Order by:

Smt.Aparana Kundi, Member

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that the complainant was availing  medi claim policy covering himself and his wife namely Sudarshan Sehgal from United India Insurance Co. Ltd. since 2012. Thereafter on the allurement of agent of the Opposite Parties, the complainant purchased the medi claim policy from the Opposite Parties, vide policy no.P/211222/01/2021/009148 for the period 31.03.2021 to 30.03.2022 and the said policy was further renewed for the period 31.03.2022 to 30.03.2023 and thereafter for the period 31.03.2023 to 30.03.2024. During the pendency of said policy, unfortunately complainant suffered from lower back ache due to which he was unable to walk and got admitted in Dayanand Medical College and Hospital, Ludhiana on 07.08.2023 and Opposite Parties was duly informed regarding the admission of complainant and Opposite Parties assured that the cashless facility will be provided, but later on they refused to give cashless facility and due to compelling circumstances, the complainant has to pay the amount of  Rs.1,26,667/- from his pocket. After the treatment the complainant got discharged  from the hospital on 12.08.2023 and after discharged from the hospital, the complainant submitted all the relevant documents and filed the requisite form for the reimbursement of the medical expenses, but the Opposite Parties vide letter dated 10.08.2023 rejected the claim of the complainant on account of pre existing disease. Alleged that the Opposite Parties have arbitrary and illegally rejected the claim of the complainant. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay Rs.1,26,667/- alongwith interest thereon @ 24% p.a.

b)      To pay an amount of Rs.1,00,000/- as compensation for mental tension and harassment.

c)       And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present pre mature complaint is filed without any cause of action, as the cashless (Pre-authorization) claim of the complainant was denied by the answering Opposite Party on ground of Pre-existing & Non-disclosure of material facts. The insured/complainant by not disclosing the pre-existing/medical history before procuring the policy has violated the policy document/contract and also the core principle of insurance i.e. the Principle of Good Faith and had obtained the policy through concealment of material facts. Averred that in this case, the insurance company has rejected only cashless claim and the insured has not approached for the reimbursement of medical expenses. Hence, the company is not aware of the exact amount spent by the insured at the time of hospitalization. Averred further that the present complaint pertains to insurance claim under ‘Star Group Health Insurance Policy-Gold (for Bank Customers) bearing No.P/211222/01/2023/011870 valid from 31.03.2023 to 31.03.2024 covering himself and his wife Sudarshan Sehgal for a sum of Rs 4,00,000/-. This policy was ported from United India Insurance Co. Ltd. w.ef. 31.03.2021 onwards. However it is submitted that the aforesaid insurance policy was issued to the insured by the answering Opposite Party subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of the contract. Moreover the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same were served to the complainant along with policy schedule. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Averred further that the insured requested for cashless treatment of DISC Bulge for hospitalization on dated 07.08.2023 in DMC, Ludhiana and the cashless rejection reason was as it had been observed from the submitted records that the insured patient had undergone PTCA (Perctaneous Transluminal Coronary Angioplasty) in the year, 2019 which was prior to portability of the insurance policy from the answering insurance company and the complainant has not disclosed the above mentioned medical history/health details in the proposal form which amounts to non-disclosure of material facts. Hence, the cashless claim was rejected and the same was informed to the insured vide letter dated 07.08.2023. Averred further that the Proposer in the Proposal form has affirmed that the insured person was in good health and that he has not consulted or taken treatment which could be gathered from the following;

1.       Are you in good health and free from physical and mental disease or infirmity. If not give details:-       Yes

2.       Have you consulted/taken treatment/been admitted for any illness/disease/injury/surgery, if yes details:-           No

3.       Have you ever suffered of suffering from any of the following:-

i)       Disease of Stomach, Intestine, Liver, Gall bladder/Pancreas, Kidney, Urinary Bladder, Urinary Tract Diseases, if yes, since when:-  No.

          From the above findings, it is clearly evident that the insured is well aware of the past medical history of the insured person and failed to disclose the same in the proposal from during the porting of policy, amounting to non disclosure of material facts thus violating the Cardinal Principle of the Insurance, making the Contract of Insurance voidable and unenforceable. Averred further that Civil Court is the appropriate Forum to decide and adjudicate the present case, this Commission cannot receive evidence in detail in its summary jurisdiction under the Act; the complainant has got no cause of action and locus standi to file the present complaint; the instant complaint is false, malicious, incorrect and with malafide intent; the instant complaint is neither maintainable in law nor on facts; this Forum has got no jurisdiction to try and decide the present complaint; no deficient services have been rendered by the answering Opposite Parties as alleged by the complainant. The claim in question was duly entertained, inquired into and after due application of mind the alleged claim has been repudiated on the basis of terms and conditions of the policy. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove his case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C13.

4.       On the other hand, Opposite Parties has tendered into evidence affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1 to 3/A, Power of Attorney as Ex.OP1 to 3/B alongwith copies of documents Ex.OP1 to 3/1 to Ex.OP1 to 3/8.

5.         We have heard the ld. counsel for both the parties and also gone through the record.

6.       It is well proved on record that the complainant is the holder of Insurance policy namely “Star Group Health Insured Policy-Gold” having no.P/211222/01/2021/009148 for the period 31.03.2021 to 30.03.2022, which was further renewed for the period 31.03.2022 to 30.03.2023 and thereafter for the period 31.03.2023 to 30.03.2024. It is also proved on record that during the policy coverage, the complainant suffered some health problem and got admitted in Dayanand Medical College and Hospital, Ludhiana on 07.08.2023 and got discharged on 12.08.2023. It is also proved on record that at the time of admission in the hospital, the complainant requested to Opposite Parties for cashless authorization, but his request for cashless treatment was rejected by the Opposite Parties vide letter dated 07.08.2023 and thereafter the policy of the complainant was also cancelled, vide letter dated 10.08.2023.

7.       The perusal of letter dated 07.08.2023 reveals that the Opposite Parties rejected the pre authorization for cashless treatment of the complainant on the following grounds:-

“It is observed from the submitted records that the insured patient had undergone ptca in 2019 which is prior to portability and the above person has not disclosed the above mentioned medical history/health details of the insured-person in the proposal form which amounts to non disclosure of material facts.”

In our concerted view the rejection of cashless request of the complainant on the ground of non disclosure of material facts and pre existing disease is not genuine, as it is proved on record the complainant was availing the insurance policies from United India Insurance Company since the year 2012 continuously without any break (Ex.C3) and thereafter, they ported their policy from United India Insurance Company to Star Health & Allied Insurance Company i.e. opposite parties in the year, 2021 and that too without any break renewed till 2024. So, if the complainant ported his insurance policy from the previous insurance company to the present insurance company of the Opposite Parties, then it is mandatory for the Opposite Parties to get the details with regard to the health status of the complainant and treatment taken by him during the policy coverage, from the previous insurance company, but the Opposite Party failed to do the same.

8.       Further, thorough perusal of the policy document (Ex.OP1 to 3/2) reveals that complainant was duly covered for pre-existing diseases. Therefore, the rejection for cashless request on the ground that of pre existing disease and thereafter cancellation of the policy is unjustified.

9.       It is proved on record that the complainant got admitted in Dayanand Medical College and Hospital, Ludhiana on 07.08.2023 and got discharged on 12.08.2023. It is also proved on record that at the time of admission in the hospital, the complainant requested the Opposite Parties for cashless authorization, vide letter dated 07.08.2023, but the same was rejected by the Opposite Parties on the same day, vide letter dated 07.08.2023 and placed on record copy of the same as Ex.OP1 to 3/7 and thereafter Opposite Parties issued letter dated 10.08.02023, copy of which is Ex.OP1 to 3/8, which states as under:-

“We wish to bring your kind attention that during the scrutiny of the above claim papers, we observe that you have not declared the details; ptca 2019 (relating to Mr/MRs.Rajinder Kumar Sehgal), which were found to be pre existing at the time of taking the policy for the first time during 31-MAR-21 to 30-MAR-2022. This amounts to non disclosure of material facts.

We draw your attention to condition no.12 in the Policy clause which reads as follows.

The Company may cancel the policy on 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 person’s last known address.

This letter shall be taken as the notice of cancellation as per the above mentioned policy condition.

You are hereby informed that as per the above clause, we intend to cancel the coverage for above mentioned person with effect from 19-SEP-23.”

          Meaning thereby that at the time of admission in the hospital i.e. on dated 07.08.2023, the complainant was duly covered under the policy in question, as the complainant was intimated about the cancellation of the policy only on 10.08.2023, whereas the policy was to be cancelled on 19.09.2023. So, it is well proved on record that at the time of taking the treatment, the complainant was covered under the policy in question, which was not denied by the Opposite Parties anywhere.

10.     Further perusal of the record shows that the complainant admitted in the hospital for the treatment of ‘Disc Bulge’ whereas the Opposite Parties are alleging that the complainant has already taking the treatment for PTCA in the year, 2019. However, both the diseases are not related. The hospitalization and treatment  taken of one disease whereas the rejection of claim and cancellation of policy on account of another disease is not justified. This shows the behavior of the Opposite Parties to hesitate from giving genuine claim to the complainant while quoting one or the other excuse.

11.     Vide instant complaint, the complainant claimed the amount of Rs.1,26,667/- i.e. expenses incurred upon the treatment and said amount has duly been proved on record vide Ex.C9.

11.     In view of the discussion above, we party allow the complaint of the complainant and direct the Opposite Parties to pay an amount of Rs.1,26,667/-(Rupees One Lakh Twenty Six Thousand Six Hundred Sixty Seven only) to complainant with interest @ 8% p.a. from the date of filing of present complaint i.e. 04.10.2023 till its actual realization. Opposite Parties are further burdened with compository cost of Rs.8000/-(Rupees Eight Thousand only) to be paid to the complainant on account of compensation and litigation expenses incurred. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 45 days from the date of receipt of copy of this order, failing which, the Opposite Parties are burdened with additional amount of Rs.15,000/-(Rupees Fifteen Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission