Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 232.
Instituted on : 02.05.2016
Decided on : 12.07.2017.
Vijay Kumar s/o Kapoor Chand R/o 1044/4 Malgodam Road, Rohtak.
………..Complainant.
Vs.
- Chairman-cum Managing Director/CEO, Star Health & Allied Insurance Co. Ltd., Regd. & Corporate Office, 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034.
- Chief Claims Officer, Claims Dept. KRM, Center, 6th Floor, No.2, Hamington Road, Chetpet, Chennai-600031.
- The Branch Manager/Regional Manager, Star Health & allied Insurance Co. Ltd. 3rd Floor, Ashoka Plaza Rohtak-124001.
- Ms. Seema Jain, Intermediary code BA0000123659, 9466278010, Insurance Agent, Star Health & Allied Insurance Co. Ltd., 3rd Floor, Ashoka Plaza Rohtak-124001.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.JOGINDER KUMAR JAKHAR, PRESIDENT.
MS. KOMAL KHANNA, MEMBER.
SH.VED PAL, MEMBER.
Present: Smt. B.K.Chillar, Advocate for the complainant.
Sh.Gulshan Chawla, Advocate for the opposite party No.1 to 3.
Opposite party No.4 already exparte.
ORDER
SH. JOGINDER KUMAR JAKHAR, PRESIDENT :
1. The present complaint has been filed by the complainant is consumer of opposite parties vide policy No.P211118/01/2016/001003, product name Family Health Optima Insurance Plan. It is averred that on 15.11.2015 the complainant on feeling uneasy, contacted Dr. Sushil Jain for consultation and got admitted in the hospital and underwent medical tests and medical treatment and sent Rs.40000/-. It is averred that the complainant well informed the opposite parties about his admission in the hospital and filed the claim well in time as per procedure. It is averred that the opposite parties did not respond to the claim of the complainant despite his repeated requests and had repudiated the claim by giving unsatisfactory and improper reasons. It is averred that the act of opposite parties of not paying the genuine claim under the above said policy is illegal and amounts to deficiency in service. As such it is prayed that opposite parties may kindly be directed to reimburse the amount spent on treatment along with interest, compensation and litigation expenses.
2. On notice opposite parties appeared and filed their written reply submitting therein that the policy in question was issued only on the basis of declaration given by the complainant in the proposal form, subject to terms and conditions. It is averred that at the time of getting the vehicle insured, answering opposite party handed over the policy alongwith terms and conditions of the policy. It is averred that claim was received in the office of answering opposite party, with assertion that complainant was admitted in Chhotu Ram Hospital, Rohtak for the period of 15.11.15 to 19.11.2015 for the treatment of Upper GI Bleed with DM and submitted the claim record seeking reimbursement of medical expenses to an amount of Rs.37349/-. It is averred that on scrutiny of claim records, it is observed that as per Discharge Summary, the insured was admitted in 15.11.2015 and discharged on 19.11.2015 with diagnosis of Haematemesis with Melena with diabetes mellitus and USG report dated 22.11.2015 shows chronic liver disease with cirrhosis with spleenomegaly and Endoscopy report dated 16.11.2015 shows Grade 2 easophageal varices. It is averred that Cirrosis is a chronic condition which develops over a period of 5 to 8 years and in some cases 20 years, before presenting with complication, whereas in the present matter claim was reported 2½ months of inception of the policy and it is not possible to develop cirrosis of liver within this short span of time. Thus it is confirmed that the insured was suffering from the alleged disease prior to inception of the medical insurance policy and as such the claim was rightly repudiated vide letter dated 22.01.2016. It is averred that the opposite party further submits that without prejudice to whatever has been stated earlier in the written statement, even admitting without conceding that company is liable to pay the claim in terms of the contract of insurance, the maximum quantum of liability under the terms of the policy shall be Rs.26892/-. It is prayed the claim may kindly be dismissed with costs.
3. Both the parties led evidence in support of their case.
4. Ld. Counsel for the complainant in her evidence has tendered affidavits Ex.CW1/A, and documents Ex.CW2 to Ex.CW5 and has closed her evidence. On the other hand, ld. Counsel for the opposite party has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R7 and closed his evidence.
5. We have heard ld. counsel for the parties and have gone through the material aspects of the case carefully.
6. In the present case it is not disputed that as per policy schedule Ex.CW2, complainant was insured with the opposite parties for the period 31.08.2015 to 30.08.2016. It is also not disputed that as per document Ex.CW5, complainant was admitted in Chhotu Ram Hopsital and had spent an amount of Rs.37349/- on his treatment. The complainant lodged the claim with the opposite party but the same was repudiated vide letter Ex.CW4 by the opposite party on the ground that: “The insured patient is symptomatic of decompensate chronic liver disease prior to inception of the medical insurance policy and at the time of inspection of policy, the complainant had not disclosed the above mentioned health details in the proposal form which amounts to misrepresentation/non disclosure of material facts.
7. After going through the file and hearing the parties it is observed that the claim of the complainant has been repudiated by the opposite party on the ground of concealment of pre-existing disease. But no document e.g. previous record of treatment of insured from any hospital or doctor prior to taking the policy has been placed on record by the opposite party. Simply a report Ex.R5 has been placed on record which is not supported with affidavit of doctor. In this regard reliance has been placed upon the law cited in 2013(3)CLT 186 titled as Kotak Mahindra Old Mutual Life Insurance Ltd. Vs. Chander Isarsingh Dhansinghani & anr. whereby Hon’ble Gujarat State Commission, Ahemdabad has held that: “Doctor certificate without any affidavit of the doctor in support cannot be basis for repudiation of claim”, as per II(2013)CPJ 60 titled Life Insurance Corporation of India & Anr. vs. Raj Kumar Sharma it is held that: “Neither inquiry officer was examined nor his affidavit had been tendered into evidence by appellant to prove that LA was suffering from peptic ulcer at the time of filling the proposal form-Evidence of inquiry officer was withheld for unknown reasons-In repudiation letter no name and identity of person is disclosed from whom ‘LA’ had taken treatment and no proof to this effect was produced-Appellant had failed to prove that LA suffering with peptic ulcer and she had deliberately made wrong report/answer to agent at the time of filling proposal form-Repudiation not justified” as per 2011(1)CPC titled Life Insurance Corporation of India Vs. Rupinder Kaur Hon’ble National Commission has held that: “OP failed to prove by evidence that insured was suffering from blood pressure which could be checked by the doctor of OP at the time of proposal-There is no illegality in the order passed by the District Forum in allowing the complaint and upholding the same by State Commission”.
8. After going through the file, hearing the parties and above referred case law which are fully applicable on the facts and circumstances of the case, it is observed that the repudiation of claim by the opposite parties is illegal and unjustified and the complainant is entitled for the expenses incurred by him on his treatment as per terms and conditions of the policy. As per bills Ex.CW5, complainant had spent an amount of Rs.37349/- on his treatment. As such the complainant is entitled for the alleged amount.
9. In view of the facts and circumstances of the case, it is directed that opposite party No.1 to3 shall pay the amount of Rs.37349/-(Rupees thirty seven thousand three hundred forty nine only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 02.05.2016 till its actual realization and shall also pay an amount of Rs.3500/-(Rupees three thousand five hundred only) as litigation expenses to the complainant maximum within one month from the date of decision failing which opposite parties shall be liable to pay interest @ 12% p.a. on the awarded amount from the date of decision. Complaint is allowed accordingly.
10. 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:
12.07.2017.
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Joginder Kumar Jakhar, President
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Komal Khanna, Member.
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Ved Pal, Member.
