BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 286 of 2017
Date of Institution : 3.11.2017
Date of Decision : 28.3.2018.
Rajan Luthra C/o M/s Saajan Cake Palace, Near Lal Kothi, Barnala Road, Sirsa, District Sirsa (Haryana).
……Complainant.
Versus.
- Star Health and Allied Insurance Company Ltd., Branch Office: Ground Floor, Opp. Shakti Motors, Near IDBI Bank, Sirsa, Tehsil and District Sirsa, through its Branch Manager.
- Star Health and Allied Insurance Company Ltd., Regd. office : 1, New Tank Street, Valluyer Kottam High Road, Nungambakkam, Chennai- 600 034, through its authorized signatory.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SH. MOHINDER PAUL RATHEE …… MEMBER.
Present: Sh. JBL Garg, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
The case of the complainant in brief is that complainant purchased a family health optima insurance plan from the opposite parties vide policy no.P/211121/01/2017/000156 for the period w.e.f. 25.5.2016 to 24.5.2017 and got insured himself, his wife Smt. Shalu Luthra, his son Ayush and daughter Mahi Luthra for the Basic Floater Sum insured of Rs.5,00,000/- and paid a sum of Rs.11,828/- as insurance premium for the same. That son of the complainant insured namely Ayush suffered a knee injury and he underwent a surgical operation in December, 2016 and the complainant incurred about Rs.70,000/- on his operation, including fee of doctors, transportation charges, cost of medicines etc. An intimation to this effect was given by complainant to the ops. It is further averred that the complainant lodged his claim with the ops and supplied all the required documents and information and also observed all the required formalities and also fully cooperated for settlement of the claim. The ops also raised a query regarding said accident and complainant duly replied the same vide his reply dated 20.12.2016, wherein he categorically stated that on 6.6.2016, the complainant alongwith his son Ayush were travelling on bike within the city and suddenly an animal came acress the road and bike got totally imbalanced and the complainant and his son both fell on the road and son of complainant suffered injuries. But however, the ops now have repudiated the claim of complainant on the ground that it is a pre-existing injury and that the present admission and treatment of the insured is for pre-existing injury. That the complainant was shocked to know the repudiation of his claim due to above imaginary reason developed by the ops because son of complainant had no pre-existing injury, rather the same was suffered by son of complainant after the purchase of the above policy. It appears that the ops find false excuse to repudiate the claim of complainant and thereby to wriggle out of their liability to indemnify the complainant. That the complainant approached the ops and requested them on several occasions to make payment of the claim amount alongwith interest thereon and also compensation for causing unnecessary harassment but they did not pay any heed to the same. Ultimately, complainant got served a legal notice upon ops on 13.5.2017, which was duly received by the ops. The ops replied the said notice vide their reply dated 9.6.2017, wherein they gave totally false and baseless reply and refused to admit the claim of complainant. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement taking certain preliminary objections. It is submitted that the complainant has reported the claim in the 5th month of the policy and claimed an amount of Rs.36750/-. The insured patient Mr. Ayush was hospitalized at Safdar Jung Hospital on 15.10.2016 for the treatment of ACL TEAR and submitted claim records for reimbursement of medical expenses. On scrutiny of the claim records, it is observed that the OPD registration card dated 15.10.2016 states that the insured was presented with the complaints of pain and instability right knee and history of fall from bike eight months. The consultation report of Dr. V.B. Bhasin dated 4.10.2016 states that the insured had history of fall from bike six months. MRI report dated 13.10.2016 shows discoid lateral meniscus with intrameniscal myxoid degeneration. From the said findings, it is observed that the discoid lateral meniscus with intrameniscal myxoid degenerations revealed long standing disease and the present admission and treatment of the insured patient is primarily for the pre-existing injury. 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, since inception of the policy. Hence, the claim was repudiated and same was communicated to the insured vide letter dated 11.1.2017. It is further submitted that claim made by the petitioner was repudiated by the ops for reason of suppression of material facts and misrepresentation by the complainant in the proposal form. It is further submitted that complainant has no locus standi to claim any alleged sum assured, as the insurance policy was obtained by the insurer by misrepresenting the material facts in order to defraud the ops and as such the contract of insurance is void and not tenable in the eyes of law as is entered by insured to defraud the ops. It is also submitted that as per the contract of insurance, the expenses towards transportation charges are not covered and only hospitalization expenses are covered subject to the terms and conditions of the policy. It is further submitted that the complainant narrated a false story to justify his illegal claim and that answering ops are acting as per the terms and conditions of the policy. Remaining contents of complaint are also denied.
3. The complainant produced his affidavit Ex.C1, copy of insurance plan Ex.C2, copies of treatment record Ex.C3 to Ex.C25, copy of application Ex.C26, copy of letter dated 27.12.2016 Ex.C27, copy of repudiation letter dated 9.6.2017 Ex.C28, copy of legal notice Ex.C29 and postal receipts Ex.C30 and Ex.C31. On the other hand, ops produced affidavit of Sh. N.Gopalan, Chief Manager Ex.R1 and copies of documents Ex.R2 to Ex.R13.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. It is undisputed fact between the parties that complainant purchased a family health optima insurance plan from the opposite parties vide policy No.P/211121/01/2017/000156 for the period w.e.f. 25.5.2016 to 24.5.2017 and got insured himself, his wife Smt. Shalu Luthra, his son Ayush and daughter Mahi Luthra for the Basic Floater sum insured of Rs.5,00,000/- and paid a sum of Rs.11,828/- as premium for the same. As per averments of the complainant, the son of complainant received a knee injury on 6.6.2016 when he alongwith his son was travelling on bike and suddenly an animal came across the road and bike got totally imbalanced and the complainant and his son both fell on the road. It is further averred that his son Ayush underwent a surgical operation in December, 2016 and the complainant incurred about Rs.70,000/- on his operation including fee of doctors, transportation charges and costs of medicines etc. The claim was lodged with the opposite parties but ops have wrongly and illegally repudiated the claim of the complainant on the ground that it s a pre-existing injury. In order to justify the repudiation of the claim of complainant that the injury on the person of Ayush son of complainant was a pre-existing injury, the opposite parties have placed on record copy of prescription slip of Dr. V.B. Bhasin, Consultant Orthopaedic & Arthroscopic Surgeon, Sir Ganga Ram Hospital, New Delhi dated 4.10.2016 of Ayush wherein it is mentioned that fall from Bike six months meaning thereby that son of complainant received injury in the month of April, 2016. Further, the ops have produced on file copy of prescription slip of Safdarjung Hospital, New Delhi dated 15.10.2016 Ex.R12 of Ayush wherein it is mentioned that fall from bike eight months. In these circumstances, the opposite parties have proved on record that injury on the person of Ayush son of complainant was pre-existing prior to the purchase of policy which was purchased on 25.5.2016 and therefore, the opposite parties have rightly repudiated the claim of the complainant on the ground of pre-existing injury/disease as per terms and conditions of the policy.
6. In view of the above, we find no merit in the present complaint and same is hereby dismissed but with no order as to costs. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:28.03.2018. Member District Consumer Disputes
Redressal Forum, Sirsa.
