Delhi

East Delhi

CC/976/2014

KALYAN RAI - Complainant(s)

Versus

STAR HEALTH INS - Opp.Party(s)

05 Aug 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT OF NCT OF DELHI

CONVIENIENT SHOPPING CENTRE, SAINI ENCLAVE: DELHI-92

 

CC. NO-976/14

In the matter of:

Sh. Kalyan Rai Garg

S/o Sh. Ravi Prakash

H.No.83/4, Jain Mohalla, Panipat-133103       

 

         Complainant

 

Vs

 

M/S Star Health and Allied Insurance co. Ltd.

Through its Managing Director

314, Lakshmi Deep Building

Lakshmi Nagar District Centre,

•  

 

                                                                                                                      Opposite Party

 

                                                                                        DATE OF ADMISSION-20/10/2014

                                                                                    DATE OF ORDER       -23/12/2015

ORDER

SH. N.A.ZAIDI, PRESIDENT

This complaint has been filed with the allegation that the complainant was suffering from C.A.D. with H.D.A.V. and was hospitalized on 27/01/2010 to 29/01/2010 at Indraprastha Apolo Hospitat Delhi. The complainant incurred an expense of Rs.2,89,043/- under Medical Claim Policy No. P/16113/01/2010/1391 which was valid from 22/12/2009 to 21/12/2010, when he put his claim, respondent asked for the original documents but they refused to acknowledge the receipt of those documents and the complaint was filed before this Forum, which was marked as case no. 872/11, which was decided on 11/12/2013. The respondent made the payment of Rs.1,11,519/-  vide letter dated 04/03/2014 showing the following details, claim amount of Rs.79,000/- against the actual claim amount of Rs.2 lakhs and interest @ 9% p.a. Rs.7,519/- and compensation of Rs.25,000/-. The complainant accepted as part payment. The respondent liable to make payment of Rs. 2 lakhs against the total expense of Rs.2,89,043/-. The complainant has prayed for a sum of Rs.1,21,000/- being difference in sum payable and sum paid against claim of the complainant and interest @ 24% on this amount, interest on Rs.79,000/- for 874 days of shorter period of 386 days which amount of Rs.17,025/- and Rs. 1 lakh towards compensation.

            Notice were issued to the respondent they were served and file the written statement where in the respondent have taken the plea of Section 26 of the Consumer Protection Act. The Forum has directed by their order dated 11/12/2013 to decide the legitimate claim within 30 days from the date of receiving this order along with 9% interest on the claim amount from the date of filing this petition till it is finally paid. The respondent evaluate the claim as per the terms and condition of the policy and paid Rs.79,000/- with 9% interest from 12/02/2013 to 04/03/2014 and the compensation awarded. As per treating doctor certificate, the insured had diabetes mellitus since 2-3 years, which is prior to the policy and the same was not disclosed by the insured in the proposal form. Condition 5 of the policy, 50% co pay of each ad every claim arising out of all pre existing diseases as defined  and 30% co pay in case of all other claims which are to be borne by the insured. The present admission is due to the complication of pre existing disease and the 50% co pay as per the terms and condition of the policy. Thus this is the maximum amount payable as per the terms and condition of the policy. The suppression of the material facts vitiates the good faith as such the present petition is not maintainable.

We have heard the Ld. Counsels for the parties and perused the record.

The complainant counsel pointed out that the cause of action has arisen by the disposal of the claim as per the direction of this Forum below the insured amount. It is not denied that under the policy in question complainant has a cover up to Rs.2 lakhs. It is for the respondent to establish that the complainant has suppressed the material facts from the respondent regarding illness when the policy in question was purchase by the complainant. No such documents have been filed on record by the respondent which could prove the allegation that he was suffering from the diabetes mellitus when this policy was purchase by him. It was argued by the complainant counsel that the complainant was admittedly hospitalized for C.A.D with H.D.A.V. which is related to heart and has nothing to do with the diabetes mellitus. This fact is not denied that the complainant was not operated upon at Indraprastha Apollo Hospital Delhi and he had incurred the expense of Rs.2,89,043/-. The complainant argued that had the hospitalization be in connection with the ailment of diabetes mellitus the arguments advance by the respondent could be taken into consideration. The medical certificates issued by the treating doctor shows that the nature of the treatment was PTCA + Stenting of LAD  and OM 1 Arteries, there is nothing in this report that any expense were incurred  on any type of diabetes management. The bill which has been filed along with the complaint shows that the complainant paid the total amount of Rs.2,89,042/- as such the deduction made by the respondent to the extent of 50% is unjustified. The complainants cover up to Rs.2 lakhs and he was entitled for reimbursement of the amount paid for treatment up to Rs.2 lakhs. As such the amount paid to the complainant is less than the due and it amounts to unfair trade practice.

We allow this complaint. We direct the respondent to pay to the complainant amount of Rs.2 lakhs, after deducting the amount already paid together with 9% interest thereon from the date of the payment made to the hospital till it is finally paid to the complainant. We further award the compensation of Rs.30,000/- on account of harassment, mental pain and agony which shall also include the cost of litigation.

Copy be served to both the parties as per rule. 

 

Dr. P.N. TIWARI                        POONAM MALHOTRA                     N.A.ZAIDI

      MEMBER                                          MEMBER                                         PRESIDENT