Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 311
Instituted on : 13.07.2018
Decided on : 31.10.2023
RachnaGargsince deceased represented through her Lrs.
- Deepak Garg son of Sh. SudarshanGarg
- Samridhi minor daughter of Deepak Garg
- Sayam minor son of Deepak Garg, both minor through their father Deepak Garg as their natural guardian, rs/o A-391/33 Vaish College Road, NayaParav, Rohtak.
………..Complainants.
Vs.
- Star Health and Allied Insurance Company Limited(Family Health Optima Insurance Plan), R/o 8th Floor, Plan Court, MaharanaPartap Circle, Gurgaon-122001, through its Branch Manager.
- Star Health and Allied Insurance Company Limited Regd. And Corporate Office:1, New Tank Street, ValluvarKottam, High Road, Nungambakkam, Chennai-600034, through its Authorized Signatory/General Manager.
- Star Health and Allied Insurance Company Ltd. Through its Branch Office IInd Floor, Ashoka Plaza Rohtak.
…….Opposite parties
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR.VIJENDER SINGH, MEMBER.
Present: Sh.S.B.Vashisht, Advocate for the complainant.
Sh.Gulshan Chawla, Advocate for opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case, as per the complainant(since deceased)are thaton 22.03.2017, husband of the complainant took an insurance policy vide policy no.P/161117/01/2017/012470, Family Health Optima Insurance plan from opposite parties in which risk covered upto Rs.5,00,000/-, which is applicable for 2 Adults +2 children and valid from 22.03.2017 to midnight 21.03.2018. On 21.12.2017, the complainant fell ill and admitted in BLK Super SpecialityHospital, New Delhi. She remained admitted upto 26.12.2017 and she spent an amount of Rs.2,79,893/-. It is further submitted that after discharge from the hospital, she claimed the above said amount from opposite parties and tried her best to fulfill all the requirements of the opposite parties but they did not pay any heed towards the genuine requests of the complainant. The act of the opposite parties is wrong & illegal and there is deficiency in service on the part of opposite parties. Hence this complaint and it is prayed that opposite parties may kindly be directed topaya sum of Rs.2,79,893/- on account of expenses on the treatment of complainant and further Rs.1,00,000/- as harassment and litigation expenses to the complainant.
2. After registration of complaint, notice was issued to the opposite parties. Opposite parties appeared and filed their replysubmitting therein that the policy in question was issued only on the basis of declaration given by the complainant in the proposal form and subject to terms and conditions of the policy. It is submitted that claim form request was received in the office of the answering opposite party for reimbursement of claim amount of Rs.2,63,969/- wherein the complainant has alleged to have been admitted in BLK Super Specialty Hospital New Delhi for the period 16.12.2017 to 21.12.2017. The claim of the complainant was evaluated in the light of policy and terms and condition and the claim of the complainant was rightly repudiated vide letter dated 05.02.2018, as MRI brain report dated 21.02.2017 shows large 20 mm(AP) *22mm(h) sized lobulated well defined homogenous sol in sellar supra sellar regions with extensions and mass effect and this factum can also can be corroborated with the report of MRI of the patient dated 16.12.2017 issued by Sukhija MRI Rohtak, which shows longstanding changes that takes more than a year to develop, Hence the claim of the complainant was rightly repudiated vide letter dated 05.02.2018.As per contract of insurance, the medical history/health details of the person(s) proposed for insurance are to be disclosed in the proposal form at the time of the inception of the policy. Since the insured have not disclosed the pre-existing disease in the proposal form at the time of the inception of the policy, it is now incorporated in the policy as pre existing disease/condition by passing endorsement.As per Exclusion No.1 of the policy, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/condition, until 48 months of continuous coverage has elapsed. In the present matter policy was issued on 22.03.2017 and complainant is demanding treatment for the period 16.12.2017 to 02.12.2017. Hence the claim was rightly declined. All the other contents of the complaint were stated to be wrong and denied and opposite partiesprayed for dismissal of complaint with cost.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1 documents Ex.C1 to Ex.C23 and closed his evidence on dated 17.05.2019.Ld. counsel for the opposite parties has tendered affidavit Ex.RW1/Aand documents Ex. R-1 to Ex. R-13in his evidence and closedhis evidence on dated 05.11.2019.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case claim of the complainant has been repudiated by the opposite parties on the ground that as per Exclusion No.1 of the policy, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/condition, until 48 months of continuous coverage has elapsed. In the present matter policy was issued on 22.03.2017 and complainant is demanding expenditure of treatment for the period 16.12.2017 to 02.12.2017. We have minutely perused the documents placed on record by both the parties. As per Ex.R11, patient RachnaGarg(since deceased) was admitted in the hospital on 16.12.2017 and was discharged on 21.12.2017. At the time of admission the history of patient is mentioned as under”: “The patient was apparently well 10 days back when she started complaining of headache which was sudden in onset and progressive in nature. It is associated with vertigo. Then she went to doctor on 15.12.2017 and got MRI Brain was done which was s/o large sized lobulated SOL in supraseller region. Now she has been brought up here for further evaluation and management”. Meaning thereby the complainant has not pre existing disease at the time of inception of the policy and he was not aware about her illness. So it cannot be presumed thatthe insured has not disclosed the pre-existing disease in the proposal form at the time of the inception of the policy. No evidence of pre existing disease has been placed on record by the opposite parties.. Merely an opinion has been made by the doctor of the opposite parties that the disease takes more than a year to develop. The same cannot be appeared just within few days and it takes long time but the complainant should aware about the same. As the same was not within the knowledge of the complainant(since deceased) so there is no false declaration on the part of complainant. The complainant was not suffering from any other disease. As per our opinion these ailments are occurred sudden. Hence the repudiation of claim on this ground is illegal and amounts to deficiency in service. As such opposite parties are liable to pay the claim amount to the complainant. As per the calculation sheet placed on record by the opposite parties as Ex.R13, the total payable amount is Rs.236828/-. In the present complaint the complainant has demanded an amount of Rs.279893/- but he is entitled for Rs.236838/- as per the calculation made by the opposite parties vide document Ex.R13.
6 In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite parties to pay the amount of Rs.236838/-(Rupees two lac thirty six thousand eight hundred and thirty eight only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 13.07.2018 till its realization and shall also pay a sum of Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) to the LRs of deceased namely Sh. Deepak Garg husband, Ms. Samridhi daughter and Mr.Sayam son of deceased RachnaGarg in equal share.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
31.10.2023
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Nagender Singh Kadian, President
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TriptiPannu, Member.
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Vijender Singh, Member.
