BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, FATEHABAD.
Complaint no. 188/2018. Date of instt. 13.07.2018 Date of Decision: 24.02.2020
Raj Rani wife of Ramesh Chander resident of Shakti Nagar, Inderpura Mohalla c/o Mutreja Vastar Bhandar, Ratia Gate, Near Gopi Ram Dharamshala, Fatehabad District Fatehabad.
..Complainant.
Versus
- Star Health and Allied Insurance Company Limited through its Branch Manager, S.C.O. 149 2nd Floor, CUE-1, Red Square Market, Hisar Haryana-125001(Insurer of complainant vide medi claim policy No. P/211119/01/2018/000106 valid from 09.04.2017 to 08.04.2018
- Mrs. Sonu Bala c/o Tarun Madan, Madaan Consultancy, Shop No. 25 Jaat Dharamshala, G.T.Road, Fatehabad District Fatehabad(agent of the respondent no. 1)
..Respondents/OPs.
Complaint under Section 12 of Consumer Protection Act, 1986.
Before: Sh. Raghbir Singh, President. Sh. Jasvinder Singh, Member.
Argued by: Sh. Amit Wadhera, Advocate for complainant. Sh. Sachdev Bishnoi, Advocate for OP No.1. None for OP No. 2.
ORDER
The present complaint under Section 12 of Consumer Protection Act, 1986 has been filed by the complainant against the Opposite Parties (hereinafter to be referred as OPs) with the averments that he had obtained a family medi claim policy in the year 2015 and the same has been renewed timely with OP No. 1 by making payment of premium in time to cover the health insurance of the complainant and her husband. Last time, the policy was renewed on 09.04.2017 by making a payment of Rs.19,136/- as premium to the Ops having validity period from 09.04.2017 to 08.04.2018. The said policy covers the medical health risk of the complainant and her husband Ramesh Chander. Therefore the complainant is consumer of the Ops.
2. It is further submitted that at the time of obtaining the medi claim policy in question the complainant and her husband were not having any previous history of ailments. However in the month of July 2017, the complainant was having pain in her both knee and as such she was taken to Fortis Hospital, Mohali for the first time on 11.07.2017 and wherein she was treated by Dr. Harsimran Singh and various type of medical test were also conducted upon the complainant and lastly she was diagnosed by the doctors that the complainant is having a problem of Osteoarthritis and she was advised for replacement of the both knees. Prior to that the complainant was not having any kind of problem or pain in her knees and she had never taken any kind of medicine or treatment from any doctor or hospital.
3. It is further submitted that on 16.08.2017, she was taken to the above said hospital for the replacement of both knees and both the knees were replaced by the doctors and she remained admitted in the hospital from 16.08.2017 to 23.08.2017.
4. It is further submitted that information regarding admission and replacement of both the knees was sent to the Ops by the complainant but no payment has been made by the Ops for her treatment, medical bills and hospital charges occurred in replacement of the knees. Therefore, the complainant had to make the payment of Rs.3,61,488/- to the hospital from her own packet.
5. It is further submitted that the complainant visited and contacted the Ops many times for reimbursement of the claim but on 02.02.2018 she was surprised to know that the health insurance claim of the complainant has been repudiated by the Ops on a false and fabricated ground. It is further submitted that the repudiation of the insurance claim of the complainant by the Ops is totally illegal, wrong, arbitrary and as such the same is liable to be dismissed.
6. It is also further submitted that the insurance claim of the complainant has been repudiated by the Ops on account of a clerical mistake made by the doctor of the Fortis Hospital, Mohali at the time of admission and there is no fault on the part of the complainant. It is further submitted that the above said act on the part of Ops amounts to deficiency and the complainant is entitled for receiving the health insurance claim alongwith compensation. The complainant has further prayed that the Ops may be directed for making a payment of Rs.3,61,488/- to the complainant alongwith interest and a sum of Rs.50,000/- as compensation on account of mental agony and physical harassment. Hence, the present complaint.
7. On being served, the Ops appeared through their counsel and resisted the complaint by filing a written version wherein various preliminary objections with regard to maintainability, cause of action, concealment of true and correct facts etc. have been raised.
8. In reply, on merits it is further submitted that the complainant at the time of inception of the policy and at the time of filing of the proposal form have not disclosed correct facts regarding the pre existing disease as is evident from the records submitted at the time of admission in the hospital. As per the diagnosis by the consulting doctor the complainant was having the pre existing disease. It is further submitted that the complainant was admitted in the hospital on 19.07.2018 for the treatment of Osteoarthritis of both knee joints and as per the indoor case papers the patient admitted with complaints of pain knees for 6 years which was tampered as 6 months. In the history of present illness, it is mentioned that complaint of pain in both knees since past 6 years but the symptoms worsened since past 6 months. All these findings reveal that the complainant was suffering from the disease prior to inception of the medical insurance policy in question. At the time of inception of first year policy which is from 09.04.2015 to 08.04.2016, the insured had not disclosed the above mentioned medical history in the proposal form. The same amount to concealment of material fact regarding her state of health. Since the complainant had misrepresented regarding her state of health at the time of filing the proposal form as such the repudiation of the health insurance claim of the complainant by the Ops is perfectly inaccordance with the terms and conditions of the insurance policy and the same is sustainable in the eyes of law. Therefore, the present complaint is without any merits and the same is liable to be dismissed.
9. The OP no. 2 also resisted the complaint by filing a written version wherein various preliminary objections with regard to limitation, jurisdiction, maintainability and cause of action etc. have been raised.
10. In reply on merits, it is submitted that the OP No. 2 has only acted as an agent and cannot be refastened with insurance liability. It is further submitted that as per the settled proposition of law an agent cannot be sued on behalf of his principle. All the allegations levelled by the complainant against OP No. 2 have been denied and it has been further prayed that there is no deficiency on the part of OP No. 2 in rendering service to the complainant and as such the present complaint against OP No. 2is liable to be dismissed.
11. The learned counsel for the complainant has tendered in evidence affidavit of the complainant as Ex. CW-1/A and the documents as Annexure C-1 to Annexure C-10 and closed the evidence of the complainant.
12. On the other hand, the learned counsel for the OP NO. 1 tendered in evidence affidavit of Rajiv Jain as Annexure RW-1/A and the documents as Annexure R-1 to Annexure R-16 and closed the evidence of the OP No. 1.
13. We have heard the learned counsel for the complainant and have also perused the documents placed on record.
14. In view of the position as discussed above the health insurance claim of the complainant has been repudiated by the OP No. 1 on the ground that the complainant was suffering from Osteoarthritis of both the knee joints since last six years but the above said fact regarding her state of health was concealed by the complainant at the time of inception of the health insurance policy and filing of the proposal form. Therefore the prime issue involved for determination by this Forum in the present case is as to whether the complainant was suffering from the above said diseased prior to the filing of the proposal form and the same was within her knowledge. The issue as to whether the complainant was feeling pain in both the knee joints since last six months or since last six years has been clarified by the Doctor of Fortis Hospital vide his opinion placed on record as Annexure C-10. Vide Annexure C-10 the concerned doctor has clarified that as per the hospital record and discharge summary the duration of the present complaint is six months and in one of the papers there is over writing by mistake.
15. In view of the above said clarification by the concerned doctor it is well established that the complainant was suffering from the joint pain since last six months and not since last six years. We are therefore of the considered opinion that the complainant has not concealed any material fact regarding her state of health at the time of inception of the health insurance policy and filing of the proposal form by the complainant.
16. In view of the aforesaid discussion, the complainant has been able to prove deficiency on the part of OP No. 1 in rendering service to him. The present complaint is accordingly allowed and the OP No.1 is directed for making a payment of Rs.3,23,708/-(as per terms and conditions of the health insurance policy) to the complainant alongwith interest at the rate of 8% per annum from the date of filing of the present complaint till realisation. The OP No. 1 is further directed to continue the health insurance policy of the complainant. The OP No.1 is directed for making a payment of Rs.5,000/- to the complainant as compensation and litigation charges. The present complaint is accordingly disposed off. A copy of this order be furnished to both the parties free of cost as provided in the rules. File be consigned to record room after due compliance.
Announced in open Forum: Dt. 24.02.2020
(Jasvinder Singh) (Raghbir Singh) Member President DCDRF, Fatehabad.
