with M/s. Star Health & Allied Insurance Company Ltd. Vide insurance policy No. P/161124/01/2020/006823 for the period 15.12.2019 to 14.12.2020, pursuant to executing and signing of ‘Proposal Form” with “Portability Form” dated 14.12.2019. As per the proposal form, the information was sought for from the proposer in regards to pre-existing disease, for which the proposer answered the specific query in negative. As per the contract of the insurance, it was the duty of the proposer to disclose all the material facts to the insurer under the Regulation NO. 19(2) of the Insurance Regulatory Development Authority Regulations, 2017 so that the insurer evaluates the material facts and decide whether to accept the proposer or not, as the insurance contract was based on the principle of “UberrimaeFidei” i.e. “Utmost good faith”. As a result thereof, the insurance company had issued Family Health Optima Insurance Policy No. P/161124/01/2020/006823 valid from 15.12.2019 to 14.12.2020 for covering the family for the sum insured of Rs.4,00,000/-. The complainant had accepted the medi policy agreeing and being fully aware of such terms and conditions, pursuant to execution, signing and furnishing the proposal form in this behalf. It was submitted that the complainant had suppressed and concealed the true, material and vital facts & information from this Commission, in lodging the present complaint. As a sequel of brief history of the case in hand and for the purposes of facilitation of the true, vital and material facts & information, it was submitted that the insurance company received a “Request for Cashless Hospitalization” and enclosing therewith “Details of Patient’s admission” dated 11.12.2021 from Fortis escorts Hospital, Neelam Bata Road, NIT Faridabad pertaining to the Patient Aakash, aged 12 years male. As a result, the medical team of the insurance company examined the medical documents and observed diagnosis of “Epilepticus” and sought the documents from the hospital vide its querry letter dated 11.12.2021. The insurance company deputed a competent and qualified doctor to seek the hospitalization status of the patient. It was submitted that the doctor carried out his field investigation by visiting the hospital and furnished his report dated 14.12.2021 to the insurance company inter-alia by obtaining “Progress Record” (ICP. In consideration of the attending medical status of the patient, the medical team of the insurance company examined the available medical documents and arrived at its decision in declining the request for “cashless Hospitalization” vide its letter of rejection dated 14.12.2021 addressed to the insured. The medical team of the insurance company perused and examined the available medical treatment record carefully & thoroughly. As per progress record/ICP, it presents that the patient had “Seizure Disorder” since the age of 2.5 years, which disease had increased in frequency and duration with age. Further, there was a history of birth asphyxia- and gross developmental delay with Microcephaly. It was submitted that the said ailment of the insured patient was not disclosed at the time of obtaining of medi insurance policy, which constitute violation, breach and infringement of condition NO.6 of the medi insurance policy as well as Regulation NO. 19(2) of the IRDA. The insured lodged regular mediclaim with the insurance company vide claim form received by the insurance company on 30.12.2021 and enclosing therewith discharge summary for the period 11.12.2021 to 16.12.2021 and final bill at Rs.1,03,901/-. However, the insurance company being the corporate body deemed it appropriate to examine the mediclaim and reiterated its decision vide its letter dated 16.12.021 inter alia notifying condition No.10 of the medi insurance policy to the effect that “the Company may cancel the policy on the grounds of misrepresentation, fraud, moral hazard, non disclosure of material fact as declared in the proposal form and/or claim form at the time of claim and non co-operation of the insured by sending the insured 30 days notice by registered letter at the insured persons last know address” In nutshell, this notification should be taken as the “Notice of Cancellation as per the policy condition. In furtherance of letter dated 16.12.2021, the insurance company had again reiterated its decision in “Repudiating” the subject regular claim vide its letter dated 10.01.2022, which decision could not be termed unconscionable at all. Opposite parties Nos.1 & 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file as well as written submissions on behalf of the complainant and opposite parties have been perused.
5. In this case the complaint was filed by the complainant against opposite parties– Star Health and Allied Company Ltd. with the prayer to: a) make the mediclaim amount of Rs.1,03,901/- alongwith interest @ 18% which was paid by the complainant from his own pocket during the mediclaim insurance period and the said policy was the cashless policy. b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 22,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Shri Akhilesh, Ex.C-1 – Family Health Optima Insurance Plan, Ex.C-2 – Inpatient summary bill,, Ex.C-3 – legal notice, Ex.C-4 – postal receipt, Ex.C-5 – Discharge summary.
On the other hand counsel for the opposite parties strongly agitated
and opposed. As per the evidence of the opposite parties Ex.RW!/A – affidavit of Shri Sumit Kumar Sharma, Senior Manager, star Health & Allied Insurance Company Ltd., Ist floor, Himalaya House, 23, Kasturba Gandhi Marg, New Delhi, Annx..R/1 – proposal form, Annx.R/2 – insurance policy with terms & conditions, Annx.R-3 – Pre-authorization request with consultation, Annx.R-4 - Query on Authorization for cashless treatment, Annx. R4/A- Brain MRI (contrast), Annx.R/5 – Field Visit Report, Annx.R/6 – Progress record, Annx.R/7 – letter dated 14.12.2021 regarding Rejection and withdrawal of approval given earlier, Annx.R/8 – Claim Form part-A, Annx.R/9 – Discharge summary, Annx.R/10 – Inpatient detail bill, Annx.R/11 - letter dated 16.12.2021 regarding no disclosure of pre-existing disease, Annx.R/12 – repudiation letter dated 10.01.2022, Annx. R-13 –IRDA guidelines.
6. In this case, the complainant has obtained mediclaim policy bearing No. P/161124/01/2021/009951 valid from 21.12.2020 to 20.12.2021. During the mediclaim policy covering the family for sum insured at Rs.4,00,000/-.The son of the complainant namely Master Akash (aged 12 years) was admitted in Fortis Escorts Hospital, Faridabad on 11.12.2021 for the treatment and the doctor observed and diagnosed that Master Akash was suffering from status Epilepticus and there was no history for the same disease and the son of the complainant was discharged on 16.12.2021 after its treatment and the hospital had raised the bill amount of Rs.1,03,901/- but the opposite parties did not pay the bill amount and the complainant had to pay the said bill amount from his own pocket. Opposite parties repudiated the claim of the complainant vide letter dated 10.01.2022 on the ground that “you have not declared the details; Epilepsy with GDD with h/o birth asphyxia-HIE (relating to Mr./Mrs. Aakash) which were found to be pre existing at the time of taking the policy for the first time during 15.12.2019 to 14.12.2020. This amounts to non disclosure of material facts.”
7. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant as per the T&C of the policy within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 19.12.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
