Haryana

Kurukshetra

CC/30/2019

Ashok Kumar - Complainant(s)

Versus

Star Health Insurance - Opp.Party(s)

Raj Singh

19 Feb 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL COMMISSION KURUKSHETRA.

 

Complaint Case No.30 OF  2019

Date of instt: 21.01.2019. 

                                                                      Date of Decision: 19.02.2021.

 

Ashok Kumar Arora aged about 56 years, son of Ramji Dass resident of house No.371, Ward No.2, Street No.3, Near Mahavir Colony Ladwa, Tehsil Ladwa, District Kurukshetra.

                                                          ……..Complainant.

                             Vs.

1. Star Health and Allied Insurance Company Limited, Registered & Corporate Office: 1 New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-60034  through its Managing Director.

 

2.  Star Health and Allied Company Limited, SCO 242, 1^st Floor Sector 12,

     Opposite Mini Secretariat Karnal, District Karnal through its Branch

     Manager.

 

..………Opposite parties.

 

Complaint under section 12 of Consumer Protection Act.                             

 

Before         Smt. Neelam Kashyap, President.

                   Ms. Neelam, Member.

                   Sh. Sunil Mohan Tirkha, Member.

 

Present:      Shri Raj Singh, Adv. for complainant.

Sh. Gaurav Gupta, Adv. for OPs.

             

ORDER      

 

                   This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Ashok Kumar against Star Health and Allied Insurance Company Limited, the opposite parties.

2.                Brief facts of the present complaint are that the complainant purchased an insurance policy bearing No.P/211114/01/2018/005025 dated 1.11.2017 and period of insurance  was from 1.11.2017 to 31.10.2018 Mid night from the OPs.  The complainant purchased the said policy for him and for his wife Varsa Rani and paid the premium of Rs.19417/- to the OPs. The OPs issued the said policy after  getting the medical check up of the complainant and his wife from their approved doctor and the complainant alongwith his wife were found quite hale and healthy in good condition.  At the time of filling up of proposal form for the said policy, the complainant disclosed all the facts regarding his helath  and he was not having any disease nor uilcerative colitis at that time.  The complainant was medically examined at Mohali on 26.10.2017 for going to Canada  and at that time he was having no disease of any type and the medical certificate was sent to Embassy of Canada in  Delhi by the doctor and then VISA  granted him the VISA. The complainant went to Canada on 3.2.2018  and came back to India in May 2018. Due to change in food stuff, water climate changed and the change of atmosphere the complainant felt pain in his stomach for the first time on 19.4.2018 and went to doctor in Canada for check up. The complainant caqme to India and admitted in Amrit  Dhara  my Hospital ITI Chowk, Karnal from 16.5.2018 to 26.5.2018 and went to Sahara Institute of Medical Sciences Model Town, Hissar on 27.05.2018. The complainat  was again got admitted in Medanta Hospital, Gurugram on 4.6.2018 and was discharged on 13.6.2018 .The complainant submitted the claim to the OPs vide claim No.CLI/2019/211114/0077525  of Amrit Dhara Hospital for Rs.76,313/- , claim No.CLI/2019/211114/0114816 of Madanta Hospital for Rs.1,70,774/- and medical bill of Rs.13372/- totaling Rs.1,84,146/- , both the claims amounting to Rs.260459/-. The complainant submitted all the required bills and documents with the OPs. The OPs vide letter dated 10.8.2018  asked for some other documents which were also supplied by the complainant and the OPs even verified  the treatment record from  Canada  and Canada hospital also send  the required documents to the OPs. Vide letter dated 22.09.2018 OPs repudiated the claim of the complainant by observing “ that from the consultlation report dated 27.5.2018 submitted vide claim No.0077525  it is observed that the patient took some injectable therapy in Canada. We requested the  insured to furnish the said medical records but the same were not furnished and as such OPs wrote that they are unable to proceed further with his claim.    The OPs observed that insured patient has chronic long standing ulcerative colitis with cytomegalovirus colitis existing prior to  inception of the first medical insurance policy.  Therefore, complainant has averred that his claim has wrongly been repudiated and such act on the part of OPs amounts to deficiency in services on the part of OPs and has filed this complaint alleging deficiency in services on the part of the OPs and prayed that the OPs be directed to pay the claim ofRs.260,459/- alongwith interest, compensation for the mental harassment and agony caused to him and the litigation expenses.

 

3.                Upon notice, OPs appeared and filed their written statement disputing the claim of the complainant. Obtaianing of insurance policy by the complainant from the OPs is admitted. It is submitted that two claims in the 7^th month of the policy were submitted vide claim No. CLI/2019/211114/0077525  of Amrit Dhara Hospital for Rs.76,313/- , claim No.CLI/2019/211114/0114816   both totaling toRs.1,70, 774/- . The complainant got hospitalized on 16.5.2018 in Amrit5dhara hospital Rasulpur Kalan (93) discharged on 26.5.2018 and submitted the claim of Rs.76513 vide claim No. CLI/2019/211114/0077525 . On scrutiny of documents, it was observed by the OPs that

          a)      As per consultation report dated 27.5.2018, the insured patient took some injectable therapy in Canada, thus, we have raised query to submit the treatment documents, whereas the insured denied the history of the same vide letter dated 22.08.2018.

          b)      Sigmoidoscopy  report dated 5.06.2018 shows multiple ulcers, which is long standing in nature and take more than seven months to develop. Hence, it is a PED and the same is not disclosed in the proposal form which is non disclosure of material facts. 

               As per condition No.3 of the policy, the insured shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim is based and shall also give the company such additional information and assistance  as company may required in dealing with the claim. 

 

                   It is further submitted that as per condition no.6 of the policy, if there is any misrepresentation/non disclosure whether  by the insured or any other person acting on his behalf, the company isnot liable to make any payment in respect of any claim.

 

                   Thus, it is submitted that the above findings of misrepresentation and non cooperation by the insured.  Thus, both the claims were repudiated and the same was informed to the insured vide letters dated 22.09.2018 and 25.10.2018.

 

                   Thus, the OPs have submitted that there is no deficiency in services on the part of the OPs and prayed for dismissal of the complaint.

 

 

4.                The complainant in support of his claim has filed his affidavit Ex.CW1/A and tendered documents Ex.C-1 to Ex.C-12 and closed his evidence.

 

5.                On the other hand, OPs in support of their case have filed affidavit Ex.RW1/A and tendered documents Ex.R-1 to Ex.R-25 and closed their evidence.

 

6.                We  have heard the learned counsel for the parties and gone through the material available on the case file.

 

7.                The learned counsel for the  complainant has argued that he purchased an insurance policy bearing No.P/211114/01/2018/005025 dated 1.11.2017 and period of insurance  was from 1.11.2017 to 31.10.2018 Mid night from the OPs.  The complainant purchased the said policy for him and for his wife Varsa Rani and paid the premium of Rs.19417/- to the OPs. The OPs issued the said policy after  getting the medical check up of the complainant and his wife from their approved doctor and the complainant alongwith his wife were found quite hale and healthy in good condition.  It is also argued that at the time of filling up of proposal form for the said policy, the complainant disclosed all the facts regarding his health  and he was not having any disease nor ulcerative colitis at that time.   It is argued that the  complainant was medically examined at Mohali on 26.10.2017 for going to Canada  and at that time he was having no disease of any type and the medical certificate was sent to Embassy of Canada in  Delhi by the doctor and then VISA  granted him the VISA. It is further argued that  complainant went to Canada on 3.2.2018  and came back to India in May 2018. Due to change in food stuff, water climate changed and the change of atmosphere the complainant felt pain in his stomach for the first time on 19.4.2018 and went to doctor in Canada for check up. The complainant came to India and admitted in Amrit  Dhara  my Hospital ITI Chowk, Karnal from 16.5.2018 to 26.5.2018 and went to Sahara Institute of Medical Sciences Model Town, Hissar on 27.05.2018. The complainant  was again got admitted in Medanta Hospital, Gurugram on 4.6.2018 and was discharged on 13.6.2018 .The complainant submitted the claim to the OPs vide claim No.CLI/2019/211114/0077525  of Amrit Dhara Hospital for Rs.76,313/- , claim No.CLI/2019/211114/0114816 of Medanta Hospital for Rs.1,70,774/- and medical bill of Rs.13372/- totaling Rs.1,84,146/- , both the claims amounting to Rs.260459/-.It is  thus, argued that the claim of Rs.2,60,459/- was not paid to the complainant which amounts to deficiency in services.

 

8.                On the other hand, learned counsel for the OPs while reiterating the submissions made in the written statement has argued  that the complainant has concealed the true and material facts while obtaining the present insurance policy.  It is argued that as per Sigmoidoscopy report dated 5.6.2018, there were multiple ulcers, which is long standing in nature and take more than  seven months to develop. Hence, it is a Pre existing disease and the same is not disclosed in the proposal form which is non disclosure of the material facts and is clear violation of condition no.6 of the insurance policy.  It is also argued that the complainant has also violated the condition no.3 of the insurance policy because he has not furnished the treatment record of hospital of Canada. It is argued that the company is liable to pay claim, if any,  in terms of contract of insurance issued to the claimant and that the maximum quantum of liability under the terms and conditions of the policy shall be Rs.1,77,396/- in  both the claims. Thus, it is argued that the OPs are not liable to pay any claim to the complainant and prayed for dismissal of the complaint.

 

9.                 The arguments advanced on behalf of the learned counsel for the OPs are devoid of any merit because in  this case, after coming from  Canada, the insured was admitted to Amritdhara Hospital, at Karnal  on  16.05.2018 and was discharged on 26.5.2018 vide Ex.R-20. Perusal of the document Ex.R-20 shows that the “ patient was brought to emergency with case of loose stools x 20 episodes a day from last ten days.  After investigation patient was diagnosed to have colitis. Thus, from this document, it is not proved that the complainant was having this problem for the last long period. Ex.C-8 is discharge summary issued by Medanta Hospital  and perusal of this  document shows that  the life assured was admitted there in the Medanta  on  4.6.2018 “Ashok Kumar Arora, 55 years, old male, presented in emergency with complaints of large bowel type diarrhea since  one and a half months (loose watery stools with blood and 10-14 times/day). He was evaluated at Karnal Hospital where Sigmoidoscopy was done and patient was diagnosed to have anal ulcer. He was admitted here for further evaluation and management.  The  insurance policy in question was issued 1.11.2017 and  for the first time he was admitted in the Amritdhara Hospital, Karnal on 16.5.2018 where he was diagnosed to have colitis.  So far as treatment taken in Canada by the complainant is concerned, from the document Ex.C-13, he was admitted for abdominal pain and Blood diarrhea. Thus, from the documents of Amritdhara hospital, Medanta and  Ex.C-13 issued of Hospital of Canada, it is not established that the patient was having ulcer disease at the time of obtaining of the insurance policy and claims submitted by the complainant cannot be said to be in violation of condition no.3, 6 and 12 of the insurance policy and as such repudiation of the claims of the complainant by the OPs are not sustainable in the eyes of law and the complainant is entitled to the claim and the present complaint is liable to be accepted.  Thus, deficiency in services on the part of the OPs is established for wrongly repudiating the claims of the complainant.

 

10.              So far as the quantum of the claim amount is concerned, the complainant has claimed the amount of Rs.2,60,459/- and the OPs have  no where stated that such amount was not spent by the complainant in his treatment nor any such evidence has been led on their behalf to rebut this submission of the complainant.   Therefore, the complainant shall be entitled to Rs.2.60.459/- alongwith interest @ 6% per annum from the date of institution of the present complaint i.e. 21.01.2019 till realization. The complainant shall also be entitled to compensation for the mental harassment and agony caused to him and the litigation expenses.

 

                   As a result of our above discussion, we accept the present complaint and direct the OPs to make the payment of Rs.2.60.459/- to the complainant alongwith interest @ 6% per annum from the date of institution of the present complaint i.e. 21.01.2019 till its actual realization. The complainant shall also be entitled for compensation of Rs.10,000/- for the mental harassment and agony caused to him and Rs.5000/- towards litigation expenses. The OP  are    further directed to make the compliance of this order within a  period of  45 days from the date of preparation of certified copy of this order, failing which, the complainant will be at liberty to initiate proceedings under Section 25/27 of the Act against the OPs. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

 

Announced in open commission:

Dt.:19.02.2021                                                     (Neelam Kashyap)

                                                                                  President.

 

 

(Issam Singh Sagwal),              (Neelam)         

 Member                                     Member.