THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR
Consumer Complaint No. 24 of 2015
Date of Institution : 8.1.2015
Date of Decision : 4.06.2015
Shri Arun Kumar son of Sh. Manohar Lal, aged about 56 years, resident of H.No. 29-G, Street No.4, Krishna Nagar, Gali Murabbe Wali, Tarn Taran Road, Amritsar
...Complainant
Vs.
Star Health and allied Insurance Company Ltd., KRM Centre, 6th Floor No.2 Harrington Road, Chetpet, Chennai 600031
The Branch Manager, Star Health and Allied Insurance Company Limited, SCO 25, First Floor, Ranjit Avenue, District Shopping Complex, Amritsar 143001
....Opp.parties
Complaint under section 12/13 of the Consumer Protection Act, 1986
Present : For the complainant : Sh.Ganesh Kumar Sharma,Advocate
For the opposite parties : Sh.S.S.Salaria,Advocate
Quorum : Sh. Bhupinder Singh, President ,Ms. Kulwant Bajwa,Member &
Sh.Anoop Sharma,Member
Order dictated by :-
-2-
Bhupinder Singh, President
1 Present complaint has been filed by Sh. Arun Kumar under the provisions of the Consumer Protection Act alleging therein that he has been obtaining health insurance policies from the opposite party regularly i.e. policy for the period from 20.5.2010 to 19.5.2011 vide policy No. P/211111/01/2011/000157 , policy for the period from 20.5.2011 to 19.5.2012 vide policy No. P/211111/01/2012/000287, policy for the period from 20.5.2012 to 19.5.2013 vide No. P/211111/01/2013/000238, policy for the period from 20.5.2013 to 19.5.2014 vide No. P/211111/01/2014/000464 and lastly policy for the period from 20.5.2014 to 19.5.2015 vide No. P/211111/01/2015/000410. According to the complainant during the subsistence of policy period from 20.5.2014 to 19.5.2015 , he remained admitted in EMC Super Speciality Hospital, Amritsar due to urine infection for the period from 21.7.2014 to 23.7.2014. Complainant informed the opposite parties vide intimation No. CLI/2015/211111/0087457 and claim of Rs. 15888/- was lodged with the opposite parties . Opposite parties vide letter dated 20.9.2014 repudiated the claim of the complainant on the ground of non-disclosure of pre-existing disease. In the said letter dated 20.9.2014 it is submitted that complainant remained admitted in hospital from 18.6.2005 to 19.6.2005 due to Rheumatic heart disease . But there is no nexus of pre existing Rheumatic heart disease and urinal infection for which the complainant remained admitted in the hospital for the period from 21.7.2014 to 23.7.2014 and the opposite parties illegally repudiated the claim of the complainant. Alleging the same to be deficiency in service complaint was filed seeking directions to the opposite parties to pay Rs. 15888/- which were spent by him on his treatment . Compensation of Rs. 50000/- alongwith litigation expenses were also demanded.
2. On notice, opposite parties appeared and filed written version in which it was submitted that complainant had obtained the policy under Family Health Optima Insurance Policy No. P/211111/01/2015/000410 effective from 20.5.2014 to 19.5.2015. The complainant admitted in EMC Super Speciality Hospital,Amritsar on 21.7.2014 and on receipt of the pre-authorization request from the treating hospital, the opposite party called and scrutinized the claim records and it was observed that the complainant had Balloon Mitral Valvotomy and Rheumatic Heart disease (RHD), as such the cashless authorization was denied on the basis of non-disclosure of material facts and the same was duly communicated to the complainant vide letter dated 22.7.2014. It was submitted that the complainant submitted the claim form alongwith documents for reimbursement of hospitalization expenses for treatment of Rheumatic heart disease (RHD) , Multiple Organ dysfunction, Multiple Sclerosis (MS), Balloon Mitral Valvotomy, severe, Aortic Stenosis, Congestive Heart failure and Acute kidney injury and same were duly perused and claim was processed and on scrutiny of same, it was observed that the complainant is a known case of Rheumatic heart disease (RHD) and had undergone treatment for the Balloon Mitral Valvotomy and from consultation report dated 19.7.2014 it was observed that the complainant had a history of CAD (Mitral Valvoplast) since 2005. It was further submitted that at the time of inception of first policy, the complainant had not disclosed the above mentioned medical history/health details of the insured in the proposal form which amounts to non-disclosure of material facts and as such in view of condition No. 7 of the policy, if there is any misrepresentation/non-disclosure of material facts, the company is not liable to make payment in respect of any claim and as such the claim was repudiated and the complainant was duly informed in this regard vide letter dated 20.9.2014 and there is no deficiency of service on the part of the opposite parties.
3. Complainant tendered into evidence his affidavit Ex.CW1/A, copies of policy schedules Ex.C-1 to C-5, claim status Ex.C-6, repudiation letter dated 20.9.2014 Ex.C-7, letter dated 3.11.2014 Ex.C-8, copy of legal notice Ex.C-9, postal receipts Ex.C-10 and C-11, reply to legal notice Ex.C-12, letter dated 9.12.2014 Ex.C-13, copy of draft of Rs. 2107/- Ex.C-14, endorsement schedule dated 3.12.2014 Ex.C-15, policy schedule dated 3.12.2014 Ex.C-16, advanced premium receipt datd 3.12.2014 Ex.C-17, undated letter sent by the opposite party Ex.C-18, another undated lettr sent by the opposite party Ex.C-19.
4. Opposite parties No.1 & 2 tenderd affidavit of Sh. Rajnish Kohli ,Asstt.Vice President Ex.OP1,2/1, copy of terms and conditions of family health Optima Insurance Plan Ex.OP1,2/2, copy of proposal form Ex.OP1,2/3, copy of policy schedule Ex.OP1,2/4, copy of endorsement schedule Ex.OP1,2/5, copy of policy individual schedule Ex.OP1,2/6, copy of claim form for medical insurance Ex.OP1,2/7, copy of medical certificate from treating doctor Ex.OP1,2/8, copy of discharge card Ex.OP1,2/9, copy of pre-authorization request form Ex.OP1,2/10, copy of denial for pre authorization for cashless treatment Ex.OP1,2/11, copy of status of intimation Ex.OP1,2/12, repudiation of claim Ex.OP1,2/13, copy of intimation letter dated 3.11.2014 Ex.OP1,2/14, copy of legal notice dated 3.12.2014 Ex.OP1,2/15, copy of reply to legal notice Ex.OP1,2/16, copy of letter regarding non disclosure of policy cancellation Ex.OP1,2/17, copy of refund draft of Rs. 2107/- Ex.OP1,2/18, copy of discharge summary dated 19.6.2005 19, copy of Lab report Ex.OP1,2/20, copy of ECG report Ex.OP1,2/21, copy of renal and liver profile report Ex.OP1,2/22, copy of X-ray chest report Ex.OP1,2/23, copy of ultrasound report Ex.OP1,2/24, copy of Lab investigation report Ex.OP1,2/25, copy of ECG report Ex.OP1,2/26, copy of fluid examination report Ex.OP1,2/27, copy of rnal profile report Ex.OP1,2/28.
5. We have carefully gone through the pleadings of the parties, arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by both the parties , it is clear that complainant obtained health policy from the opposite parties for the period from 20.5.2010 to 19.5.2011, 20.5.2011 to 19.5.2012, 20.5.2012 to 19.5.2013, 20.5.2013 to 19.5.2014 and from 20.5.2014 to 19.5.2015 Ex.C-1 to Ex.C-5 respectively. The complainant became ill due to urine infection and was admitted in EMC Super Speciality Hospital on 21.7.2014 and was discharged on 23.7.2014. The complainant spent Rs.15,888/- on his medical treatment. Claim was lodged with the opposite party alongwith all the relevant documents. But the opposite party repudiated the claim of the complainant vide letter dated 20.9.2014 Ex.C-7 on the ground that at the time of inception of first policy Ex.C-1 for the period from 20.5.2010 to 19.5.2011 the complainant has not disclosed the true status of his health and has concealed the material facts because the complainant remained admitted in Fortis Escort Hospital from 18.6.2005 to 19.6.2005 as a case of Rheumatic Heart disease etc. Not only this the opposite party sent another letter dated 3.11.2014 Ex.C-8 telling the complainant that policy of the complainant has been cancelled. The complainant served legal notice dated 3.12.2014 Ex.C-9 but the opposite party did not pay any heed to the request of the complainant. Ld.counsel for the complainant submitted that all this amounts to deficiency of service on the part of the opposite parties qua the complainant.
7. Whereas the case of the opposite parties is that on receipt of the request of the complainant regarding admission in EMC Super Speciality Hospital,Amritsar on 21.7.2014 the opposite party called and scrutinized the claim records and it was found that complainant had Balloon Mitral Valvotomy and Rheumatic Heart Disease (RHD), so the cashless question was denied on the basis of non-disclosure of material facts and this fact was duly communicated to the treating hospital as well as to the complainant vide letter dated 22.7.2014. However, claim form was sent to the complainant to submit the claim for reimbursement . The complainant submitted the claim form alongwith documents for reimbursement of expenses for treatment of Rheumatic Heart Disease (RHD), multiple organ dysfunction, multiple sclerosis (MS), Balloon Mitral Valvotomy, Congestive Heart Failure etc. The same were duly perused. Claim was processed and on scrutiny of discharge summary dated 18.6.2005 of the complainant, it was observed that complainant is a known case of Rheumatic Heart Disease detected long back and he had undergone treatment for Balloon Mitral Valvotomy and the complainant had a history of CAD (Mitral Valvoplast) since 2005. So at the time of inception of the first policy w.e.f 20.5.2010, the complainant had not disclosed the above mentioned medical history/health details in the proposal form which amounts to mis-representation/non-disclosure of material facts . Therefore, as per condition No. 7 of the policy, the complainant is not liable to make payment in resepct of any claim and the same was duly repudiated and the complainant was informed vide letter dated 20.9.2014. Not only this the policy of the complainant was also cancelled by the opposite party. ld.counsel for the opposite party submitted that as the complainant is at fault, so he cannot claim any equity from the opposite parties. As such there is no deficiency of service on the part of the opposite parties qua the complainant.
8. From the entire above discussion, we have come to the conclusion that the complainant obtained first health insurance policy from the opposite party for the period from 20.5.2010 to 19.5.2011 Ex.C-1 and thereafter he continued the same vide policy Ex.C-2 to Ex.C-5 respectively i.e. lastly Ex.C-5 for the period from 20.5.2014 to 19.5.2015. The complainant was admittd in EMC hospital,Amritsar from 21.7.2014 to 23.7.2014 as per discharge card Ex.OP9 and the complainant was diagnosed suffering from Rheumatic heart disease (RHD), BMV (Balloon Mitral Valvotomy) etc. The complainant while taking the first policy from the opposite parties i.e. policy Ex.C-1 for the period from 20.5.2010 to 19.5.2011 has not disclosed his real status of health. In the proposal form Ex.OP/3 which was duly filled in and signed by the complainant, he has not mentioned this fact that he remained admitted in Fortis Escort Hospital from 18.6.2005 to 19.6.2005 and he was diagnosed as a known case of Rheumatic heart disease and had undergone treatment for Balloon Mitral Valvotomy and the complainant had a history of CAD (Mitral Valvoplast) since 2005 and this status intimation Ex.OP/12 was sent to the complainant. The discharge summary of Fortis Escort Hospital in this regard is Ex.OP/19. Rather the complainant has disclosed his health status as good and has categorically stated in his proposal form Ex.OP/3 that he did not suffer from any disease and he never remained admitted in any hospital. All this fully proves that complainant has concealed the material facts while obtaining the first insurance policy from the opposite party Ex.C-1 for the period from 20.5.2010 to 19.5.2011. The complainant is,therefore, responsible for concealment of facts as he has obtained the policy in question from the opposite party by mis-representation as a result of concealment of true facts. It has been held by the Hon'ble National Commission in case Revision Petition No. 578 of 2013 titled as Smt.Shakuntala Vs. Life Insurance Corporation of India 2014(2) CLT 261 that where it is proved that the complainant has concealed the material information regarding surgery of the insured, the opposite party is not liable to pay any claim to the insured. Same view has been taken by the Hon'ble Supreme Court of India in Satwant Kaur Sandhu Vs,. New India Assurance Company Limited 2009(4) CLT 398 (SC) as well as in case V.N. Shrikhande (Dr.) Versus Anita Sena Fernandes 2011(1) CLT 262 (SC).
9. In view of these facts , we are of the opinion that the opposite party was justified in repudiating the claim of the complainant.
10. Resultantly we hold that complaint is without merit and the same is hereby dismissed with no order as to costs. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
11. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
4.06.2015 ( Bhupinder Singh )
President
( Kulwant Kaur Bajwa) (Anoop Sharma)
/R/ Member Member
