Haryana

Kaithal

215/20

Manoj Kumar - Complainant(s)

Versus

Star Health and Alloed Insurance Co. - Opp.Party(s)

Sh.P.S Walia

01 Sep 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAITHAL.

                                                     Complaint Case No.215/2020.

                                                     Date of institution: 22.07.2020.

                                                     Date of decision:01.09.2023.

Manoj Kumar S/o Sh. Ram Murti R/o 43A, Radha Nursing Home, SCF 174, HUDA Market, near Bus Stand, Pundri, Distt. Kaithal.

                                                                        …Complainant.

                        Versus

1. Star Health and Allied Insurance Co. Ltd. through its Branch Manager, 930/8, RJ Tower, 2^nd Floor, G.T.Road, Opp. IB College Panipat-132103 (Policy Issuing Office).
2. Star Health and Allied Insurance Co. Ltd., No.5, Sri Balaji Complex, Ist Floor, whites lane, Royerpettah, Cheenai-600014 through its Manager/Director.

….OPs.

        Complaint under Section 35 of the Consumer Protection Act

CORAM:     SMT. NEELAM KASHYAP, PRESIDENT.

                SMT. SUMAN RANA, MEMBER.

                SH. SUNIL MOHAN TRIKHA, MEMBER.

       

Present:     Sh. P.S.Walia, Advocate, for the complainant.   

                Sh. Naresh Sharma, Advocate for the OPs.

               

ORDER

NEELAM KASHYAP, PRESIDENT

        Manoj Kumar-Complainant has filed this complaint under Section 35 of Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the OPs.

2.             In nutshell, the facts of present case are that the complainant had purchased the accident and health insurance policy bearing No.P/211124/01/2020/004316 from the OPs for the sum assured of Rs.5,00,000/- in the year 2017 and renewed the same from time to time.  It is alleged that in the above-said policy on the inspection dated 06.07.2017, no pre-existing disease was found to the complainant and his family members.    The case of complainant is that on 14.11.2019 the complainant’s wife namely Manisha Mangal suddenly having the pain in the lower part of abdomen and immediately she was admitted to Guru Nanak Multi Specialty Hospital & Trauma Centre at Pundri and after got conducting the ultrasound, the doctor found large complex cyst in pelvis likely left ovarian in origin and suggested for operation.  On the next day i.e. 15.11.2019, the complainant had admitted his wife at Dev Nursing Home at Kaithal and was operated and after that for further treatment, she was admitted to hospital till date 29.11.2019.  During the treatment period from 15.11.2019 to 29.11.2019 i.e. 15 days treatment, the complainant spend the amount of Rs.85,000/- on the treatment of his wife.  The complainant lodged the claim with the OPs and submitted all the necessary documents but the OPs repudiated the claim of complainant vide letter dt. 20.02.2020.  The said repudiation of claim is stated to be wrong and illegal.  So, it is a clear cut case of deficiency in service on the part of OPs and prayed for acceptance of complaint.     

3.            Upon notice, the OPs appeared before this Commission and contested the complaint by filing their written version raising preliminary objections with regard to locus-standi; maintainability; cause of action; that this Commission has no jurisdiction to entertain the present complaint as the policy in question was issued by the Branch Office of the answering OP situated at Panipat; that the answering OPs have no branch office at Pundri or at Kaithal; that the complainant has concealed the true and material facts from this Commission; the true facts are that the complainant had purchased the policy in question for the sum assured of Rs.5,00,000/-; that the complainant submitted claim documents of medical expenses for treatment of left overian cyst adherent to large intestine at Dev Nursing Home, Kaithal from 15.11.2019 to 29.11.2019.  On scrutiny of claim documents for reimbursement, it was observed that the insured patient has a history of total hysterectomy done 3 years back.  Based upon the above finding, the complainant was called for the necessary documents vide letters dt. 11.01.2020 and reminder dt. 26.01.2020 but the complainant did not submit all the required documents.  Hence, the claim was rightly repudiated vide letter dt. 20.02.2020 and was communicated to the complainant accordingly.  There is no deficiency in service on the part of OPs.  On merits, the objections raised in the preliminary objections are rebutted and so, prayed for dismissal of complaint.

4.             To prove his case, the complainant tendered into evidence affidavit Ex.CW1/A alongwith documents Annexure-C1 to Annexure-C49 and thereafter, closed the evidence.

5.             On the other hand, the OPs tendered into evidence affidavit Ex.RW1/A alongwith documents Annexure-R1 to Annexure-R13 and thereafter, closed the evidence.

6.             We have heard the learned Counsel for both the parties and perused the record carefully.

7.             Ld. counsel for the complainant has argued that the complainant had purchased the accident and health insurance policy bearing No.P/211124/01/2020/004316 from the OPs for the sum assured of Rs.5,00,000/- in the year 2017 and renewed the same from time to time.  It is further argued that in the above-said policy on the inspection dated 06.07.2017, no pre-existing disease was found to the complainant and his family members.  It is further argued that on 14.11.2019 the complainant’s wife namely Manisha Mangal suddenly having the pain in the lower part of abdomen and immediately she was admitted to Guru Nanak Multi Specialty Hospital & Trauma Centre at Pundri and after got conducting the ultrasound, the doctor found large complex cyst in pelvis likely left ovarian in origin and suggested for operation.  It is further argued that on the next day i.e. 15.11.2019, the complainant had admitted his wife at Dev Nursing Home at Kaithal and was operated and after that for further treatment, she was admitted to hospital till date 29.11.2019.  It is further argued that during the treatment period from 15.11.2019 to 29.11.2019 i.e. 15 days treatment, the complainant spend the amount of Rs.85,000/- on the treatment of his wife.  The complainant lodged the claim with the OPs and submitted all the necessary documents but the OPs repudiated the claim of complainant vide letter dt. 20.02.2020.  The said repudiation of claim is stated to be wrong and illegal.  So, it is a clear cut case of deficiency in service on the part of OPs.  Ld. counsel for the complainant has placed reliance upon the case law titled as SBI General Insurance Company Ltd. Vs. Balwinder Singh bearing appeal No.278 of 2016 decided by Hon’ble Chandigarh State Commission (U.T.), date of decision: 05.10.2016 reported in 2016(4) CLT 372 and Krapa Vidyavathi and others Vs. LIC bearing AS No.2444 of 1993, date of decision: 30.11.2011 reported in 2011(22) RCR (Civil) 88.

8.             On the other hand, ld. counsel for the OPs has argued that that this Commission has no jurisdiction to entertain the present complaint as the policy in question was issued by the Branch Office of the OPs situated at Panipat.  It is further argued that the complainant submitted claim documents of medical expenses for treatment of left ovarian cyst adherent to large intestine at Dev Nursing Home, Kaithal from 15.11.2019 to 29.11.2019.  It is further argued that on scrutiny of claim documents for reimbursement, it was observed that the insured patient has a history of total hysterectomy done 3 years back.  Based upon the above finding, the complainant was called for the necessary documents vide letters dt. 11.01.2020 and reminder dt. 26.01.2020 but the complainant did not submit all the required documents.  Hence, the claim was rightly repudiated vide letter dt. 20.02.2020 and was communicated to the complainant accordingly. 

9.             We have considered the rival contentions of both the parties.  The OPs have repudiated the claim of complainant vide letter dt. 20.02.2020 as per Annexure-R11 on the ground that the insured patient has a history of total abdominal hysterectomy done 3 years back.  The contention of ld. counsel for the OPs is that vide letters dt. 11.01.2020 and 26.01.2020 as per Annexure-R9 & Annexure-R10 respectively, the complainant was asked to provide documents i.e. 1. Past consultation papers prior to admission 2. A letter from treating doctor stating that exact duration of present illness 3. Routine investigation reports and biopsy, USG report during admission 4. As per submitted indoor case papers, history of TAH done 3 years back, hence provide that discharge summary, USG, CT abdomen report and biopsy reports but the complainant has not furnished the documents i.e. previous hospitalization record including the investigation reports relating to his wife.  So, ultimately the claim of complainant was repudiated by the OPs.  During the course of arguments, ld. counsel for the OPs has drawn our attention towards the treatment record of wife of complainant namely Manisha as per discharge summary, which is Annexure-C6/Annexure-R6, wherein it is mentioned in the column of Complete Diagnosis: Large Lt. Ovarian Cyst adherent to large Intestine.  Similarly in the Annexure-C7/Annexure-R8, large Lt. Ovarian Cyst is mentioned by treating doctor namely D.P.Gupta.  On the other hand, ld. counsel for the complainant has vehemently contended that as per Section 45 of the Insurance Act, 1938, if any person suffers from some disease but after the lapse of two years, the said disease does not exist as pre-existing disease.  To rebut the said contention, ld. counsel for the OPs has vehemently contended that the aforesaid provision applies in the case of life insurance policy and does not apply in medi-claim policy.  He has vehemently contended that in the present case, the complainant has obtained medi-claim policy and he has strongly drawn our attention towards para No.12 of the judgment titled as Satwant Kaur Sandhu Vs. NIA bearing Civil Appeal No.2776 of 2002 decided by Hon’ble Supreme Court on 10.07.2009, relevant portion of para No.12 is mentioned as under:-

                “12. There is no dispute that Section 45 of the Insurance Act, 1938, which places restrictions on the right of the insurer to call in question a life insurance policy on the ground of mis-statement after a particular period, has no applicable on facts at hand, in as much as the said provision applies only in a case of life insurance policy.  The present case relates to a medi-claim policy, which is entirely different from a life insurance policy.”               

                In the ratio of law laid down by ld. counsel for the OPs, the contention of complainant that after the lapse of two years, the disease does not exist as pre-existing disease has no force.  So, from the facts and circumstances of the case, it is established on file that the wife of complainant namely Manisha was suffering from pre-existing disease i.e. hysterectomy done 3 years back and she has concealed the true and material facts from the Ops, hence, the Ops have rightly repudiated the claim of complainant.  In this regard, we can rely upon the authority reported as Satwant Kaur Sandhu Vs. NIA 2009(4) RCR (Civil) page 692 decided by Hon’ble Supreme Court, wherein it has been held that Suppression of-“Material fact” means any fact which would influence the judgment of a prudent insurer in fixing the premium or determining whether to accept the risk or not-If the proposer has knowledge of such fact, he is obliged to disclose the same-Failure to do so entitled the insurer to repudiate his liability under the policy.  The said authority is fully applicable to the facts of instant case, whereas the authorities submitted by ld. counsel for the complainant are not distinguishable but the same are not applicable to the facts of instant case.  Hence, the complainant has failed to prove any deficiency in service on the part of Ops.          

10.            Thus, in view of above discussion, we find no merit in the present complaint and hence, same is hereby dismissed.  There is no order as to costs.  A copy of this order be sent to both the parties free of cost.  File be consigned to the record room after due compliance.     

Announced in open court:

Dt.:01.09.2023.

                                                                (Neelam Kashyap)

                                                                President.

 

(Sunil Mohan Trikha),           (Suman Rana),          

Member.                            Member.

 

Typed by: Sanjay Kumar, S.G.