BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BHIWANI.
CONSUMER COMPLAINT NO.267 of 2015
DATE OF INSTITUTION: - 10.09.2015
DATE OF ORDER: -27.02.2018
Smt. Madhu Jalan aged about 40 years wife of Sh. Bajrang Jalan, resident of Gali Aalmal, Prathan Pana, Bhiwani.
……………Complainant.
VERSUS
- Branch Manager, Star Health and Allied Insurance Co. Ltd., Ashoka Plaza 3rd Floor, Delhi Road, Rohtak.
- Senior Manager, Start Health and Allied Insurance Co. Ltd. 1st Floor, Himalaya House, 23, Kasturba Gandhi Marg, New Delhi.
………….. Opposite Parties.
COMPLAINT U/S 12 & 13 OF CONSUMER PROECTION ACT
BEFORE :- Shri Rajesh Jindal, President
Shri Parmod Kumar, Member
Smt. Sudesh, Member
Present: - Shri Ashok Gupta, Advocate for complainant.
Shri Satender Ghanghas, Advocate proxy counsel of
Shri A. Sardana, Advocate for OPs.
ORDER:-
Rajesh Jindal, President:
The case of the complainant in brief, is that the complainant alongwith her other family members had taken a Family Health Optima Insurance Plan from the OPs vide policy no. P/211118/01/2015/001321 for a sum assured Rs. 300000/- effective from 12.1.2015 to 11.1.2016 covering the mediclaim risk of person insured at a yearly premium 11950/-. It is alleged that the complainant was suffered from enteric ferver, cough & difficulty in breathing. It is alleged that the complainant on the medical advice was admitted for treatment in Jeevan Nursing Home, Bhiwani from 31.5.2015 to 5.5.2015 and subsequently the complainant was admitted for treatment in OP Jindal Institute of Cancer & Cardiac Research, Hisar from 1.7.2015 to 5.7.2015 and complainant during the both treatment had incurred expenses to the tune of Rs. 42085/- on the treatments in cash. The complainant lodged a claim with the OP for the reimbursement of expenses alongwith original bills and other connected documents in respect of the treatment on 10.6.2015 and 16.7.2015. It is alleged that first claim of the complainant was rejected by the OPs vide letter dated 25.7.2015 on the ground that the different date of discharge shown in discharge summary was mentioned as 5.5.2015 and this was wrongly written by the staff of concerned doctor as 5.5.2015 instead of 5.6.2015, later on the correction letter of doctor was given despite the fact the respondent rejected the claim. It is further alleged that second claim of the complainant was also rejected by the OP vide their letter dated 3.7.2015 on the ground that we are unable to ascertain the duration of the presenting complaints. The complainant further alleged that due to the act and conduct of the respondents, he had to suffer mental agony, harassment and litigation expenses. Hence, it amounts to deficiency in service on the part of respondents and as such she had to file the present complaint.
2. On appearance, OPs filed written statement and took preliminary objections and denied the allegations of the complainant. It is submitted that the complainant was suffering from the disease in question prior to the inception of insurance policy but the said fact was not disclosed by the insured. It is submitted that the complainant has submitted the claim form alongwith medical documents seeking reimbursement of medical expenses for the treatment of COAD on 16.7.2015 on scrutiny of the claim records. It is submitted that at the time of inception of the first policy which is from 12.1.2015, the insured had not disclosed the above mentioned medical history of the insured person in the proposal form which amounts to misrepresentation of material facts. Hence, in view of the facts and circumstances mentioned above, there is no deficiency in service on the part of OPs and complaint of the complainant is liable to be dismissed with costs.
3. In order to make out his case, the complainant has tendered into evidence documents Annexure C-1 to Annexure C4 alongwith supporting affidavit.
4. In reply thereto, the counsel for OPs has tendered into evidence documents Annexure R-1 to Annexure R-19 alongwith supporting affidavit.
5. We have gone through the record of the case carefully and have heard the learned counsels for the parties.
6. Learned counsel for the complainant reiterated the contents of the complaint. He submitted that the complainant had taken a Family Health Optima Insurance Plan from OPs for his family members for a sum assured of Rs. 3 lakh effective from 12.1.2015 to 11.1.2016. The complainant fell ill and he taken a treatment from Jeevan Nursing Home, Dadri Road, Bhiwani from 31.1.2015 to 5.5.2015 (as mentioned by the complainant in his complaint the said wrong dates) and thereafter the complainant was admitted for treatment in OP Jindal Institute of Cancer & Cardiac Research, Model Town, Hisar from 1.7.2015 to 5.7.2015. The complainant spent Rs. 42085/- The complainant lodged the claim with the OPs alongwith original bills and documents. The OPs rejected the both claims of the complainant vide letter dated 25.7.2015 and on 3.7.2015. The claim has illegally and arbitrary repudiated by the OPs. The OPs are liable to pay the claim amount with interest etc. to the complainant.
7. Learned counsel for the opposite parties reiterated the contents of his reply. He submitted that after the receipt of the claim documents from the complainant, the OPs scrutinized the same and found as under:-
“As per the Pre-authorization request form of the above hospital submitted during cashless processing that the insured patient has chronic obstructive pulmonary disease for the post one year which is prior to inception of medical insurance policy.”
At the time of taking of the policy in question, on 12.1.2015, the insured had not disclosed the above mentioned medical hospital in the proposal form and it amounts to non-closure of the material facts. As per the condition of policy, if there is any mis-representation or non-disclosure of material facts by the insured the company is liable to make the payment of this claim. The claim of the complainant has been rightly repudiated by the OP vide letter dated 14.8.2015. The counsel for the OPs relied upon the following judgment:-
I Kailash Chand Jain Versus National Insurance Co. Ltd. & Ors. III (2016) CPJ 57 of Rajasthan State Commission, Jaipur.
8. The counsel for the OPs contended that as per the discharge summary Annexure R-5, the date of admission has been shown as 31.5.2015 and date of discharge has been shown as 5.5.2015 by Jeevan Nursing Home, Bhiwani. The counsel for the complainant submitted that it is a clerical mistake and the Jeevan Nursing Home, Bhiwani vide letter dated 7.8.2015 has issued the clarification regarding the date of admission and date of discharge, it has been mentioned in the said letter that the date of admission is 31.5.2015 and date of discharge is 5.6.2015. The counsel for the OPs contended that as per the discharge card issued by Jindal Institute of Medical Sciences, Model Town, Hisar, the complainant has been diagnosed for COAD/AN and he was suffering from the said disease from the last one year as per the history, as given in the pre-authorization request form Annexure R-11. The counsel for the complainant repudiated the contention of the OP and submitted that in the discharge card no history of one year of said disease has been given in the discharge card issued by Jindal Institute of Medical Sciences.
9. The OP has not adduced any cogent evidence regarding the pre-existing disease of the complainant as contended by it. It has relied upon on the pre-authorization form Annexure R-11. No affidavit of the concerned doctor and medical treatment record regarding the said pre-existing disease has been produced by the OP in support of his contention. Taking into account each and every aspect of the case, we partly allow the complaint of the complainant against the OPs. The OPs are directed to pay Rs. 12,234/- alongwith interest at the rate of 8 per cent per annum from the date of institution of the present complaint till the date of payment. This order shall be complied with by the OPs within 90 days from the date of passing of this order. Certified copies of the order be sent to the parties free of costs. File be consigned to the record room, after due compliance.
Announced in open Forum.
Dated: 27-02-2018.
(Rajesh Jindal)
President,
District Consumer Disputes
Redressal Forum, Bhiwani.
(Parmod Kumar) (Sudesh)
Member. Member.
