Chandigarh

DF-I

CC/991/2019

Gurcharan Singh Brar - Complainant(s)

Versus

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

Pankaj Maini

05 Apr 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                                     

Consumer Complaint No.	:	CC/991/2019
Date of Institution	:	07/10/2019
Date of Decision	:	05/04/2023

 

Manav Brar son of late Sh. Gurcharan Singh Brar, age 50 years, resident of House No.5641, Modern Housing Complex, Manimajra, UT, Chandigarh.

… Complainant

V E R S U S

1. Star Health & Allied Insurance Company Limited through its Director, Registered & Corporate Office at 1, New Tank Street, ValluvarKottam High Road, Nungambakkam, Chennai 600034.
2. Star Health & Allied Insurance Company Limited, through its Zonal Manager, Area Office at SCO No.130-131, 4^th Floor, Sector 34-A, Chandigarh.
3. Gurcharan Singh, Authorized Agent of Star Health & Allied Insurance Company Limited c/o Area Office at SCO No.130-131, 4^th Floor, Sector 34-A, Chandigarh.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Pankaj Maini, Counsel for complainant
	:	Sh. Satpal Dhamija, Counsel for OPs 1 & 2
	:	OP-3 ex-parte.

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Sh.Gurcharan Singh Brar, complainant (who died during the pendency of the present consumer complaint) against the opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that the complainant had obtained a Senior Citizens Red Carpet Insurance Policy from the OPs which was valid w.e.f. 15.10.2018 to 14.10.2019 (hereinafter referred to as “Subject Policy”) for sum insured of ₹5,00,000/- by paying premium of ₹21,240/-. In fact, complainant had purchased the first policy from the OPs in the year 2014 which was valid w.e.f 15.10.2014 to 14.10.2015 (Annexure C-3), by further renewing the same annually w.e.f. 7.10.2015 to 6.10.2016 (Annexure C-5), 15.10.2016 to 14.10.2017 (Annexure C-6) and thereafter w.e.f. 15.10.2017 to 14.10.2018 (Annexure C-7).  In this manner, the complainant had been availing the aforesaid insurance policy since the year 2014 till issuance of the subject policy (Annexure C-8).  Not only this, even the wife of the complainant was also insured by the OPs.  On 6.8.2019, the complainant was having problem relating to heart and accordingly he visited the Ace Heart and Vascular Institute where his coronary angiography was done. The complainant was admitted in the aforesaid Institute on 6.8.2019 and was discharged on 17.8.2019. The aforesaid institute had raised medical bill of ₹1,59,000/- which was accordingly paid by him at the time of his discharge. The complainant had submitted the medi-claim with the OPs which was rejected by the OPs vide letter dated 9.8.2019 (Annexure C-11), by only approving an amount of ₹5,000/- for the treatment of the complainant on the basis of the documents by intimating the complainant that he was suffering from pre-existing disease which was not disclosed by him in the proposal form at the time of inception of the first policy.  It has also been observed by the OPs that the stents were implanted in the heart of the complainant in the year 2011, as a result of which the claim of the complainant was rejected. This rejection of the genuine claim of the complainant by the OPs was totally arbitrary and not as per the settled proposition of law despite of the fact that the complainant has been paying the premium to the OPs since the year 2014 and has not been getting any claim from the OPs and the said act of the OPs amounts to deficiency in service. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs 1 & 2 resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability and concealment of facts.  However, it is admitted that the complainant had obtained the subject policy from the OPs by also admitting that the complainant has been obtaining the policies from the OPs since the year 2014.  It is alleged that in fact the complainant had not disclosed about the pre-existing disease from which he was suffering before taking the first policy from the OPs in the year 2014 as the medical record even relied upon by the complainant for his treatment in the year 2019, from the aforesaid Ace Institute clearly indicates that the complainant is a known case of PCI i.e. Percutaneous Coronary Intervention (PCI) formerly known as angioplasty with stent since 7.4.2012 and as per the CAG report dated 8.8.2019, the insured had post PTCA of LM-LAD & LM – LCx since 7.4.2012.  Not only this, even it has been mentioned in the report dated 6.8.2019 (Annexure OP-9) by the doctor of the Ace Institute that the insured was a known case of hypothyrodism, CAD and PCI (2012). Since the complainant had concealed all these facts from the OPs while filling the proposal form at the time of inception of the first policy on 15.10.2014, the claim of the complainant was rightly repudiated by the OPs as per the law settled in various judgments passed by the Hon’ble Apex Court.  The OPs had already initiated the process for cancellation of the policy issued to the complainant and for refund of the amount of ₹5,000/- which has already been paid to the complainant by the OPs. On merits, the facts as stated in the preliminary objections have been re-iterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. OP-3 was properly served and when OP-3 did not turn up before this Commission, despite proper service, it was proceeded against ex-parte on 20.12.2019.
4. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the contesting parties and also gone through the file carefully, including the written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had obtained the first policy from the OPs which was valid w.e.f. 15.10.2014 to 14.10.2015 by paying premium of ₹20,225/-, as is also evident from Annexure C-4 and the said policy was continuously got renewed by the complainant on annual basis till the issuance of the subject policy (Annexure C-8), which is valid w.e.f 15.10.2018 to 14.10.2019 and also that earlier on the submission of the claim by the complainant with the OPs, they had released an amount of ₹5,000/- to the complainant and rejected and repudiated the rest of the claim of the complainant on the ground that the he was suffering from pre-existing disease at the time of inception of the first policy on 15.10.2014, the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in repudiating the genuine claim of the complainant by wrongly holding that the claim of the complainant is not covered on account of pre-existing disease from which he was suffering at the time of inception of the first policy on 15.10.2014 and he is entitled for the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs are justified in repudiating the claim of the complainant on the ground that the complainant had concealed  material facts from the OPs qua the pre-existing disease from which he was suffering at the time of inception of the first policy and the consumer complaint of the complainant is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, it is clear that the entire case of the parties is revolving around the terms and conditions of the policy i.e. the first policy which was issued on 15.10.2014 (Annexure C-4) as well as the subject policy i.e. the last policy (Annexure C-8) issued by the OPs which was valid w.e.f. 15.10.2018 to 14.10.2019. 
   3. Learned counsel for the complainant contended with vehemence that as it stands proved on record that the complainant was not suffering from any pre-existing disease as specified in the terms and conditions of the policy even at the time of inception of the first policy on 15.10.2014 or at the time when the subject policy was issued by the OPs on 15.10.2018, OPs have wrongly repudiated the claim of the complainant and the consumer complaint be allowed as prayed for.
   4. On the other hand, the defence of the OPs is that as it stands proved on record that just before the time of inception of the fist policy on 15.10.2014, complainant was suffering from pre-existing disease i.e. heart related problem for which disease he was later on treated in the year 2019 also, regarding which the complainant is seeking the claim, the consumer complaint of the complainant is liable to be dismissed. 
   5. There is no force in the contention of the OPs as even as per the terms and conditions, referred in the schedule of the policy (Annexure C-4) i.e. the first policy was issued by the OPs to the complainant on 15.10.2014 and the case is not covered under the exclusion clause. In this manner, the relevant portion of the said policy (Annexure C-4) indicating the exclusion clause is required to be scanned carefully and is reproduced below for ready reference ;-

“Exclusion No.1

All Pre Existing Diseases as defined in the policy existing and suffered by the insured person for which treatment or advise was recommended or received during the immediately preceding 12 months from the date of inception of the first policy with any Indian Insurer.  However the limit of the Company’s liability in respect of claim for Preexisting Diseases under such Portability shall be limited to the Sum Insured under the previous policy with any Indian Insurance Company.”

 

6. Thus, one thing is clear from the exclusion clause of Annexure C-4 that the pre-existing disease is only covered which is suffered by the insured person for which treatment or advice was recommended or received during the immediately preceding 12 months from the date of inception of the fist policy with any Indian insurer.  In this case, as it is an admitted case of the parties that the first policy was obtained by the complainant from the OPs on 15.10.2014, whereas the medical record having been relied upon by the OPs (Annexure OP-8) clearly indicates  that the medical officer i.e. Dr. Puneet K. Verma, who had given treatment to the complainant in the year 2019, regarding which the complainant is seeking claim, has only referred about the earlier diseases from which the complainant was suffering i.e. hypothyroidism, CAD and PCI (2012).  Thus, one thing is further clear on record that even when it has been opined by the medical officer that the complainant had taken treatment of the aforesaid diseases in the year 2012 and it has further come on record that the first policy (Annexure C-4) was issued by the OPs on 15.10.2014 i.e. after about two years of the aforesaid disease, the case of the complainant is not covered under the exclusion clause as referred in Annexure C-4 since the said disease was suffered by the complainant for which he had taken treatment or advice not during immediately preceding 12 months from the date of inception of the first policy, especially when nothing has come on record that prior to that the complainant had obtained any policy from any insurer.
7. Not only this, even proposal form (Annexure C-3), which was filled up by the insured before obtaining the first policy, nowhere indicates that the complainant had given any false information to the OPs.  Moreover, the information sought by the OPs through the said proposal form about cancer, chronic kidney disease, CVA/Brain stroke, Alzheimer disease, Parkinson’s disease was properly given by the complainant from which he has not suffered till date.
8. So far as the defence of the OPs that even the complainant had not disclosed about the pre-existing disease before obtaining the subject policy is concerned, even the exclusion clause of the subject policy does not cover the case of the complainant as it specifically says as under :-

        “3.   Exclusions

        The Company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of :

1. Pre Existing Diseases as defined in the policy until 12 consecutive months of continuous coverage having elapsed, since inception of the first policy with any Indian Insurer.
2. Any disease contracted by the Insured person during the first 30 days from the commencement date of this policy. This exclusion shall not apply in case of the insured person having been covered under any health insurance policy (individual or Group Insurance policy) with any of the Indian Insurance companies for a continuous period of preceding 12 months without a break.”

 

9. In view of the foregoing discussion it is safe to hold that the OPs are unjustified in repudiating the genuine claim of the complainant on the ground that he was suffering from pre-existing at the time of inception of the first policy and the said act of the OPs amounts to deficiency in service on their part and the present consumer complaint deserves to be allowed. 
10. The complainant has proved medical bill (Annexure C-10) which clearly indicates that he had spent an amount of ₹1,56,230/- on his treatment. As it is an admitted case of the parties that, out of the aforesaid amount, OPs had already paid an amount of ₹5,000/- to the complainant, it is safe to hold that the complainant is now entitled for an amount of ₹1,56,230 – ₹5,000 = ₹1,51,230/- alongwith interest and compensation.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay the aforesaid amount of ₹1,51,230/- to the complainant alongwith interest @ 9% per annum from the date of repudiation 9.8.2019 till realization of the same.
2. to pay an amount of ₹40,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 05/04/2023 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member
			Sd/- [Suresh Kumar Sardana] Member