DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR
Consumer Complaint No. 262-14
Date of Institution : 14.5.2014
Date of Decision : 12.3.2015
Narinder Pal Singh,Advocate S/o Satpal Singh resident of # 21, Gayatri Colony,Kale Road, Chheharta,Amritsar (Punjab)
...Complainant
Vs.
Star Health and Allied Insurance Co.Ltd., SCO 25,First Floor, Ranjit Avenue,District Shopping Complex, Amritsar 143001 through its Manager
....Opp.party
Complaint: under section 12/13 of the Consumer Protection Act, 1986
Present : For the complainant : S/Sh. Rajesh Sharma & Sunil Nayyar,Adv
For the opposite party : Sh.R.P.Singh,Adv.
Quorum : Sh. Bhupinder Singh, President,
Ms.Kulwant Kaur Bajwa,Member & Sh. Anoop Sharma, Member
Order dictated by :-
Bhupinder Singh, President
-2-
1. Present complaint has been filed by Narinder Pal Singh under the provisions of Consumer Protection Act alleging therein that he had renewed Insurance policy namely Family Health Optima Insurance Policy bearing No. P/211111/01/2015/000205 for the sum assured Rs. 3,75,000/- for the period from 22.4.2014 (00:00:00) to the midnight of 21.4.2015 and the original policy No. was P/211111/1/2014/000157 of the sum assured Rs. 3,00,000/ for the period from 19.4.2013 to 20.4.2014. According to the complainant since 20.4.2014 was Sunday, so the policy could not be renewed. On 21.4.2014 when complainant went to the opposite party to renew the policy, he was told by the official of the opposite party that the server was down and asked the complainant that the policy will be renewed and the complainant should deposit the renewal money. The complainant deposited the money on 21.4.2014. According to the complainant on the intervening night of 21st and 22nd April 2014 at around 12.30 a.m he suffered uneasiness and restlessness and he went to Arora Hospital at 1.00 a.m where the doctor immediately took ECG of the complainant and got him admitted in the hospital at 1.07 a.m. On 22.4.2014 at about 1.35 a.m some tests were conducted at Dukh Niwaran Lab and the doctor of Arora Hospital referred the complainant to Fortis Escort Hospital . The complainant was shifted to Fortis Escort Hospital on 22.4.2014 at 3.00 p.m and after conducting various medical tests coronary Angiography was done and on the same evening Coronary Angioplasty was done and the complainant spent Rs. 3,48,907.42 paise on his medical treatment. The complainant lodged the claim with the opposite party but the opposite party repudiated the claim of the complainant on the ground that as per the documents provided, patient was symptomatic during break period when policy was not invoke as such the claim is not admissible and rejected. Alleging the same to be deficiency in service complaint was filed seeking directions to the opposite party to pay a sum of Rs. 3,48,907.42 paise alongwith interest. Compensation of Rs. 1,40,000/- alongwith litigation expenses were also demanded.
2. On notice opposite party appeared and filed written version in which it was submitted that complainant has concealed the material facts from this forum as such he is not entitled to any claim. It was submitted that complainant had earlier policy which was valid from 20.4.2013 to 19.4.2014. Thereafter the complainant obtained second policy which was issued for the period from 22.4.2014 to 21.4.2015 and there is a gap of three days and during this gap period the complainant suffered the problem which is not covered under the policy, therefore, th claim was repudiated and due intimation was given to the complainant vide letter dated 24.4.2014. It was denied that complainant went to the opposite party on 21.4.2014 to get the policy renewed. It was also denied that the opposite party informed that the server was down or asked the complainant that the policy will be renewed or the complainant should deposit the renewed money on 21.4.2014. It was submitted that previous policy was expired on 19.4.2014 , therefore, it was required to be renewed on 19.4.2014. As the policy was renewed by the complainant on 22.4.2014,therefore, there is a gap of three days in continuation between the two policies,therefore, it cannot be said that the second policy is in continuation of previous policy. As per terms and conditions of the policy, there is no provision that if on the next day of expiry of the policy is Sunday, the expiry of policy will extend. The complainant was required to get the policy renewed on or before 19.4.2014 for the continuation of the previous policy. It was denied that on the intervening night of 21/22.4.2014 at about 12.30 am complainant felt uneasiness and restlessness the complainant went to Arora Hospital at Chheharta where his ECG was got conducted by the doctors and after certain tests complainant was referred to Fortis Escort Hospital and after conducting various tests the procedure of Coronary Angiography was done and on the same evening Coronary Angioplasty was done and the complainant was admitted in Fortis Escort Hospital .It was submitted that the complainant suffered the disease on 21.4.2014, therefore, he was not covered under the policy. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence his affidavit Ex.C-1 alongwith documents Ex.C-2 to Ex.C-16.
4. Opposite party tendered into evidence affidavit of Sh.Karan Wadhwa Ex.OPA/1, copy of detail of policy dated 21.4.2014 Ex.OP1/A, copy of detail of policy dated 22.4.2014 Ex.OP1/B, copy of payment receipt dated 21.4.2014 Ex.OP1/C,affidavit of Sh. Rajnish Kohli Ex.OP1 alongwith documents Ex. OP2 to Ex.OP17.
5. We have carefully gone through the pleadings of the parties, arguments advanced by the ld.counsels for both the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsels for both 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 the policy namely family health optima insurance policy bearing No. P/211111/01/2015/000205 Ex.C-2 from the opposite party for the period from 22.4.2014 to 21.4.2015. The complainant submitted that the present policy has been renewed and as such this is second year . The earlier policy was for the period from 20.4.2013 to 19.4.2014 Ex.C-16. The complainant alleges that 20.4.2014 was Sunday and on 21.4.2014 the complainant went to renew the earlier policy and it was told by the clerk of the opposite party that the server was down so the policy of the complainant would be renewed later on, however the complainant deposited the money on 21.4.2014. The complainant felt uneasiness and restlessness and as such he went to Arora Hospital at Chheharta who immediately took ECG of the complainant Ex.C-4 on 22.4.2014 and got him admitted in the hospital on 22.4.2014. Thereafter the complainant was shifted to Fortis Escort Hospital on 22.4.2014 at 3.00 p.m.,where Coronary Angiography of the complainant was done and on the same evening Coronary Angioplasty was done and was discharged on 24.4.2014 as per inpatient bill of Fortis Escort Hospital Ex.C-12.The complainant spent Rs. 3,48,907.42 paise on his medical treatment. Claim was lodged with the opposite party But the opposite party repudiated the claim of the complainant on the ground that as per documents provided, the patient was symptomatic during break period when the policy was not invoke,so the claim is not admissible and repudiated. Ld.counsel for the complainant submitted that all this amounts to deficiency of service on the part of the opposite party.
7. Whereas the case of the opposite party is that complainant had earlier got insurance policy from the opposite party which was valid from 20.4.2013 to 19.4.2014. Thereafter the complainant obtained second policy from the opposite party for the period from 22.4.2014 to 21.4.2015 and as such there was a gap of three days and during this gap period the complainant suffered the problem which is not covered under the policy. Resultantly the claim was repudiated and due intimation was given to the complainant vide letter dated 24.4.2014. Policy in question was required to be renewed by the complainant on 19.4.2014 but the policy was got renewed by the complainant on 22.4.2014. Resultantly there is gap of three days in continuation towards two policies. The opposite party denied that the server of the opposite party was down on 21.4.2014 and the clerk of the opposite party told the complainant that the policy will be renewed and told the complainant to deposit renewed money on 21.4.2014.No advance receipt was ever issued by the opposite party on 21.4.2014. The complainant was admitted in hospital on 22.4.2014 at 1.07 a.m. and the other tests of the complainant was conducted at Dukh Niwaran Lab on 22.4.2014 at 8.35 a.m and the complainant was admitted in Fortis Escort Hospital on 22.4.2014 in the evening. However, the complainant himself has admitted that he suffered disease on 21.4.2014. So he was not covered under the policy. The opposite party was justified in repudiating the claim of the complainant.
8. From the entire above discussion, we have come to the conclusion that complainant had insurance policy bearing No. P/211111/01/2014/000157 for the period from 20.4.2013 to 19.4.2014. The complainant did not get the policy renewed on 19.4.2014 and 20.4.2014 but got the second policy from the opposite party bearing No.P/211111/01/2015/000205 for the period from 22.4.2014 to 21.4.2015.As per record produced by the complainant himself he suffered heart problem as is evident from the medical treatment record of the complainant and as reported by the investigator in his report Ex.OP5 that date of onset of illness was 21.4.2014 and duration was 3 days. The complainant went to Arora Hospital where he got his ECG conducted on 22.4.2014 at 1.07 a.m and he was admitted in that hospital and thereafter the complainant got other tests conducted from Dukh Niwaran Lab of Arora Hospital,Chheharta,Amritsar on 22.4.2014 at 1.35 a.m.Ex.C-7 and other tests at 8.42 a.m Ex.C-3. The complainant was discharged from Arora Hospital on the same day i.e. 22.4.2014 but no time has been mentioned in the admission and discharge record of Arora Hospital produced by the complainant Ex.C-9. Thereafter complainant went to Fortis Escort Hospital and was admitted there on 22.4.2014 and was discharged on 24.4.2014 as is evident from inpatient bill produced by the complainant Ex.C-12. All this fully proves that the complainant suffered this disease i.e. heart ailment on 21.4.2014 but his earlier policy Ex.C-16 had already expired on 19.4.2014. So the complainant in order to cover this disease got second insurance policy on 22.4.2014 i.e. after a gap of a period of three days. This policy Ex.C-2 appears to have been obtained by some other person on behalf of the complainant on 22.4.2014 and not by the complainant because the complainant on 22.4.2014 was already admitted in the hospital and insurance company shall not issue insurance policy without getting the patient medically checked when he was already admitted in the hospital on that date i.e. 22.4.2014 and that too with serious disease of heart ailment. So this policy has been obtained by some person on behalf of the complainant from the opposite party with concealment of facts, on 22.4.2014 when the complainant had already suffered heart ailment on the night of 21.4.2014.
9. Consequently we hold that opposite party was justified in repudiating the claim of the complainant. As such we hold that the complaint is without merit and the same is hereby dismissed with no order as to costs. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room.
10. Case could not be disposed of within the stipulated period due to heavy
pendency of the cases in this Forum.
12.3.2015 ( Bhupinder Singh )
President
( Kulwant Kaur Bajwa) (Anoop Sharma)
/R/ Member Member
