Haryana

Kurukshetra

244/2017

Pooja Sharma - Complainant(s)

Versus

Star Health - Opp.Party(s)

S.P.Sharma

26 Apr 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, KURUKSHETRA.

 

Complaint Case No.244 of 2017.

Date of instt: 15.11.2017. 

                                                                        Date of Decision: 26.04.2019.

 

Pooja Sharma w/o late Sh. Anil Sharma son of Shri Bal Kishan Sharma, resident of village Hathira, District Kurukshetra.

 

                                                ……..Complainant.

                        Vs.

1. Star Health and Allied Insurance Company Ltd., through its Branch Manager, SCO 242, First Floor Sector 12, Opp. Mini Secretariat, Karnal.
2. Star Health and Allied Insurance Company Ltd., through its Branch Manager, SCO 44, Sector 17, Kurukshetra.

..………Opposite parties.

 

Complaint under section 12 of Consumer Protection Act.                   

 

Before       Smt. Neelam Kashyap, President.

                Ms. Neelam, Member.

                Sh. Sunil Mohan Tirkha, Member.

 

Present:     Sh. S.P. Sharma, Advocate for complainant.

Sh. Gaurav Gupta, Advocate for opposite parties.

           

ORDER     

 

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

2.            Brief facts of the present complaint are that the complainant purchased the health insurance policy i.e. Family Health Optima Insurance Plan bearing no.P/211114/01/2017/003262 from ops for sum assured of Rs.5,00,000/- for the period 22.9.2016 to 21.9.2017. The complainant and her husband Anil Sharma were insured for the aforesaid sum and the premium of Rs.6630/- was paid by her husband to the op. It is further alleged that in the last week of January, 2017 the husband of complainant Anil Kumar felt problem of jaundice upon which he took treatment from Aggarwal Nursing Home, Kurukshetra and various tests were conducted there but the same was not controlled and due to his serious condition he was referred to higher institution. Then he was taken to Max Super specialty Hospital, Mohali on 17.3.2017 and he was admitted there. The doctors diagnosed decompesated of liver, varices, ascites, jaundice etc. He remained admitted there from 17.3.2017 to 22.3.2017 and thereafter he remained under treatment as outdoor patient. It is further alleged that doctor of Max Hospital immediately gave intimation to the ops regarding admission of the complainant’s husband for the aforesaid problem and treatment and the correspondence was going on between the ops and hospital regarding the approval of cashless facility, but the attitude and conduct of the official of the ops was very inhuman and unusual and ultimately the ops denied the cashless facility without any sufficient reason or cause by stating that the insured can file claim for reimbursement of the bills of the hospital and due to the act and conduct of ops, the complainant faced physical as well as mental agony. It is further alleged that her husband was hale and healthy prior to the last week of January, 2017 i.e. before the aforementioned treatment. He was again admitted in Max Hospital Mohali from 27.7.2017 to 31.7.2017 and thereafter remained in OPD. Thereafter he was also admitted from 12.8.2017 to 13.8.2017. Due to his condition, he was referred to higher institution for further treatment and he was got admitted in institution of liver and biliary sciences (ILBS), Delhi and then he was taken to Sir Ganga Ram Hospital, Delhi where he died during treatment on 20.8.2017. He remained under treatment there from 14.8.2017 till his death. It is further alleged that complainant spent total sum of Rs.4,86,948/- on the treatment of her husband for which the ops are liable to indemnify as per the policy in question. That the ops repudiated the claim of complainant arbitrarily and cancelled the insurance policy vide letter dated 10.5.2017 illegally. Thereafter, the complainant visited the office of the ops number of times but in vain. Hence, this complaint.

3.             On notice, opposite parties appeared and filed written statement raising certain preliminary objections. It is submitted that claim was reported in sixth month of the policy and as per claim form, the complainant claimed amount of Rs.89,702/-. The insured was admitted at Max Super Specialty Hospital, Mohali on 17.3.2017 for the treatment of chronic liver disease and submitted pre authorization request for cashless treatment and the same was denied vide letter dated 19.3.2017 stating that the exact diagnosis not provided and exact onset of illness cannot be ascertained with the available documents. Subsequently, the complainant submitted claim records for reimbursement of medical expenses. On scrutiny of the claim records, it is observed that as per Discharge Summary:

                The patient was admitted on 17.3.2017 and discharged on 21.3.2017

                The patient was admitted with the past history of EVL Done x 3 years back

                Diagnosis: DECOMPESATED CIRRHOSIS OF LIVER, VARICES, ASCITES, JAUNDICE

                The ICP states that the complaint was presented with the past medical history of large gastric varices x treated for three years back. From the above findings, it is observed that the patient has undergone oesophageal varices ligation surgery three years back which is prior to inception of the medical insurance policy and the admission and treatment of the patient is for the non disclosed liver disease. At the time of inception of the policy, the insured had not disclosed the above mentioned medical history/ health details in the proposal form which amounts to misrepresentation/ non disclosure of material facts. As per condition No.8 of the policy, if there is any misrepresentation/ non-disclosure of material facts whether by the complainant person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim. It is further submitted that insurance is based on utmost good faith. As it is a contract of health insurance, the complainant is expected to declare in the proposal form about the details of his ailment/ sickness- past medical history which helps the insurer to evaluate the material facts and to decide whether to accept the proposal or not. Thus, if the insured has failed to disclose any medical history in the proposal form, there is no liability on the insurer. It is further submitted that as per condition no.15 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.” Thus, the policy in respect of Mr. Anil Sharma was cancelled with effect from 26.6.2017 due to non disclosure of above facts as per terms and conditions of the policy. In consequence thereof, the entire policy was cancelled and fresh policy was issued to the rest of the family members. With these averments, prayer for dismissal of complaint made.     

4.             The complainant tendered affidavit AW1/A and documents Annexures A1 to A48. On the other hand, ops tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R15.

5.             We have heard learned counsel for the parties and have perused the case file carefully.

6.             Learned counsel for the complainant has contended that it is an admitted fact that husband of complainant purchased health insurance policy from the opposite parties for sum assured of Rs.5,00,000/- which was effective from 22.9.2016 to 21.9.2017 vide which the complainant and her husband Anil Kumar were insured. The husband of complainant paid premium of Rs.6630/- to the ops. He has further contended that in the last week of January, 2017 the husband of complainant suffered from jaundice and he took treatments from various hospitals but the ops denied the cashless facility without any sufficient reason or cause by stating that the insured can file claim for reimbursement of the bills of the hospital paid by him. He has further argued that husband of complainant was not suffering from any disease prior to January, 2017. However, as he suffered jaundice in last week of January, 2017 i.e. after inception of the policy, he took treatment from various hospitals as outdoor patient as well as indoor patient and ultimately he died during treatment in Sir Ganga Ram Hospital, Delhi on 20.8.2017. He has further argued that complainant has spent total amount of Rs.4,86,948/- and the opposite parties are liable to indemnify the said amount as per policy in question but the ops have wrongly and illegally repudiated the claim of complainant on the false ground of pre-existing disease and non disclosure of material facts and have only sent cheque of Rs.788/-. The ops have not proved on record any pre-existing disease of husband of complainant through reliable and cogent evidence and prayed for acceptance of the complaint. Learned counsel for complainant has relied upon judgment of the Hon’ble Rajasthan State Commission Jaipur in case titled as NIC & Anr. Vs. Mahendra Singh, 2009(4) CPJ 519, also decision of the Hon’ble National Commission in case titled as Branch Manager, Star Health & Allied Insurance Co. Ltd. Vs. Umesh Badani & Ors. 2016 (3) Law Herald 2102 and decision of Hon’ble Haryana State Consumer Disputes Redressal Commission, Panchkula in case titled as LIC of India Vs. Bidya Devi & Ors. 1995 (3) CPJ 481.

7.             On the other hand, learned counsel for ops has argued that husband of complainant obtained the policy in question by suppressing the material fact of his pre-existing disease and he answered the questions that whether he is suffering from any disease in negative but however he was already suffering from disease of liver and as such the opposite parties have rightly repudiated the claim of complainant on the ground of non disclosure of material fact of pre-existing disease in the proposal form. He has further contended that in the discharge summary of Max Healthcare Hospital, Mohali Ex.R9 dated 21.3.2017 of Anil Sharma,  it is mentioned that small esophageal varices and large gastic varices, EVL done three years back and chronic alcohol consumption. Learned counsel for ops has relied upon judgments of the Hon’ble Supreme Court in cases titled as Satwant Kaur Sandhu Vs. NIAC, CA No.2776 of 2002 decided on 10.7.2009, P.C. Chako and another vs. Chairman, LIC and others, CA No.5322 of 2007 decided on 20.11.2007, decision of Hon’ble National Commission in case titled as UIIC Vs. Umrao Chand Daga & Ors. RP No.3821 to 3823 of 2010 decided on 14.9.2016, Surinder Kaur vs. NIC, Misc. Application No.129 of 2016 decided on 4.5.2016 (NC), and C.N. Mohan Raj vs. NIAC, RP No.2314 of 2012 decided on 8.10.2012 (NC).

8.             We have considered the rival contentions of the parties and have gone through the case file carefully.

9.             There is no dispute that husband of complainant namely Anil Kumar purchased health insurance policy from the opposite parties by paying a premium of Rs.6630/- and the complainant and Anil Kumar were insured under the policy which was effective from 22.9.2016 to 21.9.2017. The complainant claims that his husband Anil Kumar suffered problem of jaundice in the first week of January, 2017 i.e. during subsistence of the policy in question and prior to that he was hale and hearty and was not suffering any problem and the ops have wrongly repudiated the claim of complainant on false ground of pre-existing disease. According to the complainant, she has spent an amount of Rs.4,86,948/- on the treatment of his husband and the ops are liable to reimburse the same to the complainant and has relied upon various bills/ receipts. Whereas, the opposite parties to support their plea of pre-existing disease have relied upon copy of discharge summary of Max Healthcare Hospital Mohali Ex.R9 wherein  under history it is mentioned that Past Medical History, No significant past medical history, jaundice x 3 months, small esopohageal varices and large gastric varices, EVL done x 3 years back, chronic alcohol consumption but the opposite parties have not proved the said document by reliable and cogent evidence and have also not proved on record that insured Anil Kumar since deceased took any treatment for any pre-existing disease. The said document is only a photocopy and not signed by any doctor and therefore, it cannot be safely relied upon. The Hon’ble National Commission in case titled as Branch Manager, Star Health & Allied Insurance Co. Ltd. & anr. Vs. Umesh Badai & Ors. (supra) has held that “No proof has been brought on record to establish that the complainant took any treatment for pre-existing diseases- Appellants failed to establish, if there was any willful suppression of material facts on the part of the complainants- No grounds to interfere- Impugned order confirmed that insurer is also liable- Appeal dismissed.” The other authorities relied upon by learned counsel for complainant are also applicable to the facts and circumstances of the present case wherein it has been held that burden of proving suppression of facts upon appellants not discharged. The authorities relied upon by learned counsel for ops are not disputed but same are not applicable to the facts and circumstances of the present case. The ops have caused deficiency in service by not paying the genuine claim of the complainant.

10.            In view of the above, we allow the present complaint and direct the opposite parties to pay the amount of Rs.4,86,948/- to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which the complainant will be entitled to interest @9% per annum on the above said amount from the date of order till actual realization. We also direct the ops to further pay a sum of Rs.5000/- as compensation to the complainant for harassment, mental agony and litigation expenses. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.

Announced in open Forum:

Dt.:26.4.2019.  

                                                                        (Neelam Kashyap)

                                                                        President.

 

 

(Sunil Mohan Tirkha),           (Neelam)       

Member                             Member.