Punjab

Ludhiana

CC/19/361

Deepak Kumar - Complainant(s)

Versus

Star Health Allied Ins.Co.Ltd. - Opp.Party(s)

R.K.Nayyar Adv.

14 Oct 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 361 dated 25.07.2019.                                                        Date of decision: 14.10.2022.

 

Deepak Kumar Arora son of Shri Surjit Paul Arora, aged 44 years, B-34/7245, Durga Puri, Near Shiv Mandir, Haibowal Kalan, Ludhiana-141001.

                                                                                      ..…Complainant 

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1. The Star Health & Allied Insurance Co. Ltd., 2716, Gagan Complex, 1^st Floor, Gurdev Nagar, Pakhowal Road, Ludhiana-141001 through Manager/Authorized Signatory.
2. The Star Health & Allied Insurance Co. Ltd., SCF 12-13, Improvement Trust Market, Above ICICI Bank, G.T. Road, Moga-141001 through Authorized Signatory.
3. The Star Health & Allied Insurance Co. Ltd. Himalaya House, 1^st Floor, 23, Kasturba Gandhi Marg, New Delhi-11001 through Authorized Signatory.
4. The Star Health & Allied Insurance Co. Ltd., No.1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-60003 through Managing Director.                                                                                                                                                  …..Opposite parties 

Complaint under Section 12 of the Consumer Protection Act,      1986.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. M.S. Sethi, Advocate.

For OPs                          :         Sh. Rajeev Abhi, Advocate.

 

ORDER

PER K.K. KAREER, PRESIDENT

 

1.                In brief, the case of the complainant is that on 21.07.2014, the complainant along with his family members subscribed to Swasthya Kavach (Family Health Policy) of Iffco Tokio General Insurance Ltd. who issued a policy valid from 21.07.2014 to 20.07.2015. The said policy was renewed from time to time up to 20.07.2018. Thereafter, the complainant subscribed to Family Health Optima Insurance Plan of OP4 which was valid from 21.07.2018 to 20.07.2019 with basic sum assured of Rs.5,00,000/- and paid a premium of Rs.15,287/-.

2.                It is further alleged that the complainant got admitted in D.M.C. Hospital on 26.08.2018 and was discharged on 30.08.2018. A request for cashless treatment was sent to the OPs which was rejected by the OPs vide letter dated 28.08.2018. The complainant incurred expenses of Rs.89,932/- as per the final bill issued by DMC Hospital. However, OP4 rejected the claim vide letter dated 07.09.2018 on the ground of non-disclosure of pre-existing disease of Hepatitis-C. In addition to this, the OPs further informed the complainant that they might cancel the policy on the ground of misrepresentation, fraud and non-disclosure of material facts in the proposal form. The genuine claim has been repudiated by the OPs without application of mind and holding an enquiry as to whether hepatitis-C has any connection with neurology disease for which the complainant took treatment from the hospital. Thus, the repudiation of the claim is totally arbitrary, illegal and amounts to deficiency of service. In the end, it has been requested that the OPs be directed to reimburse the claim of Rs.89,932/- and the OPs be further made to pay compensation of Rs.3,00,000/- to the complainant for having caused harassment, pain and mental agony along with litigation expenses of Rs.15,000/-.

3.                The complaint has been resisted by the OPs. In the written statement filed by the OPs, it has been, inter alia, pleaded that the complaint is not maintainable. According to the OPs, the complainant obtained family health optima plan covering the complainant, his wife Kavita Arora, son Bhuwan Arora and daughter Vritika Arora for sum assured of Rs.2,00,000/- vide policy which was valid from 21.07.2014 to 20.07.2018. The claim was reported in the fifth year of the ported policy. The OPs have further pleaded that the complainant was admitted in DMC itself on 26.08.2018 for treatment of Left MCA infarct. The said hospital raised pre-authorization request for cashless treatment stating that the complainant had a history of hepatitis-C. After the receipt of the pre-authorization request, a query dated 27.08.2017 was raised from the hospital seeking certain information as the patient had a history of hepatitis-C. The hospital sent reply dated 27.08.2018.After scrutinizing the documents, request for cashless treatment was declined vide letter dated 28.08.2018 on the ground that the complainant was a known case of hepatitis-C prior to porting the policy with the OPs but this fact was not disclosed by the complainant. However, the complainant has not lodged any claim for reimbursement till date after his discharge from the hospital. Thus, there is no deficiency of service on the part of the OPs. Besides, a notice of cancellation dated 07.09.2018 was issued for the cancellation of the policy qua the complainant Deepak Kumar Arora w.e.f. 17.10.2018 on the ground that he had not disclosed the disease of hepatitis-C which was found to be pre-existing at the time of taking the policy for the first time during 21.07.2018 to 20.07.2019. It is claimed that the OPs have right to cancel the policy on this ground. The other allegations made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

4.                In evidence, the complainant tendered his affidavit Ex. CA1 along with documents Ex. C1 to Ex. C14 and closed the evidence.

5.                On the other hand, the counsel for the OPs tendered affidavit Ex. RA along with documents Ex. R1 to Ex. R10 and closed the evidence.  

6.                We have heard the arguments advanced by the counsel for the parties and have also gone through the record.

7.                In this case, it has been pointed out by the counsel for the OPs that though the pre-authorization request was declined but the complainant has not submitted the final claim for reimbursement and, therefore, the present complaint is immature. Incidentally, the cashless treatment was declined on the ground that the complainant did not disclose that he had history of suffering from hepatitis-C prior to porting the policy with the OPs. It is not disputed that initially, the complainant purchased the policy from Iffko Tokio in the year 2014 and the policy was ported with the OPs in the year 2018, more particularly w.e.f. 21.07.2018. The complainant was hospitalized with DMC from 26.08.2018 to 30.08.2018. In the medical record Ex. R7 and Ex. R8 of DMC Hospital, there is a mention that the complainant suffered from Hepatitis-C two years ago but the OPs have not taken any plea nor have led any evidence to prove that the disease for which the complainant was hospitalized had any nexus with the disease of hepatitis-C as mentioned in the discharge summary.

8.                Having thoughtfully considered the facts of the case, since the main claim has not been lodged, it emerges that the present complaint is premature as the regular claim has not been lodged by the complainant till date. More decline of the pre-authorization request cannot tantamount to rejection of the claim finally. . Under the circumstances, it would be just and proper if this complaint is disposed of with an order that the complainant shall lodge the claim of his treatment with DMC Hospital, Ludhiana from 26.08.2018 to 30.08.2018  along with requisite documents within a period of 30 days from the date of receipt of copy of the order and the OPs shall consider the claim strictly in accordance with terms and conditions of the policy within a period of 30 days from the date of lodgment of the claim by the complainant. However, there shall be no order as to costs. In case the claim is not dealt with by the OPs in accordance with the terms and conditions of the policy, the complainant shall be at liberty to challenge the same.

9.                As a result of above discussion, this complaint is disposed of with an order that the complainant shall lodge the claim of his treatment with DMC Hospital, Ludhiana from 26.08.2018 to 30.08.2018  along with requisite documents within a period of 30 days from the date of receipt of copy of the order and the OPs shall consider the claim strictly in accordance with terms and conditions of the policy within a period of 30 days from the date of lodgment of the claim by the complainant. However, there shall be no order as to costs. In case the claim is not dealt with by the OPs in accordance with the terms and conditions of the policy, the complainant shall be at liberty to challenge the same. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

10.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:14.10.2022.

Gobind Ram.

Deepak Kumar Arora Vs Star Health and Allied Insurance       CC/19/361

Present:       Sh. M.S. Sethi, Advocate for the complainant.

                   Sh. Rajeev Abhi, Advocate for the OPs.

 

                   Arguments heard. Vide separate detailed order of today, this complaint is disposed of with an order that the complainant shall lodge the claim of his treatment with DMC Hospital, Ludhiana from 26.08.2018 to 30.08.2018  along with requisite documents within a period of 30 days from the date of receipt of copy of the order and the OPs shall consider the claim strictly in accordance with terms and conditions of the policy within a period of 30 days from the date of lodgment of the claim by the complainant. However, there shall be no order as to costs. In case the claim is not dealt with by the OPs in accordance with the terms and conditions of the policy, the complainant shall be at liberty to challenge the same. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:14.10.2022.

Gobind Ram.