Haryana

Kurukshetra

188/2016

Satnam Singh - Complainant(s)

Versus

Star Health - Opp.Party(s)

A.R.Singh

28 Mar 2018

ORDER

BEFORE THE  DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, KURUKSHETRA.

 

Complaint no.188/16.

Date of instt.11.7.16. 

                                        Date of Decision: 28.03.2018.

Satnam Singh son of Gurbax Singh, resident of village Bachki, Post Office Lukhi , District Kurukshetra.

•  

                        Versus

1. Star Health & Allied Insurance Company Limited, Branch Office at SCO No.242, 1^st Floor, Sector-12, Opposite Mini Sectt. Karnal, through its Manager.
2. Smt. Parveen Lata wife of Sunil Kumar Sharma, Salesman/Agent of Star Health and Allied Insurance Company Limited, resident of village and post office Ajrana Kalan, Tehsil Thanesar, District Kurukshetra.

………Opposite parties.

 

Complaint under section 12 of Consumer Protection Act.                   

                                                                                      

 

Before                Sh. G.C. Garg, President.    

         Sh. Kapil Dev Sharma, Member

 

Present :            Sh.A.R.Singh, Adv. for complainant.

                        Sh. Mohit Goel, Adv. for Op No.1.

        Sh. Rajesh Kumar Tanwar,   Adv. for OP No.2.

                   

 

ORDER

 

                    This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Satnam Singh against Star Health and another, the opposite parties.

2.             It is stated in the complaint that the complainant has obtained a cashless medical policy bearing No.P/2111114/01/2015/000840 on 5.8.2014 from Op No.1 through Op No.2 valid for the period w.e.f. 5.8.2014 to 4.8.2015. At the time of taking policy, the complainant was quite fit, hale and hearty. Unfortunately, on 3.3.2015, the complainant felt ill and got high temperature/fever and on the advice of local doctor, the complainant got his blood examination and other tests conducted from Max Diagnostics and got general medicine for fever but in the night of 5.3.2015, the complainant felt uneasiness and could not had sound sleep, so in the intervening night of 5/6^th March, 2015 the complainant was taken to Aggarwal Nursing Home, Kurukshetra for better check up and treatment where the complainant was medico legally checked and his ECG, Blood test etc. were conducted in the hospital, where the doctor detected it to be a heart problem and the complainant was referred to Cardiac Surgeon, Max Hospital, Phase-6, Mohali on 6.3.2015 itself and required medicines were prescribed on the slip.  Thereafter, on the same day, the complainant was got admitted at Max Superspeciality Hospital, Mohali which was in the list of prescribed hospital covered under the insurance policy and the required medical tests including angiography were conducted and thereafter the bypass surgery was done by the concerned doctor and the complainant was discharged from the said hospital on 13.3.2015. An intimation in this regard was immediately given to the Ops and it was assured by the Ops that all the bills will be paid by Op No.1 being insurer as it is a cashless medical policy and it was also informed by the Ops that Max Hospital is in the list of the Hospitals of the OP. When the complainant was admitted in the Hospital, the relatives of the complainant on asking of staff of Hospital have deposited an amount of Rs.15,000/- on 6.3.2015 and also deposited a sum of Rs.1,80,000/- on 9.3.2015 as a security and it was assured that when the insurance company will pay the actual medical bills of the insured then the said amount will be refunded to the complainant. The staff of the Hospital waited sufficiently qua the payment of bills by the OP No.1 but when no bills were paid by OP No.1 up to lapse of sufficient time, the said bill to the tune of Rs.2,00,725/- was paid by the family of complainant. After being discharged from the hospital the family members of the complainant met to Ops and requested to pay the medical expenses upon which OP No.1 asked to submit all the original medical bills and complete record for investigation and it was assured that the amount of bill will be refunded to the complainant shortly. But later on the complainant was shocked when he received a letter dated 9.3.2015 from Op No.1  regarding denial of pre-authorization for cashless treatment wherein a vague reason was assigned that “as per submitted documents and CAG report, it is a case of chronic longs standing severe multi-vessel coronary artery disease, so the cashless authorization denied. The complainant time and again requested the Ops to pay the insured amount but they did not listen the request of complainant. Hence, it amounts to deficiency in service on the part of Ops. So, the present complaint has been moved by the complainant with the prayer to direct the Ops to pay Rs.2,00,725/-  as well as Rs.25,000/- which has been spent on medicines, follow up treatment etc. along with 18% interest, Rs.1,00,000/- as damages/compensation for mental agony and physical harassment and Rs.11,000/- as litigation expenses.

3.            Upon notice, opposite parties appeared. Opposite party no.1 contested the complaint by filing written statement alleging therein that the complainant has not approached to this Forum with clean hands as he has suppressed the material facts to get the claim; that the true and material facts of the case are of the complainant was suffering from MULTIPLE CORONARY ARTERY DISEASE, which was present prior to the inception of this policy. At the time of inspection of policy which is from 5.8.2014 to 4.8.2015, the insured has not disclosed the above mentioned medical history/health details of the insured person in the proposal form which amounts to misrepresentation/non disclosure of material facts and as per terms and condition No.7 of the policy, there is any misrepresentation/non disclosure of material facts whether the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of this claim. So, the claim was repudiated and the same was communicated to the insured vide letter dated 27.8.2015. Hence, in view of the facts and circumstances mentioned above, there is no deficiency in service on the part of answering Op and as such, the complaint of the complainant is liable to be dismissed with costs. On merits, the contents of the complaint were denied to be wrong. Preliminary objections were repeated. Prayer for dismissal of the complaint was made. 

5.             Opposite party no.2 contested the complaint by filing separate written statement alleging therein that the answering OP is only agent of OP No.1 and has nothing to do with the matter in dispute and it is in between complainant and OP No.1. Hence, in view of the facts and circumstances mentioned above, there is no deficiency in service on the part of answering Op and as such, the complaint of the complainant is liable to be dismissed with costs. On merits, the contents of the complaint were denied to be wrong. Preliminary objections were repeated. Prayer for dismissal of the complaint was made. 

4.            The complainant proved on records his own affidavit as Ex.CW1/A and documents as Annexure C1 to Annexure C16 and thereafter closed the evidence. On the other hand, the Op No.1 tendered into evidence affidavit, Ex.Rw1/A and documents Ex.R1 to Ex.R2 and closed the evidence. 

5.             We have heard learned counsel for the parties and have gone through the record carefully.

6.             The only question to be decided by this Forum is as to whether the complainant was suffering from the disease in question at the time of purchasing the policy or not.  The contention of ld. counsel for the complainant is that the complainant was suffering from such disease at the time of purchasing the policy.  However, the contention of Op No.1 is that the complainant was not suffering from any such disease at the time when the policy was purchased.  He has made the reference of certain documents.  As per Ex.R8 page 2, it is mentioned as CAD-USA-Not on RX which means CAD=Coronary Artery Disease, USA=Unstable Angina, not on RX=Not on medicines treatment.  Further, it is mentioned chest pain during exertion, relieved on rest.  Palpitation, Cold cough from y-5 days.  Further as per Ex.R1, it is mentioned JHD Unstable Angina, coronary angiography.  As per Ex.R5 in the discharge summary, final diagnosis is CAD, TVD, LVEF=45%.  In the past history of the same document, it is mentioned as Nil.   

                The contention of ld. counsel for the Op No.1 is that no angiography was got done of the complainant and as such, it cannot be said that the complainant was suffering from such disease at the time of purchasing the policy. 

                However, the counsel for the complainant has made the reference of certain documents as per second page of Ex.R2, it is mentioned that similar complaints of and on in less than two years for coronary angiography done today.  Similar is mentioned on the next page.  However, it cannot be said that the complainant was suffering from said diseases at the time when he was got admitted in the Max Hospital.  The ld. counsel for Op No.1 has relied upon Ex.R10, the repudiation letter in which it is mentioned that having this problem of and on past the two years, which is prior to inception of medical policy.  However, it cannot be said on what basis this is so mentioned in Ex.R10 without getting the angiography.  From the document Annexure C6, it is clear that the complainant has spent the amount of Rs.2,00,725/-.  It being the cashless policy, the complainant is entitled for the said amount from Op No.1.  The Op No.2 being merely an agent cannot be said to any liability. 

7.             Thus, as a sequel of above discussion, we allow the complaint and direct the Op No.1 to pay Rs.2,00,725/- to the complainant.  The order; be complied within two months, failing which, the complainant shall be entitled interest @ 6% p.a. from the date of order till its realization and in that eventuality, penal action under Section 27 of the Consumer Protection Act, 1986 would be initiated against the opposite party No.1.  Copy of this order be communicated to the parties free of cost.  File be consigned to record after due compliance. 

Announced in open court:

Dt.:28.03.2018.  

                                                                        (G.C.Garg)

                                                                        President.

 

 

(Kapil Dev Sharma)         

                                        Member