Haryana

Karnal

CC/198/2020

Raj Kumar - Complainant(s)

Versus

Star Health And Allies Insurance Company Limited - Opp.Party(s)

Akshat Sharma

27 Oct 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                      Complaint No. 198 of 2020

                                                      Date of instt.04.06.2020

                                                      Date of Decision:27.10.2023

 

Raj Kumar son of Shri Jagdish Chand, resident of 16/2068, Gali no.1 Khera Colony, Karnal, age 47 years (Aadhar card no.5663 6594 1718). Mobile no.7206659125.

                                               …….Complainant.

                                              Versus

 

Star Health and Allied Insurance Company Limited. Branch Office, 2^nd floor, SCF 137 Sector-13, Urban Estate, near ICICI Bank, Karnal-132 001. (Haryana)

…..Opposite Party.

       

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.

              Shri Vineet Kaushik……Member

              Dr. Rekha Chaudhary…..Member

                   

Argued by: Shri Akshat Sharma, counsel for the complainant.

                   Shri Mohit Goyal, counsel for the opposite party.

 

                    (Dr. Rekha Chaudhary, Member)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant had purchased a health insurance policy from the OP, bearing no.P/211114/01/2020/003988, which was valid from 22.07.2019 to 21.07.2020. The said policy is cashless policy. In the said policy the complainant himself, his spouse Reeta Rani and dependent children Deepak Gupta and Dhruv Gupta are covered. Suddenly, the son of complainant Dhruv Gupta was fallen from the roof and then he was admitted to Virk Hospital Pvt. Ltd., Karnal. Son of complainant remained admitted in the said hospital from 06.02.2020 to 09.02.2020. Complainant had paid Rs.26805/- on the treatment of his son. Thereafter, complainant lodged a claim with the OP for reimbursement of the said amount and submitted all the required documents but OP did not settle the claim despite repeated visits and requests. Ultimately, OP repudiated the claim of complainant, vide letter dated 09.03.2020 on the ground that non-disclosure of pre-existing disease. In fact prior to this son of complainant was not suffering from any disease and in this regard Doctor/Director of Virk hospital Pvt. Ltd. has given certificate/letter and same has been submitted before the OP. After that complainant visited the office of OP several times and requested to pay the claim but OP did not pay any heed to the request of complainant and lingered the matter on one pretext or the other and lastly refused to release the claim against the said policy. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence this complaint.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that on receipt of claim of Rs.26,805/- regarding hospitalization of insured patient Dhruv Gupta at Virk Hospital, Karnal with undergone for the treatment of FFH With Spinal Inry with STI Ankle Joint, OPs proceed the claim records and observed that :

1. The injured patient was hospitalized for the treatment of fall from height with spine injury with soft tissue injury right ankle joint. Although the present admission and treatment of the insured patient is for fall from height with spine injury with soft tissue injury right ankle joint, it is observed from following documents:-

1. As per discharge summary dated 06.02.2020, the insured has a history of seizure disorder on regular treatment.
2. As per ICP dated 06.02.2020, the insured has a past history of complaint of seizure’s disorder.
3. As per the consultation slip dated 13.02.2020, the insured has a past history of complaint of seizure’s disorder.
4. The letter dated 24.02.2020 of the above hospital submitted in response to our query the insured patient had history of seizures since birth. The above facts confirm that the insured patient has seizure prior to the date of commencement of first year policy. At the time of inception of first year policy which is from 22.07.2019 to 21.07.2020, the insured has not disclosed the above mentioned medical history/health details of the insured person in the proposal form which amounts to misrepresentation/non-disclosure of material facts. As per policy condition no.6, if there is any misrepresentation/non-disclosure of material fact was conducted by complainant/insured thus his claim is not payable.

Hence the claim of the complainant was repudiated and it was communicated to the insured, vide letter dated 10.03.2020. It is further pleaded that insurance is based on utmost good faith, as per the contract of insurance, the insured is expected to declare in the proposal form about the details of his ailments/sickness-past medical history and the reply for the same helps the insurer to evaluates the material facts and decides, whether to accept the proposal or not. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Complainant has tendered into evidence his affidavit Ex.CW1/A, copy of policy cover note Ex.C1, copy of Admission form of Virk Hospital, Karnal Ex.C2, copy of discharge summary Ex.C3, copy of certificate issued by Dr. Ashwani Kumar Ex.C3/A, copies of medical bills Ex.C4 to Ex.C13, copy of certificate issued by Dr. Ashwani Kumar Ex.C14, copy of letter dated 09.03.2020 regarding cancellation of the policy in question Ex.C15, copy of aadhar card Ex.C16, copy of aadhar card of Dhruv Gupta Ex.C17 and closed the evidence on 16.06.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Sumit Kumar Sharma Ex.OPW1/A, copy of insurance policy Ex.OP1, copy of terms and conditions of the policy Ex.OP2, copy of proposal form Ex.OP3, copy of Field Visit Report Ex.OP4, copy of claim from Ex.OP5, copy of discharge summary Ex.OP6, copy of patient profile Ex.OP7, copy of consultation slip Ex.OP8, copy of certificate dated 24.02.2020 issued by Dr. Ashwani Kumar Ex.OP9, copy of medical bill Ex.OP10, copy of repudiation letter dated 10.03.2020 Ex.OP11, copy of bill assessment sheet Ex.OP12, copy of IRDA guidelines Ex.OP13 and closed the evidence on 13.07.2023 by suffering separate statement.

 6.            We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that complainant purchased a health insurance policy from the OP. In the said policy the complainant himself, his spouse and dependent children are covered. The son of complainant Dhruv Gupta was fallen from the roof and then he was admitted to Virk Hospital Pvt. Ltd. Karnal and he remained admitted in the said hospital from 06.02.2020 to 09.02.2020. Complainant has spent Rs.26805/- on the treatment of his son. Complainant lodged a claim with the OP for reimbursement of the said amount and submitted all the required documents but OP did not settle the claim and repudiated the claim of complainant, vide letter dated 09.03.2020 on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that on receipt of claim intimation regarding hospitalization of insured patient Dhruv Gupta at Virk Hospital, Karnal. OP proceed the claim records and observed that the insured has a history of seizure disorder since birth and has taken the regular treatment. At the time of inception of the policy, the insured has not disclosed the above medical history, which amounts to misrepresentation/non-disclosure of material facts, thus the claim of the complainant was rightly repudiated by the OP, vide letter dated 10.03.2020 and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, the complainant purchased a mediclaim policy namely ”Family Health Optima Insurance Plan”, from the OP. It is also admitted that during the subsistence of the insurance policy, son of complainant has taken the treatment from Virk Hospital, Pvt. Ltd. Karnal.

11.           The claim of the complainant has been repudiated the by the OP, vide repudiation letter Ex.OP11 dated 10.03.2020 on the ground, which is reproduced as under:-

“we have processed the claim records relating to the above insured patient seeking reimbursement of hospitalization expenses for treatment of fall from height with spine injury with soft tissue injury right ankle joint.

Although the present admission and treatment of the insured patient is for fall from height with spine injury with soft tissue injury right ankle joint, it is observed from the letter dated 24.02.2020 of the above hospital submitted in response to our query that the insured patient has seizure prior to date of commencement of first year policy.

At the time of inception of your first year policy which is from 22.07.2019 to 21.07.2020, you have not disclosed the above mentioned medical history/health details of the insured person in the proposal form which amounts to misrepresentation/non-disclosure of material facts.

As per condition no.6 of the policy issued to you, if there is any misrepresentation/non disclosure of material facts whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim.

We are, therefore, unable to settle your claim under the above policy and we hereby repudiate your claim.

As per condition no.12, the policy is also liable to be cancelled and necessary action will be taken by our Corporate office”.

 

12.           The claim of the complainant has been repudiated by the OP on the ground of concealment of material facts with regard to the health of his son.

13.           The claim of the complainant has been repudiated by the OPs on the basis of discharge summary Ex.OP6, copy of patient profile Ex.OP7 and copy of consultation slip Ex.OP8. Both the parties have relied upon the certificate issued by Dr. Ashwani Kumar Ex.C3/A and Ex.OP9. In the said certificate, it has been specifically mentioned that “As per file record patient had HO Seizure since birth. As per attendants he had few episode of seizure in first year of birth and since then he is having no seizure and not on any treatment. In discharge summary, it is written that he is an regular treatment for seizure, which is a clerical mistake as patient was not given any antiseptic during hospitalization and on discharge. Also as per patient he had seizure since birth and only in the first year of birth. No previous documents available. No previous MRI/ECG available. No previous admission for seizure”.

14.           Hence, it has been proved from the said certificate that the insured patient was having seizure only on the first year of the birth. Thereafter, he has not having any treatment for seizure. Hence, plea taken by the OP has no force.

15.  

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

 

16.           Keeping in view the ratio of the law laid down in the abovesaid judgment, facts and circumstances of the complaint, we are of the considered view that act of the OP amounts to deficiency in service and unfair trade practice, while repudiating the claim of complainant, which is otherwise proved as genuine one. 

17.           The complainant has spent Rs.26,805/- on the treatment of his son and in this regard he has placed on record medical bills Ex.C4 to Ex.C13. The said bills have not been denied by the OP. Hence the complainant is entitled for the said amount alongwith interest, compensation for harassment, mental pain and agony and litigation expenses etc.

18.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.26,805/- (Rs.twenty six thousand eight hundred five only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of claim i.e.10.03.2020 till its realization. We further direct the OP to pay Rs.10,000/- to the complainant on account of mental agony and harassment and  Rs.5500/- towards the litigation expenses. This order shall be complied with within 45 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.

Dated:27.10.2023

                                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 (Vineet Kaushik)       (Dr. Rekha Chaudhary)

                    Member                         Member