Case No. 164/2022   

IN THE MATTER OF

Bimal Kumar S/o Brij Kishore R/o 61 Kapil Vihar Colony GT Road, Aligarh

                                                         V/s

Star Health and Allied Insurance Company Ltd. Regd. Office 1, New Tank Streat, Valluvar Kottam High Road, Nungambakkam Chennai through the authorized signatory Branch Office Aligarg 2^nd Floor, Krishna Complex J -77 Jankpuri colony Ramghat Road, Aligarh                                    (Through: Navin Kumar Saxena)

CORAM

 Present:

1. Shri Hasnain Qureshi, President
2. Shri Alok Upadhayay, Member

PRONOUNCED by Shri Hasnain Qureshi, President

JUDGMENT

1. The present complaint has been filed by the complainant before this commission for  the following reliefs-

1. The Op be directed to discontinue unfair trade practice adopted in cancellation of the policy ending year 2022 and treating the cancellation of the policy as non-est and the policy as being enforceable for renewal ending the year 2023 on payment of premium by the complainant through cheque.
2. The Op be directed to pay to the complainant the litigation expenses Rs.25000/.

2. The Complainant has stated that he is a super senior citizen aged about 71 years. He has his account at Punjab National Bank i.e. linked with the group Health Insurance for its Costumers as intermediary and ties up with different Insurance Company from time to time. The Punjab National Bank was tied up with the Oriental Insurance Company, New India Assurance Company and Star Group Health Insurance.  Complainant had purchased PNB- Oriental Royal medi claim policy for the period from 11.9.2012 to 10.9.2013, from 11.9.2013 to 10.9.2014, from11.9.2014 to 10.9.2015, from 11.9.2015 to 10.9.2016, from 11.9.2016 to 10.9.2017 and from 11.9.2017 to 10.9.2018.  Complainant had purchased Group health Insurance of New India Assurance Company’s policy Known as New India Flexi Floater Group Medi Claim Policy for the period from 6.9.2018 to 5.9.2019 and from 6.9.2019 to 5.9.2020. Complainant had purchased Star Group Health Insurance Company’s policy for the period from 27.8.2020 to 26.8.2021 and  from 27.8.2021 to 26.7.2022. Complainant has further stated that at the time of purchasing the Star Group Health Insurance Policy for the period from 27.8.2020 to 26.8.2021, the proposal form was filled in by the agent of the OP wherein pre-existing disease (PED) was shown in negative and the policy was issued showing the PED as nill. When the complainant came to know about it he informed the Op through letter dated 29.9.2020 brining about the fact of PED into the notice of the Op and requested to include PED and BP in the policy. Complainant stated that this was the fact which was not written by the agent in the proposal form and the complainant was got signed the proposal form unconsciously without reading over and explaining the contents of the form to him by the agent. OP had issued endorsement schedule dated 22.10.2020 in respect of the policy ending in the year 2021 in connection with changing risk element with the description to the effect that the policy is subject to the PED and hypertension and its complications. This condition cannot be made applicable in the present case in view of its facts and circumstances. On renewing the policy for the period from 27.8.2021 to 26.8.2022 OP issued notice dated 14.3.2022 to the complainant whereby the policy was stated to be cancelled on the ground of non-disclosure of material fact on the alleged violation of condition no. 12 of the policy and the cheque of the premium was stated to be returned but no cheque received by the complainant and the OP was estopped from taking any action to cancel the policy. The alleged violation of condition no.12 of the policy is not applicable in the case. Complainant had replied Op’s notice dated 14.3.2022 through his reply dated 27.8.2022 wherein he had mentioned that he had disclosed about PED in his letter dated 29.9.2020. Complainant has also stated the product features of Star Group Health Insurance for PNB customers which provide the coverage of PED after 36 months. The standard definition of PED as provided by the Op for Star Group Health Insurance is any condition, ailment, injury or disease diagnosed by a physician within 48 months prior to the effective date of policy issued by the insurer or its reinstatement. The standard exclusions issued by the op provide that coverage under the policy after expiry of 48 months for any PED is subject to the same being declared at the time of application and accepted by the insurer. Complainant was not aware about the fact of describing the PED at the time of filling up the proposal form by the agent and he cannot be said to have concealed the fact of PED and he cannot be blamed for violation of any condition of the policy. The product feature covers the PED after 36 months and as per standard definition given by the Op PED is one which is diagnosed within 48 months prior to the effective date of policy. In such a case subscribing the policy cannot be treated as a PED effective policy and it would be a fact having no effect on the policy. Complainant had informed the OP by letter dated 29.9.2020 sending his clinical diagnosis issued by Forties Hospital, Noida regarding the fact that stent was placed in his coronary artery sometime in August, 2008 prior to subscribing first group insurance policy for period from 11.9.2012 to 10.9.2013 after expiry of four year within which he was diagnosed a disease which was cured. Complainant cannot be said to have suffered from any PED for subscribing the policy. As per standard definition of PED the maximum waiting period was four year and the policy was purchased by the complainant in the year 2012. Complainant has been continuously subscribing  Health Insurance policy starting from PNB Oriental Medi claim Policy, thereafter new India Group Insurance Policy and lastly Star Group Health Insurance. Complainant is a senior citizen and insurance policy is a beneficial scheme under the social welfare legislation. Complainant cannot be deprived from availing the benefit of the policy at the critical age of 71 year. Complainant was never explained and informed the terms and conditions of the exclusion clause by the agent or any other officer of the company at the time of filling up the proposal form or at any time thereafter. The act of the Op subjecting the policy for the period ending 2021 to PED and cancelling the policy for the period ending 2022 are unwarranted and not fair. Op has exercised unfair trade practice refusing to renew the policy for the period ending in the year 2023 on submitting cheque of the premium by the complainant on 16.8.2022 which amounts to deficiency in service.                 
3. Op stated in the WS that Mr. Bimal Kumar had proposed Star Group Health Insurance policy Gold coving self, spouse Mrs. Anjana Sharma for a floater   assured sum Rs.500000/ for the period from 27.8.2020 to 26.8.2021 and the same renewed from the period 27.8.2021 to 26.8.2021. The insured Bimal Kumar was served with the terms and condition of the policy and were explained to him at the time of proposing the policy and the same was served to him along with the policy schedule. The policy is contractual in nature and the claims arising therein are subject to the terms and condition forming part of the policy. Complainant had accepted the policy agreeing and being fully aware of terms and conditions and executed the proposal form. On 20.10.2020, PED and hypertension of the complainant was endorsed which was not disclosed at the time of inception of the policy. Complainant did not disclose the cardiovascular disease at the time of inception of the policy form 27.8.2020 to 26.8.2021. Complainant had undergone angioplasty in the year 2008 which was not disclosed in the proposal form. The policy was cancelled with effect from 23.4.2022 due to non-disclosure of PED treatment related cardiovascular and cancellation of policy was informed to policy holder. Complainant had a duty to disclose all material facts in the proposal form. Complaint is not maintainable and is liable to be dismissed.
4.  Complainant has filed his affidavit and papers in support of his pleadings. Op has also filed affidavit in support of its pleadings.
5. We have perused the material available on record and heard the parties counsel.
6. The first question of consideration before us is whether the complainant is entitled to the relief claimed?
7. On perusal of the pleadings of the complainant we are convinced with the reasons and explanations given by the complainant that the cancellation of the policy ending the year 2022 by letter dated 14.3.2022 was unwarranted and non-est in the eye of law and is enforceable for all the benefits. Resultantly, complainant is entitled for getting the benefits arising out of the policy ending the year 2021 and 2022. Op is bound to treat the policy ending in the year 2022 as subsisting and to renew the policy for the period ending in the year 2023 on payment of premium through cheque to be given by the complainant.     
8.  The question formulated above is decided in favour of the complainat.
9. We hereby direct the Op to treat the policy ending in the year 2022 as subsisting  and enforceable for renewal of the policy ending in the year 2023 on payment of premium through cheque by the complainant. Op is also directed to pay the complainant Rs.10000/for litigation expenses.
10. A copy of this judgment be provided to all the parties as per rule as mandated by Consumer Protection Act, 2019. The judgment be uploaded forthwith on the website of the commission for the perusal of the parties.
11. File be consigned to record room along with a copy of this judgment.