Delhi

West Delhi

CC/16/162

Krishan chand - Complainant(s)

Versus

Star health - Opp.Party(s)

25 Feb 2019

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (WEST)

150-151; COMMUNINTY CENTER ; C-BLOCK; JANAK PURI; NEW DELHI

 

CASE NO.  162/16

Krishan Chand Nasa

Senior Citizen

MG-1, Flat No. 58, Vikas Puri,

New Delhi-110018

MOB: 9717380758

VERSUS

Star Health  & Allied Companies

Plot No. 4, 3^RD Floor,

Near West Janakpuri,

Metro Station, Vikas Puri,

New  Delhi                                                              ….. Opposite Party-1

 

Star Health & Allied Companies,

Kasturba Gandhi  Marg, Ist Floor,

Himalaya  House,

New Delhi-110001                                               ….. Opposite Party-2

 

O R D E R

 

K.S. MOHI, PRESIDENT

 

The complainant has filed the present complaint against the O.P under section 12 of Consumer Protection Act, 1986.  The facts as alleged in the complaint are that the complainant had taken insurance policy of OP on 24.03.2013 and got the same renewed in 2014-2015.  The complainant stated that one  form was got filled in good faith  which he signed. On 26.03.2016 complainant  went to Super Specialty Hospital Janak Puri  and his blood  Sugar and Lipid Profile  was in  normal range, however, ECG showed one artery  and interior wall   of heart  blocked.  He was told   that he had suffered silent heart attack.  The doctor advised him to visit G.B.Pant  hospital because heart beat rate was on lower side.  Accordingly complainant visited G.B.Pant Hospital where he was advised Holter Test and certain medicines. The complainant also got done Eco Cardiograph from Deen Dayal Upadhyay Hospital, Hari Nagar, New Delhi and the report was within normal range and minor changes were there on account of old age.   It is a case of complainant that in 2014  he again went for check up  in Super  Specialty   Hospital,  Janak Puri  and  had infact no problem that  time  too.  On   01.08.2015 he visited Super Specialty  Hospitality  for check up and  there ECG was done.  But he had no problem  on said two occasions. Since ECG showed less heart  beat so he was advised to go to some other hospital  for evaluation   but in discharge slip the doctor concerned wrote that he had  heart problem and  bradycardia (less  heart beat)for the last 3 years.  The heart beat recorded was @ 44 per minute to 42 per minute.  Since  complainant had  first OP card of  dated 22.06.2013  ,therefore, doctor counted three years of illness  from 2013 to 2015 therefore,  he recorded past  history of 3 years of heart ailment.  Complainant further submitted that he was admitted  in Artemis Hospital, Dwarka, Delhi, which was on the panel of OP.  The  hospital  did some investigation  and gave him medicines as a result his heart beat improved   and  it was almost  normal.  On 5^th day he was told  that he could not  get further medical treatment  because OP  had  refused  payment of  his treatment  on the ground that complainant was suffering from heart disease and bradycardia which was not  disclosed to OP at the time of  taking policy .  Since  cashless facility was not  provided to him by  OP, complainant  made a representation  to IRDA Ombudsman  stating that  OP  had refused the payment to hospital  for his treatment  and  terminated his policy. Case was still pending before Ombudsman in the meantime complainant started  going to G.B. Pant  Hospital  Cardiology Department for checkup. The Ombudsman gave verdict against  complainant on the ground that he was suffering  from heart disease  and bradycardia (DM2/HTN/CAD/CAD) before  taking policy and   had not disclosed this material fact in the proposal  form. Since OP terminated his policy  even  the decision of Ombudsman,  he was sent one draft of  HDFC bank.  It is sated that complainant spent Rs.12,000/- in Artemis Hospital, Dwarka, Delhi for  5 days  hospitalization, paid Rs. 20,000/- to Wipro for 14 days  ECG , spent about Rs. 13,000/- on going G.B. Pant Hospital and  Super Specialty , Janak Puri demanded bank draft of  Rs. 14,494/-.   Complainant in total prayed for award of Rs. 59,494/-  alongwith compensation for harassment and mental agony. 

2.     OP filed written submission  taking  preliminary objection  inter-alia  that the complaint  is bad on account of Resjudicata because  the matter was first heard and decided by Ombudsman.   Also complainant  suppressed material  fact   as to his state of health  at the time of taking policy  thus breached fundamental condition of utmost good faith  of the insurance contract.   It has been further stated that on account of  proposal policy schedule, claim form, medical record of the  Super Specialty Hospital Janak Puri, details of pre-existing disease cumulatively demonstrated that it is a clear case of misrepresentation  as to the previous  pre-existing  disease hence complainant  is not entitled to the claim on merits.  It is, however,  admitted that complainant had taken policy of the OP.

3.     Complainant has filed replication denying contents of written statement and re-affirming the contents of complaint.  He has filed his affidavit in evidence testifying all the facts stated in the complaint. On the other hand Sh. Gopalan  S/o  Late Sh. K. Narayana Rao, Chief Manager, Star Health & Allied Insurance  Co. Ltd.  filed evidence on behalf of O.P.

4.     In the instant case OP rejected the claim of complainant on the ground  of non discloser of previous disease for which complainant  had obtained treatment from the hospital  as such  complainant suppressed material facts which disentitled  him to claim compensation.  The complainant had also  denied the illness in the  proposal Forum.  The case of complainant, on the other hand,  is that  he is a senior citizen  and has approached  hospital for routine check up wherein he was told  the  his heart  beat was slow  @ 40 per minutes  and was admitted for  observation and discharged after  few hours. 

5.     We have gone through the entire medical record of the complainant which does not fall whether the category of pre-existing disease.  Even otherwise hypertension or diabetes can never be said to a pre existing disease which are related to the life style of an individual and can be controlled  with conservative medicine .  Even otherwise  the proposal form  according the complainant was filled in up by the  staff  of the OP and complainant merely put his signature thereon .  This type of practice  by OP also amounts  to unfair trade  practice.

5.     In  view of the  discussion stated above we are of the view that  the complainant had made out a valid case in his favour.  He is entitled to the  medical  expenses  spent  by him during hospitalization with Artemis Hospital, Dwarka, Delhi, however, he is not entitled  to other expenses such as  expenses for ECG and transportation charges for  going to G.B.Pant Hospital and Super Specialty Hospital.  He is no doubt  entitled to refund of   amount of Rs. 14,494/-, therefore, we award an amount of Rs. 12,000+14,449 total  Rs. 26,449/- within 45 days from receipt of this order failing which  interest @ 6% from the date of institution of complaint till realization.  The complainant is also awarded  a sum of Rs. 5,000/- towards  mental agony, harassment  and litigation expenses.

Copy of this order be sent to the parties as per rules.

File be consigned to the record room. 

  Announced this___25  ___ day of _February _ _ 2019.

 

                                                                                                                       ( K.S. MOHI )                                                    (PUNEET LAMBA)                                                                                     PRESIDENT                                                            

  MEMBER