Delhi

East Delhi

CC/714/2015

SUNDER SINGH - Complainant(s)

Versus

STAR HEALTH - Opp.Party(s)

30 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.      714/2015

                                                                                                   Date of Institution              16/09/2015

                                                                                                   Order reserved on              30/01/2018        

                                                                                                   Date of Order                      01/02/2018                                                                                     

 

In matter of

Mr Sunder Singh, adult   

S/o- Kishan Pal Singh,

R/o- C- 164, Gharoli Extn.

Mulla Colony, Delhi 110096…….…………………...…………….Complainant

                             

                                      Vs

1-The Manager

Star Health Insurance Co. Ltd. (Grievance Dept.)

HO.- No.1, New Tank Street, Valluvar Kottam High Road,

Nungambakkam, Chennai- 600034

 

2-Mr Ateekur Rehman, Agent

BO- 209-210, Laxmi Deep Building,

District Centre, Lamxi Nagar, Delhi 110092…….…………..Opponents

 

Complainant’s Advocate        Vipin Kumar   

Opponent  Advocate               Amit kumar Mathan

 

Quorum                                     Sh Sukhdev  Singh       President

                                                    Dr P N Tiwari                Member

                                                    Mrs Harpreet Kaur      Member                                                                                              

 

Order by Dr P N Tiwari  Member -

Brief -

This complainant has been filed u/s 12 of the Consumer Protection Act, 1986 against OP for alleged deficiency in their services for repudiating mediclaim under pre existing diseases in mediclaim policy.

Facts of the case-                                                                                                

Complainant took Family Health Optima Insurance Policy as Family Floater policy from OP2/agent and received mediclaim policy from OP1 vide policy no. P/1661111/01/2015/006182  having its tenure from 14/10/2014 to 13/10/2015 insured for a sum of Rs 3 lacs covering four members (Ex CW1/1) after filing policy proposal form and paying premium amount Rs 8140/-.  

Complainant stated that he was admitted in Kailash hospital at Noida on 22/12/2014 and was discharged on 25/12/2014 (Ex CW1/2,2A & 2B) after proper investigations as MRI (Ex CW1/3), brain EEG (Ex CW1/6), Head NCCT (Ex CW1/5) and treatments. His cashless request was denied by OP (Ex CW1/8A), so paid treatment bill of Rs 66,504/-(Ex CW1/2, 2A & 2B).

Complainant submitted claim with all the required claim documents on 10/01/2015 (Ex CW1/8), but complainant did not get any response about his claim status, so he visited OP2 office number of times and finally on 17/04/2015, he received repudiation letter from OP2 that his claim was rejected on the basis of pre existing disease and non disclosure of previous admission in 2013, prior taking policy (Ex CW1/8A). Complainant wrote request letters for re- consideration of his claim (Ex CW1/9), but did not get any reply, so sent legal notice to OP for paying his claim amount (ExCW1/10). When no reply was received complainant filed this compliant claiming treatment bills of Rs 66,504/-with compensation of Rs 80,000/-as mental harassment and Rs 30,000/- as litigation charges.  

OP1 submitted written statement denying all the facts and allegations of deficiency in services. It was submitted that the complainant was an educated person and had gone through all the terms and conditions carefully while filing the policy proposal form and thereafter he signed the declaration form. It was also submitted that OP2 was not a necessary party as agent was working on their behalf at OP2 office. OP admitted that the said Family Floater policy was issued to complainant after proper filing proposal form and non disclosing correct facts about his health conditions. Policy was issued from 14/10/2014 to 13/10/2015 based on the declared facts and in good faith. Claim was filed within three months of issuing of policy, proper scrutiny was done and it was found that complainant had under gone Angiography on 11/06/2013 at Kailash Hospital, but this fact was not disclosed in the policy proposal form (Ex OPW1/1). The details papers pertaining to Angiography were submitted by OP2 and based on these facts claim was repudiated under policy exclusion clause 1 (Ex OPW1/3) and repudiation letter was sent to the complainant on 15/05/2015 (Ex OPW1/4).

It was clearly mentioned that the present claim for “Seizures Disorders with Calcified Granulomma” was payable after 48 months of continuous policy without break, but this claim was reported within three months. Thus OP had no deficiency in their services and acted as per the policy terms and conditions, so complaint may be dismissed.

Complainant filed his rejoinder and denied all the replies submitted by OP and stated that his genuine claim was wrongly denied. He had submitted all relevant evidences on affidavit and reaffirmed on oath that all facts and evidences were correct and true.

OP also submitted their evidences by way of affidavit through Mr Rajnish Kohli working as Assist. Vice President claims with OP stated that all their evidences and replies to the complaint were correct and true, It was also stated that all the policies were issued on the basis of good faith after policy seeker wished to take policy and did not disclose his all facts asked in policy proposal form. Based on the citation of Hon. Supreme Court as Satwant Kumar vs NIA, 2009, where it was laid down that all the facts as material be mentioned clearly in the policy proposal form and suppression of any fact material for the consideration to Insurance Co. Company shall not be liable for claim.

It was also stated that complainant was an educated person and had read all the contents of the policy proposal form and not mentioning correctly for Heart and Brain related queries pertains to intentionally hiding material facts. It was stated that complainant did not mention anywhere about Angiography was done in 2013 and reason for getting examined and investigated for Heart related or Hypertension related problem, if any, but mentioned all “NO, NO” in the required columns in policy proposal form and had signed also in declaration.

Arguments were heard from both the party counsels and order was reserved.

After scrutinizing all facts and evidences on record, it was seen that claim was filed during first year and OP had taken stand of Angiography which was dome prior to policy, but there was no evidence of Seizures Disorders prior to the inception of policy.

Appreciating the definition of exclusion clause 1 as Pre existing diseases, the onus lies on the head of OP to prove that the same disease (Seizures disorder) was present and insured was taking medicines for the disease, but here OP has not filed any concrete evidence in support of Pre Existing disease merely relying on discharge summary dated 10/06/2013 (Ex OPW1/6) from Metro Hospital, Noida.

We have analysed the discharge summary (Ex OPW1/6) which pertains to the procedure of finding any abnormality in the vascular system of heart, but the findings were normal. No treatment was adviced by the treating doctor. Hence, it cannot be assumed or presumed that complainant was having Seizures disorders and granulomas (due to abnormal findings in brain).

Thus, we find merit in this complaint and pass the following order as under—

1. OP is directed to pass the claim of Rs 66504/- as treatment cost within 30 days from the receiving of this order.
2. We also award compensation of Rs 7500/- for harassment and mental agony. This shall include the litigation charges also.
3. If OP fails to comply the order, complainant shall be entitled for 7% interest from the date of filing of this complaint till realized.
4. There shall be no order to cost.

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

(Dr) P N Tiwari  Member                                                                          Mrs  Harpreet Kaur  Member

                                       

                                                            Sukhdev Singh  President