Haryana

Karnal

CC/344/2017

Krishan Kumar - Complainant(s)

Versus

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

Narinder Kumar Zak

14 Jan 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 344 of 2017

                                                          Date of instt. 13.10.2017

                                                          Date of Decision 14.01.2019

 

Krishan Kumar son of Shri Duli Chand, resident of village Kurlan, District Karnal.

 

                                                                      …….Complainant

                                        Versus

 

Star Health and Allied Insurance Company Ltd., through its Branch Manager, SCO no.242, Sector-12, opposite Mini Secretariat, Karnal.

                                                                                                                                                          …..Opposite Party.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

                Dr. Rekha Chaudhary…….Member

 

 Present:  Shri N.K. Zak Advocate for complainant.

                  Shri Naveen Khaterpal Advocate for OP.

 

                   (Jaswant Singh President)

 

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant had taken a Medical Term Policy bearing no.P/211114/01/2017/007374 alongwith his family members including his son namely Master Ankush, on 5.3.2015, commencing from 28.3.2017 to 27.3.2018. In the month of June, 2017 Master Ankush fell ill and admitted in Fortis Hospital, Shalimar Bagh, New Delhi and spent an amount of Rs.3,77,803/- on his treatment by the complainant but unfortunately, Master Ankush could not be recovered and died on 16.6.2017 at Fortis Hosp[ital. After the death of his son complainant being nominee/proposer lodged the death claim with the OP, who instead of releasing the amount of the policy in question, repudiated the claim of the complainant, vide letter dated 29.7.2017 on the false grounds and only made the payment of medical expenses Rs.2086/-. In this way there was deficiency in service on the part of the OP. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OP, who appeared and filed written version stating therein that complainant has concealed the true and material facts from this Forum, therefore, he is not entitled to any relief. The insured availed Family Health Optima Insurance Plan covering Mr. Krishan Kumar-Self, Sushila-Spouse, Ms. Neeru & Mr. Ankush Joon-Dependent children for the Sum Insured of Rs.5,00,000/-. The insured was admitted at Fortis Hospital on 12.6.2017 for the treatment and submitted Pre Authorization request for cashless treatment. It is further stated that the Insured h as MVR done in 2013 and the same was not disclosed in the proposal form at the time of inception of the policy. At the time of inception of the policy, the insured has concealed the true and material facts regarding the health of insured Ankush. Hence the claim of the complainant was rightly repudiated. There is no deficiency in service on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C16 and closed the evidence on 31.10.2018.

4.             OP tendered into evidence affidavit of I.N.Gopalan Chief Manager Ex.RW1/A and documents Ex.R1 to Ex.R9 and closed the evidence on 26.11.2018.

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.             The case of the complainant is that complainant had taken medical term policy alongwith his family members including his son namely Master Ankush, on 5.3.2015, commencing from 28.3.2017 to 27.3.2018 from OP. Unfortunately, in the month of June, 2017, Master Ankush fell ill and got admitted in Fortis Hospital, Shalimar Bagh, New Delhi and spent an amount of Rs.3,77,803/- on his treatment by the complainant, but unfortunately Master Ankush Joon could not be recovered and died on 16.6.2017 at Fortis Hosital, Shalimar Bagh, New Delhi. The complainant lodged death claim with OP, instead of releasing the amount of the policy in question, OP repudiated the claim of the complainant vide letter dated 29.07.2017. The OP issued a cheque of Rs.2086/- only instead of making the payment of expenses incurred during medical treatment. The counsel for the complainant relied upon the authority cited in 2018(2) CPR 664 (NC) titled as Gurbax Singh and Anr. Versus Star Health and Allied Insurance.

7.             On the other hand, the case of the OP is that the complainant has suppressed the true and material facts at the time of inception of the medical policy. The insured availed Family Health Optima Insurance Plan covering Mr. Krishan Kumar-Self, Sheela-Spouse, Miss Neeru and Mr. Ankush Joon-Dependent Children, for the sum assured of Rs.5,00,000/-. The insured was admitted at Fortis Hospital on 12.06.2017 for the treatment and submitted pre-authorization request for cashless treatment. On perusal of the documents submitted by the treating hospital, it is observed that:

        . As per Pre Authorization request form, the insured was admitted the complaints of fever, breathlessness, cough and the provisional diagnosis was bilateral pneumonitis and known case of MVR done in 2013.

        . The consultation report dated 12.06.2017 stated that insured has post MVR (Mitral Valve Replacement) in 2013.

From the findings, it is observed that the insured had MVR done in 2013  and the same was not disclosed in the proposal form at the time of the inspection of the policy. As per the condition no.8 of the policy, if there is any misrepresentation/non-disclosure of the material facts, whether by the insured person or any other acting on his behalf, the company is not liable to make any payment in respect of any claim. The medical claim of the insured was rightly repudiated.

8.             Admittedly, the complainant had purchased Family Health Optima Insurance Plan covering Mr. Krishan Kumar- Self, Sheela-Spouse, Miss Neeru and Mr. Anbkush Joon-Dependent Children, for the sum assured of Rs.5,00,000/- from OP. It is also admitted that the insured, Manager Ankush Joon was admitted in Fortis Hospital, Shalimar Bagh, New Delhi. The insured was admitted in Hospital during the subsistence of the policy and incurred an amount of Rs.3,77,803/- on the treatment, which was proved by the complainant, vide bill (Ex.C7) and detail of the paid amount in the hospital is proved by Final Bill Cum Receipt (Ex.C6). It is not a case of the OP that complainant had not spent the said amount in the hospital for the treatment of the insured. Death of the insured was also proved by Death Certificate (Ex.C9). The claim of the complainant was repudiated by then OP only on the ground that insured has post MVR in 2013 and this fact was not disclosed by the complainant at the time of inception of the policy. There is no record on the file to prove that insured died due to MVR (Mitral Valve Replacement), which was done in the year 2013. The OP has collected treatment record of Master Ankush Joon from Fortis Hospital, Shalimar Bagh, New Delhi but failed to produce the record/opinion of the concerned doctor regarding case of death to prove that insured was admitted and died due to Post MVR done in year 2013. The authority cited by the complainant is fully applicable to the present case. In view of facts and circumstances of the case, we are of the considered view that OP is deficient in service while repudiating the claim of the complainant.

9.             Thus, as a sequel to above discussion, we allow the present complaint and direct the OP to pay the amount incurred by the complainant during the treatment of the insured i.e. Rs.3,77,803/- alongwith interest @ 9% per annum from the date of repudiation of the claim of complainant. We further direct the OP to pay Rs.20,000/- 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:14.01.2019

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

               

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                               Member