Haryana

Ambala

CC/175/2018

Sanjeev Kumar Sharma - Complainant(s)

Versus

Star Health - Opp.Party(s)

23 Jul 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

                                                                         Complaint case No.:  175 of 2018.

                                                                         Date of Institution         :  01.06.2018.

                                                                         Date of decision    :  23.07.2019.

 

Sanjeev Kumar Sharma s/o Shri Narinder Kumar, r/o House No.5140/3,Chowk Darzian, Ambala City.

……. Complainant.

                                                Versus

 

1. Star Health and Allied Insurance Company Ltd., 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034 through its Managing Director.
2. Star Health and Allied Insurance Company Ltd., Branch Office Ambala at SCO-180,1 to 3, 3^rd Floor, Minerva Complex, Rai Market, Ambala Cantt, through its Branch Manager.
3. Ms Rajesh Kumari, (Intermediary Code BA0000177291), Authorized Agent of Star Health and Allied Insurance Company Ltd, Branch Office Ambala at SCO-180,1 to 3, 3^rd Floor, Minerva Complex, Rai Market, Ambala Cantt.

 

     ….…. Opposite Parties.

 

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.

Shri Vinod Kumar Sharma, Member.                 

                            

Present:       Shri Sandeep Sharma, Advocate, counsel for complainant.

Shri Mohinder Bindal, Advocate, counsel for the OPs.

 

Order:        Smt. Neena Sandhu, President

Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay lump-sum amount of Rs.2,44,207/- as medi-claim alongwith interest @12% per annum.
2. To pay Rs.50,000/- as compensation for the mental agony and physical harassment suffered by the complainant alongwith litigation expenses.
   382.  

                   Any other relief which this Hon’ble Forum may deem fit.

 

Brief facts of the case are that on 17.01.2014, the complainant purchased a family floater accident and health service policy of Rs.5,00,000/- from the OPs No.1 & 2 and at the time of purchasing the policy, he made aware the OPs regarding his physical condition as well as of his family members and after verifying all the facts, the OPs issued the said policy w.e.f. 30.01.2014 covering all medical claim benefits with respect to complainant, his wife and two children. On 09.02.2014, he was suffering from bleeding from left nose and was taken to Alchemist Hospital, Panchkula, from where, his nose surgery was conducted. The said policy was cashless policy, therefore, nothing was charged from him by Alchemist Hospital and the Ops No.1 & 2 paid his medical claim to the hospital. The complainant got the said policy renewed from time to time and lastly renewed the same for the period from 30.01.2018 to 29.01.2019 for sum assured of Rs.6,50,000/- with basic floater of Rs.5,00,000/- of 2014. On 27.03.2018, complainant was having chest pain, breathlessness etc. and he was brought to the Alchemist Hospital, Panchkula on 28.03.2018, where, the doctors finally diagnosed the problem of DILATED CARDIOMYOPATHY SEVERE LV SYSTRLIC DYSFUNCTION (FF=25-30%) SYMPOTOMATIC 2:1 AV BLOCK and advised for permanent implantation of pacemaker. Vide letter dated 29.03.2018, the complainant and his family requested the OPs No.1 & 2 to provide cashless treatment, but they rejected the pre-authorized cashless treatment. As such, the complainant paid billed amount of Rs.2,44,207/- to Alchemist Hospital. He lodged the claim with the OPs No.1 & 2, but they on 10.05.2018 rejected the claim on the ground of non-disclosure of pre-existing disease, as per condition No.15 of the policy in question. The said condition of the policy was neither explained nor he ever consented. All the physical condition and treatment taken by him and his family were told to the OPs at the time of taking the said medical policy. By not paying the claim amount, the OPs have committed deficiency in service. Hence, the present complaint.

2.                 Upon notice, OPs No.1 & 2 appeared through counsel and filed written version, raising preliminary objections regarding jurisdiction and cause of action. On merits, it is stated that the complainant suppressed the true and material facts about pre-existing disease. As per the Outpatient record card dated 19.07.2012, the complainant was suffering from hypertension and the disease of DOS class II since two years and was advised Echo. As per outpatient record the complainant was diagnosed as DCMP and was under continuous treatment thereon. Moreover, as per authorization form, complainant is a known case of DCMP with EF 30% and on treatment since 2012, followed pacemaker implantation. It is also stated that the complainant was suffering from DM, HTN and heart disease since 6 years, prior to inception of first medical insurance policy in the year 2014. Under the insurance contract utmost good faith must be observed by the contracting parties and insured has a duty to disclose each and every information and material fact about pre-existing ailment at the time of availing the policy. The complainant had taken the policy by concealing these facts, hence violated the terms and conditions of the policy and thus, is not entitled to any claim and the claim was rightly repudiated on 10.05.2018. On merits, rest of the allegations levelled by the complainant were denied for lack of knowledge and prayer has been made for dismissal of the present complaint. The learned counsel for OP No.3 made a statement that he does not want to file written statement on behalf of OP No.3 and written statement filed on behalf of OPs No.1 & 2 be read as written statement of OP No.3.

3.                The ld. counsel for the complainant tendered affidavit of the complainant as Annexure CA along with documents as Annexure C-1 to C-14 and closed the evidence on behalf of complainant. On the other hand, learned counsel for OPs tendered affidavit of Mamta, Authorized Signatory, Star Health & Allied Insurance Company Ltd., Chandigarh as Annexure RA alongwith documents Annexure R1 to R10 and closed the evidence on behalf of OPs.

4.                We have heard the learned counsel of the parties and carefully gone through the case file and also the case laws referred by the ld. counsel for the complainant.

5.                 The ld. counsel for the complainant has argued that on 17.01.2014, the complainant had purchased a family floater accident and health policy for Rs.5 lacs from the OPs No.1 & 2 through OP No.3. At the time of purchase of said policy, complainant made aware the OPs regarding his physical condition as well as of his family members and after verifying all the facts, the OPs issued the said policy w.e.f. 30.01.2014 covering all medical claim benefits with respect to complainant, his wife and two children. The complainant got the said policy renewed from time to time and lastly renewed the same for the period from 30.01.2018 to 29.01.2019, for sum assured of Rs.6,50,000/-, basic floater of Rs.5,00,000/- of 2014. On 27.03.2018, the complainant was having chest pain, breathlessness etc. and he was brought to the Alchemist Hospital, Panchkula on 28.03.2018. The doctors diagnosed the problem of DILATED CARDIOMYOPATHY SEVERE LV SYSTRLIC DYSFUNCTION (FF=25-30%) SYMPOTOMATIC 2:1 AV BLOCK and advised for implantation of pacemaker. The complainant and his family vide letter dated 29.03.2018 requested the OPs No.1 & 2 for cashless treatment, but they rejected the pre-authorized cashless treatment. As a result thereof, complainant paid the bill amount of Rs.2,44,207/- to the said hospital himself. He lodged the claim with the OPs No.1 & 2, but they on 10.05.2018 rejected the claim on the ground of non-disclosure of pre-existing disease, as per condition No.15 of the policy in question. The condition No.15 of the policy was neither explained nor he ever consented. The complainant has never concealed from the OPs about his physical condition and earlier treatment taken by him. The OPs have arbitrarily repudiated his claim vide letter dated 10.05.2018, which amounts to deficiency in service. To support of his contention, the ld. counsel for the complainant has placed reliance on the cases, titled as Satish Chander Madan Vs. Bajaj Allianz General Insurance Co. Ltd., I(2016) CPJ 613 (NC); M/s New India Assurance Co. Ltd. Vs. Lalit M. Bhambani and another, 2002 (1) CLT, 649 (NC); Kamla Devi Vs. Life Insurance Corporation of India & Ors., II (2016) CPJ 649 (NC); Rajinder Singh Malik Vs. Sr. BR. Mgr., LIC of India and others, 2018 (4) CLT, 96 (NC) and M/s Bajaj Allianz Life Insurance Co. Ltd. Vs. D. Ayyapu Reddy, 2017 (4) CLT, 44 (NC).

6.                Contrary to it, the ld. counsel for the OPs has argued that the claim of the complainant has rightly been repudiated, because, he has concealed the material facts regarding his health from the insurance company. From the Outpatient record card dated 19.07.2012, it is apparent that complainant was suffering from hypertension and the disease of DOS class II since two years and was advised Echo. As per authorization form, complainant is a known case of DCMP with EF 30% and on treatment since 2012, followed pacemaker implantation. It is also stated therein that the complainant was suffering from DM, HTN and heart disease since 6 years, prior to inception of first medical insurance policy in the year 2014. The complainant had taken the policy by concealing these facts, hence violated the terms and conditions of the policy and thus, is not entitled to any claim.   

7.                From the policy document Annexure C-1, it is evident that the complainant had taken the policy in question from the OPs No.1 & 2 for the first time on 30.01.2014 for sum assured of Rs.5,00,000/- and got the same renewed from time to time and lastly renewed for the period from 30.01.2018 to 29.01.2019. From the repudiation letter dated 02.04.2018 (Annexure C3), it is evident that the OPs No.1 & 2 repudiated the claim of the complainant on the ground of non-disclosure of material facts about his health. From the perusal of proposal form Annexure R-10, it is evident that the complainant has given reply in negative to all questionnaire regarding personal history of his health. The plea of the OPs is that the complainant had taken the policy in question by concealing the material facts about his health. To corroborate this fact, they have placed on record copy of the Outpatient record dated 03.08.2012 (Annexure R3), 12.12.2012 (Annexure R-4), 19.07.2012 (Annexure R-5) of the Alchemist Hospital, Panchkula and certificate issued by the Alchemist Hospital (Annexure R-6). Perusal of Outpatient record of Alchemist Hospital, Panchkula, Annexure R2 to Annexure R5, pertaining to year 2012, reveals that complainant was taking treatment for the diseases Dilated Cardiomyopathy (DCM) i.e. heart disease, hypertension (HTN) and DOE class II, since the year 2012. As such, the complainant by giving wrong answers to the questions, put to him at the time of taking the insurance policy in the year 2014, had concealed the material information about his health, from the insurance company, whereas, from the medical record (referred to above), it is clear that the complainant was taking treatment for above-mentioned diseases since 2012. In the case of Satwant Kaur Sandhu Vs. New India Assurance Company Ltd, IV(2009) CPJ 8 (SC), the Hon’ble Supreme Court has held that in a contract of insurance, any fact which  would  influence the mind of a prudent  insurer  in deciding  whether  to accept  or not to accept  the risk is a “material fact”. If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal from. Needless to emphasise that any inaccurate answer will entitle  the insurer to repudiate his liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering  into a Contract of Insurance. It is proved on record that the complainant was suffering from the diseases (referred to above) since long, for which, he was taking treatment since 2012, but he did not disclose this fact while taking the policy in question in the year 2014, therefore, in view of the law laid down by the Hon’ble Supreme Court in the case Satwant Kaur Sandhu Vs. New India Assurance Company Ltd (supra), the complainant is not entitled to get any benefit under the policy and the complaint filed by him, is liable to be dismissed. The case laws relied upon by the ld. counsel for the complainant are not applicable to the present case.

8.                In view of the aforesaid discussion, we hereby dismiss the present complaint being devoid of merits. The parties are left to bear their own cost. Certified copies of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on :23.07.2019.

 

 

 

          (Vinod Kumar Sharma)           (Ruby Sharma)               (Neena Sandhu)

              Member                                  Member                       President