BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.              

                                                          Consumer Complaint no. 145 of 2020                                                                

                                                          Date of Institution :    02.07.2020

                                                          Date of Decision   :    07.06.2024

1. Bhawna Sethi (aged about 45 years) wife of Sh. Vinay Sethi,

2. Vinay Sethi (aged about 50 years) son of Sh. Harbans Lal Sethi, both residents of Ward No. 7, Near Sethi Petrol Pump, Chautala Road, Mandi Dabwali, Sirsa – 125104.

                            ……Complainants.

                             Versus.

1. Star Health and Allied Insurance Company Limited, Sri Bala Ji Complex, 15, Whites Road, Chennai- 600014 through its Senior Manager/ Incharge.

2. Star Health and Allied Insurance Company Limited,  Ground Floor, Rathore Tower, Dabwali Road, Near Hotel Mehak, Opposite Shakti Motors, Sirsa- 125055 through its Branch Manager.

3. Sanjay Jindal, SM, Star Health and Allied Insurance Company Ltd. Rathore Tower, Dabwali Road, Near Hotel Mehak, Opposite Shakti Motors, Sirsa – 125055. 

…….Opposite Parties.

            Complaint under Section 35 of the Consumer Protection Act, 2019.

Before:       SH. PADAM SINGH THAKUR……. PRESIDENT

                   MRS.SUKHDEEP KAUR……………MEMBER.

                   SH. OM PARKASH TUTEJA……….MEMBER                                            

Present:       Sh. Rishab Goyal,  Advocate for the complainants.

                   Sh. Ravinder Monga, Advocate for opposite parties.

ORDER

                   The complainants have filed the present complaint under Section 12 of the Consumer Protection Act, 1986 (after amendment u/s 35 of C.P. Act, 2019) against the opposite parties (hereinafter referred as Ops).

2.                In brief, the case of complainant is that complainant through agent of the ops purchased health insurance policy namely Family Health Optima Insurance-2017 No. P211121/01/2020/003815 which is being renewed from year to year after making premium amount and lastly he purchased the policy from ops for the period 03.10.2019 to 02.10.2020. The ops issued the said policy in favour of complainants and their family members after fulfillment of all the mandatory required formalities. That the afore mentioned policy purchased by complainants in the year 2017 known as a floater policy and the last policy covered the risk of Rs.6.75 lakh in all respects and complainant lastly paid the premium amount of Rs.21,654/- towards renewal of the policy. It is further averred that after purchasing the policy, a confirmation call was also received from ops and even physical verification was also done by ops no.1 to 3 regarding correct address and status of complainant and thereafter ops after fully satisfying issue customer identity cards in favour of complainants and their family members. That in the last week of January, 2020, complainant no.1 felt some trouble in abdomen and he was advised to go to higher institute/ hospital. Then they went to Fortis Hospital, Mohali on 27.01.2020 and Dr. Atul S. Joshi after clinically examined her advised for detail and deep investigation and after investigations surgery i.e. laparoscopic/ open cholecystectomy was advised. She was admitted in the said hospital on 29.01.2020 and was discharged on 30.01.2020 and ops were informed in this regard who advised to contact with their insurance branch in the hospital who will manage and arrange all the facilities for making payment of the hospital and other charges. It is further averred that complainant informed to the authorized person of the ops and filled a claim form Par-A to claim form for health insurance policy through claim No. 0858079 and complainants claimed Rs.1,07,636/- for their entire medical treatment and other charges as per terms and conditions of insurance policy. The husband of complainant submitted all the original investigation, treatment and discharge summary etc. as required by the ops. That ops earlier approved Rs.30,000/- on 29.01.2020 for the treatment of above diagnosed disease of complainant based on the pre authorization request and other documents submitted by hospital and thereafter the ops in unlawful and illegal manner issued an impugned letter dated 30.01.2020 with the remarks of rejection and withdrawal of approval given earlier. The complainants were shocked to receive such type of impugned claim rejection letter and have faced mental tension and agony. The husband of complainant somehow arranged the amount of surgery and medical treatment charges for her discharge from the hospital and ops have involved themselves in unfair trade practice. It is further averred that vide letter dated 30.01.2020 her claim has been rejected and approval has been withdrawal and even policy has been cancelled and thereafter her husband contacted with the ops and informed them that alleged base mentioned in impugned letter has no concern and cannot be treated as a pre existing disease and that neither this problem is the cause or concern with the surgery conducted in Fortis Hospital, Mohali. The ops showing their adamancy and unilateral attitude agreed to withdraw their impugned letter dated 30.01.2020 with the condition that if the complainant obtains a letter from the concerned doctor for showing no concern with the surgery, then ops are ready to pay the entire amount of Rs.1,07,636/-. That complainant and her husband went to the Fortis Hospital, Mohali and contacted with doctor Atul S. Joshi who after perusing the impugned letter dated 30.01.2020 was also surprised and immediately wrote a clarification letter explaining the fact that there is no concern with the narcolepsy and the surgery conducted by him and moreover he had also explained that alleged narcolepsy is not any disease as claimed by ops. It is further averred that husband of complainant on the advise of ops moved a written request for reconciliation of the claim file No. 0858078 supporting with said clarification and ops assured that they shall release the claim amount within few days. That complainants have contacted with the ops for a number of occasions for releasing the claim amount of Rs.1,07636/- whereas ops are now postponing the matter on one or other reason and have caused deficiency in service and unnecessary harassment to the complainant. Hence, this complaint.

3.                On notice, ops appeared and filed written version raising certain preliminary objections. It is submitted that insured complainants before purchasing the policy comfortably understood the terms and conditions of the policy and same was served to the complainant alongwith policy schedule in which is clearly mentioned that insurance under this policy is subject to conditions, clauses, warranty, exclusion clause etc. That complainant lodged the claim before the company and submitted documents for reimbursement towards treatment of Gall Stone disease for Rs.1,07,636/-. The patient was shown to be admitted in Fortis Hospital Mohali on 29.01.2020 and discharged on 30.01.2020 with the diagnosis “Chronic calculus cholecystitis with Biliary Colic with Chronic liver disease laparoscopic cholecystectomy done under high risk”. In discharge summary the concerned doctor Atul S. Joshi further mentioned under the head of past history – “K/C/O – DM (ii) Narcolepsy, depressive disorder”. After carefully analyzing the documents, it is found that the treatment is for chronic calculus cholecystitis with Biliary Colic with chronic liver disease and it is observed from the consultation report dated 09.03.2015 of the above hospital submitted in response to their query during cashless processing that the insured patient has narcolepsy which confirms that the insured patient has narcolepsy prior to the date of commencement of first year policy. It is further submitted that that time of inception of first year policy commencing from 30.09.2017 to 29.09.2018, the insured has not disclosed the above mentioned medical history/ health detail in the proposal form which amounts to misrepresentation/ non disclosure of the material facts. As per condition 6 of the insurance policy, if there is any misrepresentation/ non disclosure of material facts whether by insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of the claim. The claim of complainant was repudiated and further as per condition 12 of the policy the same has been cancelled and necessary action recommended to be taken by corporate office. The intimation in this regard has been duly sent to the complainant vide letter dated 10.03.2020. It is further submitted that though there is no nexus between the present and past ailment, it is the duty of the insured to disclose the material acts in proposal form and insured has failed to disclose the same and that in case it is found that company is liable to pay the claim in terms of the contract of insurance issued to the claimant, the maximum quantum of liability under the terms of the policy shall be of Rs.76,440/-. Remaining contents of complainant are also denied to be wrong and prayer for dismissal of complaint made.  

4.       The complainant in evidence has tendered her affidavit Ex. CW1/A and documents Ex.C1 to Ex.C28.

5.       On the other hand, ops have tendered affidavit of Sh. Sumit Kumar Sharma as Senior Manager as Ex. RW1/A and documents Ex.R1 to Ex.R19.

6.       We have heard learned counsel for the parties and have gone through the case file.

7.       From the policy schedule Ex.C19, it is evident that complainants purchased health insurance policy from ops for the period 03.10.2019 to 02.10.2020 for the sum insured amount of Rs. five lacs with other benefits (i.e. bonus of Rs.1,75,000/-, limit of coverage Rs. 6,75,000/- and recharge benefit Rs. 1,50,000) for themselves and for their girl child namely Tanisha and it is duly mentioned in the policy schedule Ex.C19 that date of inception of first policy is 30.09.2017 meaning thereby that complainants are purchasing the said health insurance policy from ops from 30.09.2017 and the policy schedules in this regard have also been placed on file by complainants. From the discharge summary Ex.C16, it is also evident that complainant insured Smt. Bhawna Sethi was admitted on Fortis Hospital, Mohali on 29.01.2020 and she was operated for laparoscopic/ open cholecystectomy as she was having chronic calculus cholecystitis with biliary colic with chronic liver disease and she was discharged from said hospital on 30.01.2020. According to complainants, they have spent an amount of Rs.1,07,636/- on her said treatment/ surgery and claim was lodged by complainants with the ops. From the cashless authorization letter dated 29.01.2020 Ex.R6, it is evident that initially ops approved amount of Rs.30,000/- against the total estimated amount of Rs.70,000/- for the cashless treatment of complainant no.1 but even this amount was also not paid to the hospital by the ops and ultimately vide letter dated 30.01.2020 the ops have rejected the claim of complainant on the ground that although the present admission is for treatment of the above disease, the insured patient has Narcolepsy since 09.03.2015 which is prior to first policy and this was not disclosed by the insured in the proposal form at the time of inception of the first policy. Hence it is a pre existing disease and that above details were not brought to their knowledge at the time of initial authorization. They have further mentioned that in view of the non disclosure of the pre existing disease, the claim is not admissible under the policy issued to the insured and as such her claim was rejected and it was also intimated to the complainants that policy is liable to be cancelled. But we are of the considered opinion that ops have wrongly withdrawal the approval earlier granted by them for an amount of Rs.30,000/- and have also wrongly and illegally rejected the claim of complainants. The present admission of the complainant and her treatment has no concern with the disease of narcolepsy and in this regard concerned doctor has clarified in certificate Ex.C22 that Narcolepsy is not associated with the disease of gall stones. The ops have failed to prove on record that any specific questions about pre existing disease of complainant no.1 were ever put to any of the insured persons and they categorically denied about any pre existing disease of complainant no.1. Although in proposal form for issuance of first policy from 30.09.2017 to 29.09.2018 Ex.R1 against the columns of various diseases, the answers have been mentioned as NO i.e. insured persons are not suffering from any of the diseases mentioned in proposal form but however it is very commonly known that at the time of filling proposal form the agent/ authorized representative of the insurance companies himself fill the proposal form and himself mentions the words ‘NO’ against the columns of diseases i.e. insured persons are not suffering from any diseases and as such it cannot be said that specific questions about suffering of diseases were put to the insured and insured did not disclose about any pre existing disease. Although ops have placed on file prescription slip dated 09.03.2015 of Fortis Hospital, Mohali allegedly pertaining to complainant Bhawna but that document itself is not sufficient to prove that actually complainant Bhawna was suffering from Narcolepsy as she herself did not go the hospital and as such word proxy is written in the prescription slip and even before disease of Narcolepsy question mark has been given by the doctor and as such it cannot be said that complainant was actually suffering from disease of Narcolepsy and that who disclosed that she was suffering from Narcolepsy. Moreover, the disease narcolepsy is only a sleep disorder and can be controlled with medicines and even if she was suffering from this disease on 09.03.2015, it cannot be said that she was also suffering from this disease at the time of purchasing of policy in question for the first time which was purchased in the month of September, 2017 and she might have been cured from this disease at that time. The ops have not placed on file any other medical record to prove that complainant no.1 was suffering from this disease at the time of purchasing of first health insurance policy on 30.09.2017. So due to above said given reasons, the repudiation of the claim of complainants on the ground of non disclosure of pre existing disease is wrong and illegal. Although complainant has claimed amount of Rs.1,07,636/- spent on her treatment but from certificate of Fortis Hospital dated 03.02.2020 Ex.R14, it is evident that patient has been charged Rs.51,040/- as the total package cost for Cholecsytectomy (Laparoscopic) and Rs.12,706/- for high risk charges and she might have spent some other amount also on medicines etc. In this regard, ops have also assessed the total payable amount as Rs.76,440/- as per bill assessment sheet Ex.R19 and as such complainants are entitled to claim amount of Rs.76,440/- as assessed by ops. Non payment of this amount clearly amounts to deficiency in service on the part of ops due to which complainants have suffered harassment.   

8.       In view of our above discussion, we allow the present complaint and direct the opposite parties to pay the insurance claim amount of Rs.76,440/- to the complainants alongwith interest at the rate of @6% per annum from the date of filing of this complaint i.e. 02.07.2020 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.10,000/- as composite compensation for harassment and litigation expenses to the complainants within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room. 

Announced.                    Member      Member                          President,

Dated: 07.06.2024.                                                        District Consumer Disputes

                                                                                     Redressal Commission, Sirsa.