Delhi

East Delhi

CC/506/2016

PARMJIT SINGH - Complainant(s)

Versus

STAR HEALTH - Opp.Party(s)

07 Aug 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 506/16

 

Shri Parmjit Singh Guleria

House No. 1087, Sector-37

Noida (UP)                                                                                   ….Complainant

Vs.     

 

Star Health & Allied Insurance Co. Ltd.

209-210, Lakshmi Deep Building

Distt. Centre, Lakshmi Nagar

Delhi – 110 092                                                                               ….Opponent

 

Date of Institution: 23.09.2016

Judgement Reserved on: 11.10.2018

Judgement Passed on: 29.10.2018

 

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By: Harpreet Kaur Charya (Member)

 

JUDGEMENT

            This complaint has been filed by Shri Parmjit Singh Guleria  against Star Health & Allied Insurance Co. Ltd. (OP) under Section 12, of the Consumer Protection Act, 1986 with allegations of unfair trade practice and deficiency in service. 

2.         The facts in brief are that in the month of January 2014, the complainant purchased a mediclaim policy through an agent of OP for which proposal form was duly signed.  The complainant has stated that he had informed OP about the pre existing diseases, which complainant was suffering from.  The complainant purchased the policy with validity of one year w.e.f. 22.01.2014 to 21.01.2015 vide policy no. P/161111/01/2014/006769 by paying an amount of Rs. 20,225/- and received only one page policy only.  There were no terms and conditions attached alongwith policy.  The policy was renewed for another one year w.e.f. 22.01.2015 to 21.01.2016 vide policy no. P/161111/01/2015/009701by paying premium of Rs. 20,225/-.

            It was stated that on 18.04.2015, the complainant felt severe pain, for which he was admitted in Healing Touch Hospital and was diagnosed as Postural Hypotension, Angina.  Intimation for admission was given to OP’s office by the hospital and request for cashless service was made.  OP asked for certain documents/information vide letter dated 19.04.2015, which was supplied by the hospital directly.  OP rejected the cashless facility vide letter dated 20.04.2014 on account of non declaration of pre existing disease at the time of taking the policy.  Hence, the complainant  was constrained to pay the bill amount of Rs. 39,860/- to the hospital at the time of discharge on 20.04.2015. 

            It was also stated that the complainant submitted his claim alongwith all necessary documents with OP.  He wrote a detailed letter on 23.03.2015, sent mails and made telephonic calls to the officials of OP.  The complainant received an email from OP wherein it was confirmed that all pre-existing diseases were declared to them at the time of taking the policy.  The complainant sent various letters to OP dated 11.06.2015, 20.06.2015 and 07.01.2016 to OP, but all in vain.   

            The complainant was shocked when he received a letter from OP dated 12.06.2015 wherein OP had cancelled the policy of the complainant without any notice and refunded a pro-rata premium of Rs. 12,246/-.  It was stated that non settlement of claim of the complainant was a case of deficiency in service.  Hence, the complainant has prayed for directions to OP to pay his claim amount of Rs. 39,860/- alongwith 24% interest;         Rs. 50,000/- as compensation on account of mental agony, pain and suffering and Rs. 21,000/- towards cost of litigation.   

            The complainant has annexed copy of proposal form, copy of both policies for the years 2014-2015 and 2015-2016, copy of letter dated 19.04.2015, 20.04.2014, copy of hospital bill, copy of letter dated 23.04.2015 and email dated 26.05.2015, copy of letters dated 11.06.2015, 20.06.2015 & 07.01.2016 and copy of cancellation letter dated 12.06.2015 alongwith the complaint.

3.  

It was stated that as per indoor case record of the hospital, it was observed that complainant was a known case of post renal transplant done in 2006 and as per field visit report of doctor of OP, the complainant had undergone CABG during 2000 and the same was also not disclosed in the proposal form at the time of taking the policy which amounts to non disclosure of material facts.

It was stated that in the Senior Citizen Red Carpet Policy, a special privilege was allowed to the senior citizen to enroll the policy without pre-insurance medical screening, therefore, the policy was served on the declaration made by the complainant in the proposal form.

It was further stated that at the time of inception of policy which is from 13.02.2016 to 12.12.2017, the complainant did not disclose the medical history/health details of the insured person and as per condition no. 13 of the policy, “the company may cancel this policy on grounds of misrepresentation/non-disclosure of material fact as declared in proposal form/at the time of claim”.Hence, the policy of the complainant was cancelled w.e.f. 14.06.2015 due to non-disclosure of PED POST RENAL TRANSPLANT 2006 AND CABG and premium of Rs. 12,246/- was refunded to the complainant.

It was also stated that without prejudice the company was liable to pay the claim to the complainant to the maximum of Rs. 27,674/- after applying 30% co-pay.Other facts have also been denied.

OP has annexed terms and conditions of the policy schedule which was served to the complainant, with the written statement

4.         Rejoinder to the WS of OP was filed by the complainant where the contents of the WS have been denied and reaffirmed the averments of his complaint. 

5.         In support of its case, the complainant has examined himself.  He has deposed on affidavit.  He has narrated the facts which have been stated in the complaint.  He has got exhibited the documents such as copy of proposal form (Annex. C-1), copy of both policies (Annex. C-2 & C-3), copy of letter dated 19.04.2015 and 20.04.2014 (Annex. C-4 & C-5), copy of hospital bill (Annex. C-6), copy of letter dated 23.04.2015 and email dated 26.05.2015 (Annex. C-7 and C-8), copy of letters dated 11.06.2015, 20.06.2015 and 07.01.2016 [Annex. C-9 (colly.)] and copy of cancellation letter dated 12.06.2015 (Annex. C-10).

            In defence, Star Health & allied Insurance Co. Ltd. (OP) have examined Shri N. Gopalan, Chief Manager, who has also deposed on oath and have narrated the facts which have been stated in the written statement.  

6.         We have heard Ld. Counsel for the parties complainant and have perused the material placed on record as none has appeared on behalf of OP to argue.  The dispute is with respect to the non-reimbursement of hospitalization bills after denial of cashless facility as assured under policy terms and conditions.  The complainant has placed on record the emails exchanged with Mr. Pravin Rajput, Team Coach-Health, Star Health Insurance of date 23.05.2015, 24.05.2015 and 26.05.2015, where the complainant has been reassured that his pre-existing conditions of heart bypass in the year 2000, kidney transplant in 2006 and insulin based diabetes were covered from second year onwards.

            Thus, it is clear that the complainant was assured that his pre-existing disease will be covered at the time of selling policy.  The claim has been filed in the second year of policy for treatment of Postural Hypotension and Angina, and the claim was rejected on account of non-declaration of pre-existing disease at the time of taking policy.  Once, the complainant had been assured by the agent of OP that his pre-existing disease shall be covered and non inclusion of same in proposal form shall amount to malpractice on the part of agent.  The complainant cannot be made to suffer for the acts and omission on the part of agent of OP. 

            Further, the complainant was hospitalized for treatment of Postural Hypotension and Angina on 18.04.2015, which is the 2^nd year of policy with OP, cashless was denied on account of non-declaration of pre-existing disease.  Here, the non disclosure of renal transplant done in 2006 and CABG during 2000 was made on the ground of rejection of claim.  These diseases pertain to almost 8-14 years prior to the issuance of policy for the first time and as per policy document “pre-existing disease means any condition, ailment or injury or related condition(s) for which the insured person had signs or symptoms and-/or was diagnosed and/or received medical advice/treatment within 48 months prior to insured person’s first policy with any Indian Insurer”. 

            Thus, the treatment of the complainant in 2000 and 2006 does not fall within the definition of pre-existing as per policy terms and conditions.  Therefore, from above discussion, we are of the opinion that the rejection of claim of the complainant was not only arbitrary, but also a case of mis-selling by the representative of OP.

            Hence, we direct OP to reimburse complainant Rs. 27,634/- as submitted by them in their written statement and calculation sheet annexed by OP with their written statement.  We also award Rs. 15,000/- as compensation on account of mental agony and pain as the complainant being a senior citizen was denied what he was promised/entitled as per policy terms and conditions.   This includes the cost of litigation.  This order be complied within a period of 45 days of receipt of order.   

            Copy of the order be supplied to the parties as per rules.

            File be consigned to Record Room.

(DR. P.N. TIWARI)                                              (HARPREET KAUR CHARYA)

       Member                                                                             Member    

            (SUKHDEV SINGH)

        President