BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 138 of 2020
Date of Institution : 02.07.2020
Date of Decision : 15.02.2024
Neelam Rani wife of Virender Kumar, resident of 78-A, New Anaj Mandi Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., Sri Bala Ji Complex, 15, Whites Road, Chennai- 600014 through its Senior Manager/ Incharge.
2. Star Health and Allied Insurance Company Ltd., 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. P.K. Kochar, Advocate for the complainant.
Sh. Ravinder Goyal, Advocate for opposite parties.
.
ORDER:-
The complainant has filed the present complaint under the provisions of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that complainant purchased a health insurance policy name Mediclassic Individual bearing No. P/211121/01/2019/003576 from the ops no.1 and 2 through their agent and the policy is being renewed every year after making payments and present policy was effective from 30.11.2018 to 29.11.2019. That on 15.10.2019 the complainant was suffering from fever so she went for check up in Medicity Hospital, Sirsa and after taking prescribed medicines, she returned to home. That on 16.10.2019 she was admitted in the Medicity Hospital with the complaint of fever high grade (3 days, bodyache with headache (3days) nausea with vomiting (1day) and after conducting her ultrasound and some medical tests, she was diagnosed that she was suffering from NS1 Antigen+ve (Dengue Fever) and she was treated for the same. On 19.10.2019 she got relief and was discharged in stable condition. The total expenses of the concerned treatment were Rs.20,881/- which included the expenses of prescription, medicines, ultrasound and medical tests etc. It is further averred that complainant informed to the authorized person of the ops and submitted claim form on 7.11.2019 as per terms and conditions of insurance policy and submitted all the requisite documents with it. The complainant also submitted additional documents i.e. prescription papers and medical records as demanded by ops vide letter dated 30.11.2019. It is further averred that then complainant received a letter dated 20.12.2019 from the ops regarding repudiation of the claim in which the ground for repudiation was that complainant has Rheumatoid Arthritis from last seven years and the claim was repudiated without any reasonable cause and said ground is not sustained in the eyes of law and liable to be set aside since the insurance claim was for Dengue Fever and same has nothing to do with the medical past history of complainant. It is further averred that even in the latest medical report dated 20.06.2020 it is certified by the doctor that she was diagnosed and treated from NS1 Antigen+ve only. That above said repudiation letter is totally against terms and conditions and wrong and illegal. The complainant contacted with the ops for a number of times and requested to pay the claim amount but ops have not paid any heed to the genuine requests of complainant and have caused deficiency in service and unnecessary harassment to the complainant. Hence, this complaint.
3. On notice, ops appeared and filed written statement raising certain preliminary objections regarding maintainability, locus standi, cause of action and that policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming port of the policy. On merits, it is submitted that claim submitted by complainant was minutely scrutinized by the ops and from the medical record furnished by complainant, it transpired that the insured patient is a known case of rheumatoid arthritis for the past seven years prior to the commencement of the first year policy. This fact was not disclosed by the insured complainant at the time of taking the policy which amounts to non disclosure of material facts. The complainant insured declared as “NO” for the above specific questions relating to her medical history in the proposal which amounts to non disclosure of material facts and thereby making the contract of insurance voidable. Therefore, there was violation of terms and conditions of the insurance policy on the part of complainant and therefore, the claim of complainant was repudiated by ops vide letter dated 20.12.2019 in a legal and lawful manner. It is also submitted that in case it is found that company is liable to pay the claim, then the maximum quantum of liability under the terms of the policy shall be Rs.14,380/- permanently excluding treatment of RA. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
4. The complainant in evidence has tendered her affidavit Ex.C1 and documents Ex.C2 to Ex.C35.
5. On the other hand, ops have tendered documents and CD Ex.R1 to Ex.R15.
6. We have heard learned counsel for the parties and have gone through the case file carefully.
7. From Ex.C2 insurance policy schedule it is evident that complainant purchased insurance policy in question from ops for the period 30.11.2018 to 29.11.2019 for the sum insured amount of Rs.5,00,000/- and the date of inception of the first policy is 30.11.2017. During the period of policy in question i.e. on 16.10.2019 complainant was admitted in Medicity Hospital, Sirsa as she suffered Dengue Fever and was treated for the said disease and was discharged on 19.10.2019. The complainant spent an amount of Rs.20,881/- on her treatment and lodged the claim with the ops but her claim has been repudiated vide letter dated 20.12.2019 by the ops on the ground that she was suffering the disease of Rheumatoid Arthritis from last seven years and this fact was not disclosed to the ops while purchasing the policy in question. But however, we are of the considered view that ops have wrongly and illegally repudiated the claim of the complainant. The complainant was treated for Dengue Fever and not for Rheumatoid Arthritis and in this regard concerned doctor also issued a certificate Ex.C29 that patient was treated for NS1 Antigen +ve only. Though ops have relied upon document Ex.R15 i.e. translation of telephonic communication allegedly between son of the complainant and officer of the ops in which the son of the complainant denied that complainant was taking any medicines but the ops have not proved on record that son of the complainant actually denied that complainant was taking any medicines prior to the purchase of policy in question. Moreover, in the said document it is no where mentioned that a query regarding pre existing disease of Rheumatoid Arthritis to the complainant was ever put to the son of the complainant and he denied that complainant was not having such disease. Moreover, the claim for said treatment of Dengue Fever has no concern at all with the disease Rheumatoid Arthritis. Further more, the ops could have examined the insured complainant from their panel doctor before issuing the policy in question to the complainant but they have failed to do so. Moreover, the Rheumatoid Arthritis is such a disease which cannot be concealed by the person suffering from it and it can be seen easily seen by another person and as such it can easily be said that agent of the ops after knowing about the said disease of the complainant got issued the policy in question from the insurance company and as such now the repudiation of the claim of complainant on the ground of pre existing disease is not sustainable and is wrong and illegal. The judgment of the Hon’ble Supreme Court in case titled as Satwant Kaur Sandhu Versus New India Assurance Company Limited (2009) 8 SCC 316 relied upon by learned counsel for ops is not applicable in this case. Though ops have averred that their maximum liability is of Rs.14,380/- and have relied upon bill assessment sheet Ex.R14 but however, it is proved on record from bills/ receipts Ex.C13 to Ex.C15, Ex.C20, Ex.C22 and Ex.C24 to Ex.C26 that complainant spent an amount of Rs.20,881/- on her treatment and as such she is entitled to reimbursement of the said amount of Rs.20,881/- from ops no.1 and 2 as ops have failed to prove on record that above said amount also included treatment of Rheumatoid Arthritis.
8. In view of our above discussion, we allow this complaint and direct the opposite parties no.1 and 2 to pay the claim amount of Rs.20,881/- to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present 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 no.1 and 2 to further pay a sum of Rs.10,000/- as compensation for harassment and Rs.5000/- as litigation expenses to the complainant 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: 15.02.2024. District Consumer Disputes
Redressal Commission, Sirsa.
JK
