Haryana

Karnal

426/2012

Pawan Kumar S/o Amar Nath - Complainant(s)

Versus

Star Health And Allied Insurance Company - Opp.Party(s)

Sh. Randeep Rana

13 Jun 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                              Complaint No. 426 of 2012

                                                             Date of instt.: 05.09.2012

                                                               Date of decision 13.6.2016

 

Pawan Kumar son of Shri Amar Nath resident of Sarafa Bazar Wali Gali Nissing, Karnal.

 

                                                                   ……..Complainant.

                                      Vs.

Star Health and Allied Insurance Company Ltd. through its Manager Karal (No.104 Mugal Canal 2^nd Floor Karnal)

 

                                                                   ………… Opposite Party.

                     Complaint u/s 12  of the Consumer Protection Act.

 

Before                   Sh.K.C.Sharma……….President.

                   Sh.Anil Sharma…….Member.

 

Present:-      Shri Randeep Rana Advocate for complainant.

                    Shri G.P . Singh Advocate for opposite party.

                    

 ORDER:

 

                   This complaint has been filed by the complainant u/s 12 of the Consumer protection Act 1986, on the averments that he obtained policy no.P/21111/04/01/2011/00314 dated 16.12.2010 from opposite party under the plan  “Family Health Optima Insurance Policy.” He paid the premium regularly. At the time of obtaining the policy he and his family members were examined by the doctors of the opposite party. His wife Suman was also covered under the said policy. Lateron, he came to know about the disease of his wife. She was suffering from heart disease and she remained admitted in various hospitals including Post Graduate Institute, Chandigarh. He spent an amount of Rs.1,50,000/- on the treatment of his wife. He lodged claim with the opposite party and submitted all the bills and other documents, but his claim was illegally rejected by the opposite party. In this way, there was deficiency in service, which caused him mental pain, agony and harassment apart from financial loss.

2.                Notice of the complaint was given to the opposite party, who appeared and filed written statement controverting the claim of the complainant. Objections have been raised that the complaint is not maintainable; that the complainant has not approached this forum with clean hands; that the complainant is estopped by his own acts and conduct and that the complainant has got no locus standi to file the complaint.

                   On merits, it has been submitted that the wife of complainant was admitted in Post Graduate Institute of Medial Education and Research, (for short PGIMER) Chandigarh on 23.4.2012 and discharged on 03.05.2012. The diagnosis was post (Balloon Mitral Valvulaplasty (BMV). She was admitted with Severe Mitral Regurgitation with moderate Tricuspid regurgitation with normal LVEF. As per clinical summary, she was known case of Rheumatic Heart Disease, severe mitral stenosis symptomatic since 5 years. She underwent BMV on 23.4.2012 following which she developed repute severe MR with pulmonary edema. Emergency Mitral Valve replacement was done on the same day. The insured had not disclosed about medical history of Rheumatic Hearth Disease of his wife in the proposal form. He suppressed the important fact of pre-existing disease of his wife at the time of obtaining the policy, therefore, his claim was rightly repudiated, vide letter dated 16.07.2012.  The policy in vogue was cancelled and a sum of Rs.884/- was refunded to the complainant vide DD no.812545 dated 8.8.2012. In this way, there was no deficiency in service on the part of the opposite party.

3.                In evidence of the complainant, his affidavit Ex.CW1/A and documents Ex.1 to C32 have been tendered.

4.                On the other hand, in evidence of the opposite party, affidavit of P.C.Tripathy, Zonal Manager Ex. O1 and documents Ex.O2 to Ex.O10 have been tendered.

5.                We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

6.                From the pleadings and evidence of the parties, it emerges that the complainant obtained policy under Family Health Optima Insurance Plan and his wife Suman was also covered under the said policy. His wife suffered from heart disease and got treatment from PGIMER, Chandigarh. She remained admitted there from 23.4.2012 to 3.5.2012. Balloon Mitral Valvulaplasty was done on 23.4.2012. The claim lodged by the complainant for medical expenses incurred on the treatment of his wife was repudiated by the opposite party, vide letter dated 16.07.2012 and the policy was also cancelled and an amount of Rs.884/- was refunded to the complainant, vide Demand Draft no.812545 dated 8.8.2012.

7.                Learned counsel for the opposite party put a great thrust upon the contention that as per medical record the wife of the complainant was admitted in PGIMER, Chandigarh on 23.4.2012 with Severe Mitral Regurgitation with moderate Tricuspid regurgitation with normal LVEF. As per clinical summary she was known case of Rheumatic Heart Disease severe mitral stenosis symptomatic since 5 years. However, while obtaining the policy the complainant did not disclose about the said disease/problem of his wife and in this way he concealed/suppressed the material fact from the opposite party, therefore, his claim was rightly repudiated.

8.                 It is settled principle of law that contract of insurance is a contract uberrima fides and utmost faith must be observed by the contracting parties. Every fact must be disclosed, otherwise there is good ground for rescission of contract. If, there is mis-statement or suppression of material fact, policy can be called into question. The concealment of previous ailment is suppression of material facts. In this context reference may be made to the judgment of Hon’ble Supreme Court in case titled Satwant Kaur Sandhu Versus New India Assurance company IV (2009) CPJ 8 (SC).

9.                The facts of the present case are to be analyzed keeping in view the aforesaid proposition of law. Thus, the material question which arises for consideration is whether the wife of the complainant was suffering from Rheumatic Heart Disease at the time of submission of the proposal form for obtaining the policy and the complainant and his wife knew about the said disease at the time of obtaining the policy. The main plank of the opposite party is the discharge summary of the wife of the complainant issued by PGIMER, Chanidgarh Ex.O5. As per the said document, she was diagnosed Post BMV (for RHD) severe MR with mod TR with normal LVEF. In the clinical summary it was mentioned that a known case of RHD severe MS symptomatic since 5 years. It is important to point out that the opposite party has not been able to produce any treatment record of the wife of the complainant prior to her admission on 23.4.2012 in PGIMER, Chandigarh. Had she been suffering from Rheumatic Heart Disease for the last five years, she must have got treatment for the same from some hospital, but there is no hospital record regarding her treatment for the said disease or any other disease. No person of ordinary prudence having knowledge that he/she is suffering from Rheumatic Heart Disease would ignore the disease for a long period of five years. Every person in order to save his/her life would try to get treatment at the earliest possible. There may be symptoms of Rheumatic Heart Disease, but the complainant and his wife may not been knowing that she was suffering from Rheumatic Heart Disease. The period of five years mentioned by the doctor in the clinical summary may be just by approximation and not exact it could be one year or two years also because the doctor had neither conducted any clinical test or nor made definite observation that the wife of the complainant had been suffering from RHD for the last five years. Under such circumstances, even if it is accepted that the wife of the complainant was having Rheumatic Heart Disease at the time of obtaining the policy, then also there is nothing on the record to establish that the complainant and his wife knew about the said disease at the time of obtaining the policy. Therefore, it cannot be said by any stretch of imagination that the complainant concealed the material fact regarding disease of his wife in the proposal form filled up by him for obtaining the policy.  Consequently, the repudiation of the claim of the complainant by the opposite party cannot be termed as justified or legal in any manner and such repudiation amounted to deficiency in service on the part of the opposite party.

10.              The wife of the complainant remained admitted in PGIMER, Chandigarh from 23.4.2012 to 3.5.2012. The complainant has produced the copies of bills Ex.C1 to C6 regarding purchase of medicines during the period while his wife remained admitted in the said hospital. The total amount to these bills comes to Rs.1,20,343/-. Therefore, complainant is entitled to get amount of Rs.1,20,343/- as compensation  as per terms and condition of the policy.      

11.              As a sequel to the foregoing discussion, we accept the present complaint and direct the opposite party to pay Rs. 1,20,343/- to the complainant alongwith interest @ 9% per annum from the date of filing the complaint till its realization. We further direct the opposite party to pay Rs.5500/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 13.06.2016

                                                                                      (K.C.Sharma)

                                                                                         President,

                                                                             District Consumer Disputes

                                                                             Redressal Forum, Karnal.

                             (Anil Sharma)

                               Member