Delhi

East Delhi

CC/119/2014

HANSRAJ JAIN - Complainant(s)

Versus

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

01 Feb 2018

ORDER

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 119/14

 

Shri Hans Raj Jain

S/o Shri Vakil Chand Jain

R/o A-85, Kaithwara

New Usman Pur, Delhi –53                                                         ….Complainant

Vs.

M/s. Star Health & Allied Insurance Co. Ltd.

Branch Off.: 209-210, Lakshmi Deep Building

District Centre, Laxmi Nagar, Delhi – 92                                        ….Opponent

 

Date of Institution: 31.01.2014

Judgment Reserved on: 01.02.2018

Judgment Passed on: 09.02.2018

CORUM:

Sh. Sukhdev Singh (President)

Ms. Harpreet Kaur Charya (Member)

 

Order By : Ms. Harpreet Kaur Charya (Member)

 

JUDGEMENT

            The present complaint has been filed by Shri Hans Raj Jain against M/s. Star Health & Allied Insurance Co. Ltd. (OP) under Section 12 of the Consumer Protection Act 1986 alleging deficiency in services.   

2.         Briefly stated the facts of the complaint are that M/s. Star Health & Allied Insurance Co. Ltd. (OP) got the complainant medically examined from Ashoka Nursing Home, Krishna Nagar in the second week of January 2013 and after that issued Senior Citizens Red Carpet Insurance Policy bearing no. P/161111/01/2013/005763 on 01.02.2013 for the complainant, the same was through his son Prabhat for a sum of Rs. 2,00,000/- on paying the premium of Rs. 9,500/- vide cheque no. 329645 dated 01.02.2013 which was valid from 01.02.2013 to 31.01.2014. 

            It was stated that the complainant was suffering from Pneumonia and other ailments on 09.03.2013 and was admitted in St. Stephen Hospital, Tis Hazari for treatment.  The complainant informed the CMO of the hospital regarding the insurance policy and also to the respondent for the treatment in St. Stephen Hospital.  He was discharged from the hospital on 10.03.2013.  Hospital charged Rs. 12,924/- from the complainant towards the treatment charges.  Thereafter, the complainant was admitted in Vallabhabhai Patel Chest Institute, Viswanathan Chest Hospital, University of Delhi from 24.04.2013 to 29.04.2013 and same was also informed to OP.  The complainant paid an amount of Rs. 4,941/- towards his treatment and incurred an amount of Rs. 1,676/- on the medicines. 

            It was also stated that the complainant raised total claim of Rs. 19,541/- on 03.06.2013 alongwith complete treatment documents.  He submitted additional documents/details on 11.07.2013 as demanded by OP through their letter dated 25.06.2013.  OP issued letters dated 25.07.2013 and 26.08.2013 to the complainant, which were replied on 03.09.2013.  OP again sent a letter dated 11.09.2013 stating that “even after several reminders, you have not sent us the above documents; we therefore, presume that you are not interested to pursue your claim, hence we have closed your claim file”. 

            On 01.11.2013, the complainant received a cheque of Rs. 9,500/- bearing no. 000481 dated 22.10.2013 alongwith covering letter stating that as per condition no. 7 of the policy, the company was not liable to make any payment and repudiated the claim of the complainant.  Hence, the complainant has prayed for direction to OP to pay amount of Rs. 84,041/- (incurred on his treatment) alongwith 15% interest; insured amount of policy of Rs. 2,00,000/-; Rs. 10,00,000/- towards compensation for causing harassment, torture, humiliation and mental pain & agony and Rs. 20,000/- towards cost of litigation. 

            The complainant has annexed copy of policy dated 01.02.2013, copies of medical bill and treatment, claim application dated 03.06.2013 alongwith documents, copy of letter dated 25.06.2013 and 11.07.2013, 25.07.2013, 28.08.2013 and reply dated 03.09.2013, copy of letter dated 11.09.2013, copy of request dated 11.10.2013, copy of cheque dated 22.10.2013 alongwith  covering letter and copy of letter dated 08.11.2013 alongwith complaint.

3.         OP filed their reply upon service of notice, wherein they took several pleas in their defence such as; the patient was a known case of bronchial asthma since 10 years, as reported in the field visit report of OP’s doctor and at the time of inception of the first policy which was from 01.02.2013 to 31.01.2014, complainant did not disclose the medical history of the insured person in the proposal form which amount to misrepresentation/non-disclosure of material facts.  As per Condition no. 7 of the policy issued, the company was not liable to pay any claim if there was any misrepresentation/non-disclosure of material facts.  Hence, the claim of the complainant repudiated vide letter dated 24.10.2013. 

4.         In his rejoinder to the WS filed by OP, the complainant has denied the contents of the WS and reiterated the averments made in the complaint. 

5.         In support of its complaint, the complainant have examined himself.  He has deposed on affidavit.  He has narrated the facts which have been stated in the complaint.  He has got exhibited documents such as photocopy of policy (Ex.CW-1/1), copies of medical bills and treatment documents (Ex.CW-1/2), copy of claim application dated 03.06.2013 alongwith documents (Ex.CW-1/3), copy of letters dated 25.06.2013 and 11.07.2013 (Ex.CW-1/4 colly.), copy of letters dated 25.07.2013 and 28.08,.2013 and reply dated 03.09.2013 (Ex.CW-1/5 colly.), copy of repudiation letter dated 11.09.2013 (Ex.CW-1/6), copy of request and copy to respondent (Ex.CW-1/7), copy of cheque alongwith covering letter (Ex.CW-1/8 colly.) and copy of letter dated 08.11.2013 (Ex.CW-1/9).  

            OP have examined Shri Rajnish Kohli, Assistant Vice President, Claim of OP, who have examined himself on affidavit.  He has narrated the facts which have been stated in their WS. 

6.         We have heard the submission on behalf of the complainant and have perused the material placed on record.  The claim of the complainant was repudiated on the ground of breach condition no. 7 of policy terms and conditions wherein it was stated that complainant had concealed/misrepresented material facts and thereby the policy was cancelled.  It is an admitted fact that the premium paid by the complainant has been returned to the complainant.  However, OP in their defence have stated that complainant was suffering Bronchial Asthma for past 10 years, but have failed to place on record even a single document despite opportunity. Neither any document was filed with their reply nor with OP evidence.  Now, if we take a look at the discharge summary of St. Stephen’s Hospital, which bears diagnosis as B/L pneumonia and CHF and complain of shortness of breath on exertion since 2 days and history of cough with yellowish expectoration since 2 days, so, it makes clear that the complainant was suffering from pneumonia, which was not pre-existing. 

Medical Certificate, filed alongwith claim, which has been filled by doctor from Viswanathan Chest Hospital, where also the diagnosis is Breathing Problem (B.A.) and the column corresponding to since when was the patient suffering from the said complaints bears “1 month”.  The OP has not placed on record any proposal form or field visit report to support their assertion regarding concealment/misrepresentation of material facts, hence, an adverse inference is to be drawn against them.  At the same time, the complainant has been successful in proving that his claim was arbitrarily repudiated by OP.  Hence, we allow the present complaint and direct OP to process the claim permissible under policy terms and conditions after deducting Rs. 9,500/- towards premium, as OP has refunded the premium to the complainant.  We also award Rs. 12,000/- as compensation on account of mental agony and harassment, which includes the cost of litigation.

            Copy of the order be supplied to both the parties as per rules.

File be consigned to Record Room.

 

(DR. P.N. TIWARI)                                              (HARPREET KAUR CHARYA)

Member                                                                                Member    

           

            (SUKHDEV SINGH)

             President