Jharkhand

Bokaro

CC/30/2022

Santosh Singh - Complainant(s)

Versus

Star Health And Allied Insurnace Co. Ltd. - Opp.Party(s)

Sanjay Kapoor

06 Sep 2023

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-03-03-2022

Date of final hearing-06-09-2023

 Date of Order-06-09-2023

Case No. 30/2022

Santosh Singh Late Malkeet Singh

R/o Sector-12/C, Qr.no. 1158, Bokaro Steel City, Bokaro

                                      Vrs.

1. Star Health and Allied Insurance Co. Limited

Through its Area Territory Manager

211 & 212 2^nd Floor, Shanti Bhawan Bank more,

Dhanbad 826001

2. The Zonal  Manager/Head,

Star Health & Allied Insurance Co. Ltd.,

4th Floor shop No. 404, Modi Heights, Opp. Air Station,

Ratu Road, Ranchi-834004

Present:-

                             Shri Jai Prakash Narayan Pandey, President

Shri Bhawani Prasad Lal Das, Sr.Member

                  Smt. Baby Kumari, Member

PER- J.P.N Pandey, President

-:Order:-

1. Complainant’s case in brief is that he purchased Family Health Optima Insurance Policy from Star Health & Allied Insurance Co. Ltd. covering him and other four family members to the tune of Rs. 5,00,000/- each which was renewed second time on 31.03.2021 vide policy No. P/231212/01/2021/010794 valid from 31.03.2021 to 30.03.2022 and paid premium of Rs. 26,302/-. Further case is that due to unbearable abdomen pain his daughter Amandeep Kaur, was admitted in the Muskan Hospital, Chas on 30.09.2021 for treatment but cashless claim was denied by the O.Ps. thereafter she was operated on 02.10.2021 and discharged on 09.10.2021 from the hospital for which Rs. 81,400/- was paid to the hospital towards medical expense. Further case is that later on complainant submitted his claim before the O.Ps. and submitted all demanded papers but his claim was repudiated on the ground of exclusion of pre existing disease. In this way there is deficiency in service by the O.Ps. Hence this case has been filed with prayer to direct the O.Ps. to pay Rs. 81,400/- as medical expense with interest @ 10% per annum and also to pay Rs. 1,00,000/- as compensation and Rs. 15,000/- as litigation cost.
2. O.Ps. have filed W.S mentioning therein that all complications directly or indirectly related to the surgeries or procedures performed previously which have already been written in the policy paper are excluded for 48 months from the date of inception of the policy. Fact related to issuance of insurance policy and its renewal are admitted facts. Further reply is that the insurance under this policy is subject to condition, clauses, warranty, exclusions etc. Further reply is that the insured Amandeep Kaur was hospitalized on 30.09.2021 at Muskan  Hospital, Chas and discharged on 09.10.2021. Further reply is that on scrutiny of the claim the medical team of the O.Ps. perused the papers and was of the opinion that the patient was having those disease prior to inception of medical insurance policy, hence it was pre-existing disease, therefore, as per terms and conditions of the policy it is not admissible during first or second  year of the policy. Further reply is that the O.P. has rightly repudiated the claim which was communicated to the complainant hence complainant has suppressed the real facts regarding the health and has filed this case to get illegal compensation, hence it is prayed to dismiss the case.
3. Point for determination is whether complainant is entitled to get relief as claimed?
4. Inception of insurance policy on 28.05.2018 to 27.05.2019 and its renewal from 11.09.20219 to 10.09.2020 and thereafter renewal for the period from 31.03.2021 to 30.03.2022 is not in dispute, coverage of insurance policy in respect to Amandeep Kaur is also not in dispute. The fact related to treatment of the insured, expense incurred in treatment as well as filing of the claim before the O.Ps. are also not in dispute.
5.  Only dispute is whether the operation of Intestinal obstruction comes within purview of exclusion of the policy ?
6. The photo copy of the policy paper has been filed by the complainant which is Annexure-1. According to this document in respect to Amandeep Kaur in the column related to details of insured persons at serial  No. 3 name of Amandeep Kaur has been mentioned and in respect to her there is exclusion of all complications directly or indirectly related to the surgeries or procedures performed previously and those problems have been brought under the category of  Pre Existing Disease.
7. On perusal of the discharge summary of the patient it shows that she was diagnosed for Acute Intestinal Obstruction for which operation was done. On perusal of para 13 of the complaint petition it appears that complainant has admitted the fact that his daughter Amandeep Kaur was treated at Sir Ganga Ram Hospital, New Delhi and treatment cost of Sir Ganga Ram Hospital has also not been paid to the complainant by the O.Ps. But it appears that all details related to treatment at Sir Ganga Ram, New Delhi have not been disclosed, rather those details have been purposely concealed by the complainant, in this way complainant has not come before this Commission with clean hands. At this place we would like to mention here that in respect to treatment at Sir Ganga Ram Hospital, New Delhi complainant has filed C.C. No. 147/2019 with prayer for direction to O.Ps. to pay expense etc. As per repudiation letter dt. 07.01.2022 (Annexure-5) the patient has undergone treatment for the said diseases which is already incorporated in the insurance policy as one of the pre existing disease at the time of inception of the insurance policy, which is effective till expiry of 48 months of continues coverage after the date of inception of the first policy. It is admitted fact that earlier for the same problem treatment of the Amandeep Kaur was done at Sir Ganga Ram Hospital, New Delhi hence O.Ps. have inserted the exclusion clause in the insurance policy itself.
8. In light of above discussion we are of the view that repudiation of the claim by the O.Ps. on the ground of exclusion related to pre existing disease mentioned in the insurance policy is correct and in accordance with the insurance policy. Therefore, this point is being decided against the complainant.
9.  Hence in light of above discussion the prayer of the complainant is being rejected with cost. 

Sd/-

(J.P.N. Pandey)

                                                                                      President

 

Sd/-

(B.P.L Das)

   Sr. Member

                                                                  

                                                Sd/-

 (Baby Kumari)

                                                                                       Member