Delhi

East Delhi

CC/998/2014

RAMESH - Complainant(s)

Versus

STAR HEALTH - Opp.Party(s)

03 Jan 2018

ORDER

          DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.       998/2014

                                                                                                   Date of Institution               01/11/2014

                                                                                                   Order reserved on               03/01/2019        

                                                                                                   Date of Order                        04/01/2018                                                                                     

 

In matter of

Mr Ramesh Sachdeva, adult   

R/o-A-11A, Block A,

East Krishna Nagar, Delhi 110051……..……….……………...…………….Complainant

                             

                                      Vs

 

1- M/s Star Health & Allied Insurance Co. Ltd.

209 & 210, 2^nd Floor, Lakshdeep Building,  

District Centre East, De;hi 110092

 

2-M/s M/s Star Health & Allied Insurance Co. Ltd. 

 VI Floor, KRM Centre, no. 2,

Harrignton Road, Chitpet Road, Chennai 600031 ……...…………..Opponents

 

Quorum   Sh Sukhdev  Singh       President

                   Dr P N Tiwari                Member

                   Mrs Harpreet Kaur      Member                                                                                             

 

Order by Dr P N Tiwari  Member

 

Brief Facts of the case                                                                                                

Complainant took Health Shield Insurance Policy from OP1/ Star Health & allied Insurance Co Ltd having its office at District centre East Delhi having tenure of policy from 10/03/2012 to 09/03/2013 vide policy no. P/161112/01/2012/008810 (Ex CW1/1) with terms and conditions printed at the back of the policy (Ex CW11/1A) and renewed up to 11/03/2014 to 10/03/2015 and had sum assured amount Rs 5 Lac (Ex CW1/2 and Ex CW1/3).  

Complainant’s wife was admitted for pain abdomen at Surya Hospital, Krishna Nagar, Delhi on 05/05/2014 and was discharged on 09/05/2014. As the cashless was denied by OP, so complainant paid treatment bill of a sum of Rs 72,917/- (Ex CW1/4) including medicines and Mesh charges. After filing reimbursement for treatment cost incurred as claim, OP1 repudiated the claim on dated 20/11/2014 (Ex CW1/8) stated that the diagnosed ailment as “Recurrent Anterior Abdominal wall Incision hernia” which was present for the last 7 years and the claim policy was in third year. It was stated that their genuine claim was not passed, but OP harassed the complainant. Seeing deficiency in service of OPs, claimed refund of treatment cost a sum of Rs 72917/- with 24% with Rs 15,000/-as litigation charges.  

OP1 and behalf of OP2 denied all the facts and alleged allegations stated in the complaint in their written statement though it was admitted that the said policy was issued by the OP from their Vaishali branch in UP and claim was lodged in the third year of the policy and cashless was rightly denied by OP as the facts given in the requisition form for cashless were pertaining to a case of recurrent anterior abdominal wall incisional hernia for the last 10 years which was due to the LSCS done at 14 years back. After scrutinizing the treatment documents, policy terms and conditions and policy proposal form which were annexed here as Anne. OPW1/2 to 7, claim was repudiated on the ground of Non disclosure of material facts in policy proposal form. Hence the claim was rightly repudiated as per the terms and condition of the clause.  

OP had annexed all the treatment documents with treating doctor/ surgeon’s prescriptions dated 28/04/2014 which clearly stated that complainant’s wife/patient had underwent surgery for the incisional hernia 10 years back for LSCS which had been done 14 years back (Ex OPW1/3 &4). Complainant had not annexed the Discharge Summary of treating hospital. Under the terms and conditions of the policy, treatment of ‘Pre existing ailments/diseases’ were covered after 48 months of policy tenure without breakup, but here claim was lodged in the third year of the policy which was not payable and complainant was duly informed about the status of his claim (Ex OPW1//5 and 6).

OP also submitted reference of Hon Supreme Court citation referring Section 45 of the Insurance Act, 1938 which were the most important for claiming reimbursement from OP as under –

• ‘the statement must be on a material matter or must suppress facts which it was material to disclose,
• The suppression must be fraudulently made by the policy holder;
• The policy holder must have known at the time of making statement that it was false or that it was suppressed facts which it has material to disclose.   

OP1 also relied on “Satish Kumar vs Branch Manager, LIC in RP 4678/2009 (NC) where it was held that “it is difficult to believe that such a major ailment was not known to the complainant. The documents relating to the treatment taken for this disease for long period are filed on record; therefore it cannot be believed that he did not know about their existence. Under these circumstances, we find that the respondent/complainant is not entitled to any relief”. Hence, OP prayed for the dismissal of this complaint.  

 

The complainant filed rejoinder where he denied all the replies submitted in written statement by OP and stated his claim as genuine. He also filed his evidences by way of affidavit where he affirmed on oath himself that his all the contents and evidence in the complaint were correct and true to his knowledge and had been on record as exhibits CW1 to 8.  

 

OP submitted evidences on affidavit through Mr.  Rajnish Kohli, working as Assistance Vice President, Claims with OP1 and affirmed that policy was issued after complainant filled his policy proposal form which had been on record and policies were always issued based on information given by the policy seekers and based on good faith. It was submitted that after claim was lodged by the complainant for recurrent anterior abdominal wall incisional hernia which was present for the last 10 years and had underwent repairs also was due to LSCS done at 14 years back. After proper scrutiny of all claim documents, it was revealed that complainant had suppressed her past ailment of LSCS leading to abdominal wall incision hernia and was repaired earlier which was not disclosed correctly by the claimant/insured in the policy proposal form where policy seeker has to disclose every details correctly. This time again hernia had re-occurred at the operation/LSCS site and Hernioplasty, a major repair by using Mash (net) was done. Henceforth, rejection by OP was justified based on terms and condition of the policy. OP had also filed their written arguments and taken on record.

Arguments were heard and after perusal of file, order was reserved.

 

After perusal of all the documents on record, we have gone through terms and conditions of the policy pertaining to the exclusion. It is clear that occurrence of Recurrent Abdominal Wall Incisional Hernia is a known cause of previous abdominal surgery and here complainant’s wife had under gone LSCS 14 years back as it corresponds to Ex CW1/1 when first policy was issued showed that the last child had 16 years of age and also from the treating surgeon’s prescription where it was mentioned that complainant’s wife had LSCS 14 years back and had undergone Herniorraphy (incisional hernia repair) 10 years back (Ex CW1/4). The first policy was taken from 10/03/2012 to 09/03/2013 and insured /complainant had not disclosed correctly for LSCS operation and Hernia repair about 10 years back in the policy proposal form which forms material fact to OP. This amounts to clear violation of policy terms and conditions of the policy as policy is issued by OP in good faith after declaration signed in the policy proposal form.   

 

Hence, we come to the conclusion that claim repudiation by OP was justified in reference to the term and conditions of the policy under non disclosure of material facts. Thus there is no merit in this case as complainant could not prove by any evidence that his wife had not under gone any such operation (LSCS) and subsequently diagnosed ‘ailment’ was for the first time.

The complaint deserves to be dismissed, so dismissed without any order to cost.

Copy of this order be sent to the parties as per the Section 18 of the Consumer Protection Regulation, 2005 (in short the CPR) and file be consigned to Record Room under Section 20(1) of the CPR.

 

(Dr) P N Tiwari  Member                                                                         Mrs  Harpreet Kaur  Member                                                                                                                         

                                      

                                                  Shri  Sukhdev Singh  President