Punjab

Rupnagar

RBT/CC/18/33

Kulwinder Singh - Complainant(s)

Versus

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

Mohit Goyal adv

09 Nov 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION CAMP COURT AT LUDHIANA

Received by way of transfer Consumer Complaint No.33 of 2018

                                               Date of institution:11.01.2018

                                               Date of Decision:09.11.2022

 

Kulwinder Singh aged about 45 years son of Shri Bhagat Singh, r/o House Noh.no.1506, sector 32-a, chandigargh road, ludhiana.

…….Complainant

Versus

1. Star Health and Allied Insurance Company Limited, 2716, First Floor, Gagan Complex, Backside Majestic Park Plaza, Manager/ authorized signatory.

IInd address:

SCO 17-18-19, Second Floor, Jhandu Tower, Ludhiana.

 

2. Star Health and Allied Insurance Company Limited, Registered and Corporate Office at 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, chennai-600 034, through its Managing Director/ Director/ Authorized Signatory.  

 …..Opposite Parties

 QUORUM:   

   HON’BLE MR. RANJIT SINGH, PRESIDENT.

                   HON’BLE MRS. RANVIR KAUR, MEMBER

 

PRESENT:

      

Sh. Mohit Goyal, Adv. for complainant

Sh. Rajeev Abhi, Adv. for OPs

              
 

ORDER

RANJIT SINGH, PRESIDENT

The present order of ours will dispose of the above complaint filed under Consumer Protection Act, by the complainant against the Opposite Parties on the ground that the complainant was covered by a Medi-claim Policy from Opposite parties no.1 and 2, obtained in the year 2015 and renewed in the year 2016. The said Policies were purchased through agent/broker of Op No. 1 and 2 and the same was renewed without break. The mediclaim Policy no. p/211218/01/2017/000336 is valid from 23/11/2016 to 22/11/2017 in which the complainant and his daughter namely Simarpreet Kaur is insured to the extent of Rs.6,25,000/-. The  OPs handed over the cover note only, but neither the  Schedule of  the insurance Policy was ever supplied /communicated nor the terms and conditions including the complainant inspite of the verbal request made by the complainant to the concerned officials of the Ops. Thereafter the complainant suffered problem of joint pain and he consulted Dr. Prashant Aggarwal, Backsider MBD Mall, Ludhiana and after checkup, he diagnosed vacuities and as such he went to medanta Hospital (Global Health Private Limited), Sector 38, Gurugram, Haryana on 19.07.2017 for treatment and he got admitted on the same day in the said hospital. It is pertinent to mention here that as the Policy in questions was for cashless treatment, the complainant informed the officials said hospital about the policy and they informed to the Ops accordingly and thereafter the officials of the said hospital intimated to the complainant that the said Insurance company has put the claim of the complainant to reimbursement and as such the complainant had to pay the expenses on account of  his treatment before the said hospital towhich the complainant agreed. After treatment , the expenses come to Rs. 9,44,122.74ps./- and the complainant paid the said amount out of his own pocket and was then discharged from the said hospital n 7.802017. After the treatment, the complainant put his claim before the Ops no. 1 and 2 supplied all the documents as demanded by them from time to time, but the said Ops  started lingering on matter on one of the other false pretext and ultimately vide e-mail dated 28.10.2017, the claim of the complainant was repudiated by giving a false, frivolous and baseless reason of pre-existing disease since November , 2015, whereas while renewing the policy for the period from 23.11.2016 to 22.11.2017, the medical checkup of the complainant was conducted and it is specifically mentioned on the policy issued by the OPs that the complainant/insurer is not suffering from any pre-existing disease prior to the purchase of the policy.  The repudiation of the claim is highly irregular, arbitrary and illegal on the following amongst other reasons:-

1.  That the treatment is question was never excluded from the policy.
2. That the complainant has no preexisting disease prior to purchase of the Policy.
3. That at the time of issuance of the policy, it is the duty of the respondents to supply the terms and conditions including exclusion clause and also to explain the same to the complainant but the respondents did nothing. As such there is a deficiency in service on the part of the OPs/ respondents. As held by the Hon’ble Apex court in various judgments that the above act and conduct of the respondents also amounts to unfair trade practices.
4.  That the respondents/Ops miserably failed to supply the terms and conditions and other schedule to the complainant inspite of repeated requests.
5. That on the perusal of discharge summary and other relevant record of medical treatment of the complainant, it is very much clear that the complainant has undergone the treatment as advised by the doctor and he has only taken the advised medicines from time to time. As such the act  of the OPs is totally illegal from his legal right. Had the exclusion clause, then he would not paid heavy  premium from the last  so many years.

Vide this instant complaint, the complainant has sought the following relief:-

1.To pay a sum of Rs.6,25,000/-as policy claim amount and Rs.2,00,000/- as compensation along with interest 24 % per annum from the date of submission of claim till the realization. It is further prayed that the OPs may kindly be directed to pay a sum of Rs. 50,000/- as litigation expense.\

2.     Upon notice, the learned counsel for the OPs No.1 & 2 has appeared and filed written reply taking preliminary objections; that the present compliant is barred u/s 26 of the consumer protection Act; that averments made in the complaint are hereby denied except those that are admitted hereunder and the complainant is put to strict proof thereof. The complaint is not maintainable either in law or on fats and is liable to be dismissed in limine. The compliant is based on self serving and misleading allegations without proper disclosure of facts; that the present compliant  is not maintainable since the compliaiant had obtained Family Health Optima Insurance covering Mr. Kulwinder singh complainant, Mrs. Simarpreet kaur dependent children for the sum insured of Rs. 5,00,000/- vide policy Nos.P/161114/01/2106/006912 21.11.2015 20.11.2016 p/161114/01/2017/000336 23.11.2016 22.11.2017 The Insurance policy is a contract in itself and the parties are about by the terms and conditions of the policy. The insurance policies are issued on the basis of utmost good faith and as per the law laid down by the Hon’ble Apex Court nothing can be added or subtracted out of it. It is one of the conditions No. 8. In the policy that “the company shall not be liable to make any payment under the policy in respect of any claim if information furnished at time of proposal is found to be incorrect or false or such claim is in any manner fraudulent of supported by any fraudulent means or device, misrepresentation whether by te insured person or by any other person acting on his behalf.” the claim was reported in the 2nd year of the policy for a sum of Rs.9,44,122/- for reimbursement of medical expenses incurred by the complainant; that complainant was admitted at Medanta The Medicity (Unit of Global Health)on 19th july,2017 for the treatment of Vassulities and  raised pre authorization request for cashless treatment. After the receipt of the pre authorization request from Medanta The Medcity, the respondent has called upon the said hospital vide their letter dated 20.07.2017 to provide the following details:-

As per the records dated 19th july, 2017, patient has been diagnosed ad steroid depen sero-ve polyarthrities. Kindly provide when was the patient first diagnosed with polyarthrities, first consultation papers, duration of symptoms, all prior consultation and treatment records

ANA reports

It is noted that the patient is under long term steroid therapy- kindly clarify since when the patient is under steroid therapy and the indication for the same.

Admission case sheet.

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Request for cashless treatment was denied vide letter dated 21.7.2017 stating that in spite of repeated queries the complainant has not submitted the initial consultations serongative polyarthirits. However, a claim form is sent with letter dated 21.7.2017 with a request to complete the sameand sent it to the respondent along with all medical documents clearly sating that issuance of claim form is not an admission of claim and on receipt of duly completed claim form and other documents, the claim will be processed as per terms and conditions of the policy issued to the complainant.

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As per discharge summary, the insured was admitted on 19.7.2017 and discharger on 7.8.2017 for the treatment of ANCA associated vasculitis.

The indoor case records of the above hospital depicts tha the insured patient is on high dosesteroid, deflzacort form November 2015.

The above finding confirms chronic, longstanding ANCA vasculities and the patient has the disease prior to inception of medical insurance policy obtained form the respondents. The present admission and treatment of the insured patient is for the pre existing disease and its realted cardic complications. At the time of inception of the policy which is form 21.11.2015 to 20.11.2016, the insured have 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.

As per conditions No. 8 of the policy if there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf the company is not liable to make any payment in respect of any claim. After the receipt of the claim records submitted by the complainant and after scrutinizing the claim for the aforesaid reason and the same was communicated to the complainant vide letter dated 14.10.2017. As per condition No.8 of the policy issued to the complainant, if there is any misrepresentation/non disclosure of material facts whether by insured person or any other person acting on his behalf, the complainant is not liable to pay the claim amount. On merits, it is denied that the policies were renewed without any break. It is submitted that the complainant availed family Health Optima Insurance Plan covering Kulwinder Singh, Simarpreet Kaur, dependent child for sum insured of Rs.5,00,000/- vide insurance policy valid from 23.11.2016 to 22.11.2017. It is further stated that the insurance policy is a contract in itself and the parties are bound by the terms and condition of the policy. It is also denied that the complainant and his daughter is insured to the extent of Rs.6,25,000/-. It is stated that basic floater sum insured and limit of coverage under policy No.P/161114/01/2016/006912 and basic floater sum insured is Rs.5,00,000/- and limit of coverage is Rs.6,25,000/- in policy No.P/211218/01/2017/000336. It is also denied that the OPs was handed over cover note only to the complainant. Thus, alleging no deficiency in service and prayed for dismissal the present complaint against the OPs.

3. In support of the complaint, the complainant has tendered various documents. On the other hand, the OPs has also tendered documents in support of their evidence.
4. We have heard the learned counsel for the complainant and have gone through the record of the file, carefully.
5.  The issue of the dispute between the parties is narrowed down, whether factum of the complainant of having pre existing disease warrants the cancellation of contract/policy of the insurance, disentitled the complainant of the insurance amount. The claim of the OPs that the complainant did not disclose the history pre existing disease does not behold legally the reason for the same being a matter of common sense that the insurance companies usually subject to prospective buyers of the insurance to medical examination thereby the OPs was free to subject the prospective buyer to the medical test to know whether he is having any history of any ailment.
6. The issue has been narrowed down to the point of rejection of the claim due to non disclosure of pre existing disease at the time of effecting the insurance contract. However, the repudiation of insurance on aforesaid aground is not justified. 
7. In view of our above discussion, we allow the complaint with the directions to the Ops to pay Rs.6,25,000/- to the complainant  along with interest @ 7% per annum from the date of repudiation of the claim of the complainant. He is also entitled Rs.40,000/- as compensation with Rs.11,000/- as litigation expenses payable from the date of order till payment. The OPs are further directed to comply with the said order within 30 days from the date of receipt of certified copy of this order. Free certified copies of this order be sent to the parties, as per rules. The file be sent back to the District Consumer Commission, Ludhiana, for consigning the same to the Record Room.
8.  

November 09, 2022

(Ranjit Singh)

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(Ranvir Kaur)

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