Haryana

Karnal

CC/241/2020

Anil Kumar - Complainant(s)

Versus

Star Health & Allied Insurance Company Limited - Opp.Party(s)

Gagan Shegal

03 Jan 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 241 of 2020

                                                        Date of instt.09.07.2020

                                                        Date of Decision:03.01.2023

 

Anil Kumar son of Shri Swaran Lal, resident of A-3, ward no.12, Neel Nagar, Nilokheri, Tehsil and District Karnal. Aadhar card no.3503 5697 2338.

                                               …….Complainant.

                                              Versus

 

1.     Star Health and Allied Insurance Company Ltd. having its registered office no.15, Shree Balaji Complex, First floor, whites lane, Royapettah, Chennai-600014.

 

2.     Star Health and Allied Insurance Company Ltd., Branch SCO no.241, First Floor, above ICICI Bank, Sector-13, Urban Estate, Karnal.

                                                                      …..Opposite Parties.

 

Complaint Under Section 12 of the Consumer Protection Act, 1986 and after amendment Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.

              Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary…….Member

                   

 Argued by: Sh. Gagan Sehgal, counsel for the complainant.

                   Sh. Ashok Vohra, counsel for the opposite parties.

 

                    (Jaswant Singh President)

 

ORDER:   

                

                   The complainant has filed the present complaint Under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant had purchased a health insurance policy under the name and style of “Family Health Optima Insurance 2017” from the OPs, vide policy no.P/211114/01/2019, valid from 30.08.2018 to 29.08.2019. Under the said policy complainant and his family insured for their  health and sum assured was Rs.5,00,000/-each and paid a premium of Rs.19,417/-. The said policy was renewed again vide policy no. P/211114/01/2020, valid from 05.11.2019 to 04.11.2020.  On 29.11.2019, suddenly complainant suffered from a severe pain in his chest and complainant got admitted in Rama Super Specialty and Critical Care Hospital, Karnal where the complainant medically treated as CAD, ACS (angiography) and complainant had spent an amount of Rs.1,50,000/- approximately on his medical treatment which had given to the hospital concerned excluding other medical expenses. As per advice of the doctor, complainant regularly purchased the medicines as prescribed by the doctor concerned. As per the policy, OPs are liable to pay the medical expenses for the past and post of 90 days. Complainant lodged the claim with the OPs for reimbursement of the amount spent by him on his treatment and completed all the formalities but OP did not pay the claim and repudiated the same, vide repudiation letter dated 06.03.2020 on the ground that “as per the submitted consolation report dated 29.11.2019 of the abovesaid hospital that the insured patient complained of chest pain for the past 25 days which confirms the onset of the abovesaid disease is during the break in policy period and the insured patient is treated subsequently which is not payable as per the condition of the policy”.  The said observation of the OP is wrong and illegal, since the policy has been occurred in the year 2018 and complainant had paid the full premium to the OP and no claim was ever lodged during the first period of policy with the OP. At the time of medical treatment, the policy of complainant was renewed and OP has obtained the full payment of the policy of Rs.19,417/- and even the complainant had paid the fine of the breaking period of policy. If the complainant has suffered any chest pain for the last about 25 days from the date of admission in the hospital, that does not mean the pain was as severe which required to get medical treatment and even when complainant was got admitted in the hospital, his condition was not good and may his family members and other companion could ask to the official of the OP or to the doctor concerned that complainant was complaining the chest pain for the last 25 days. If a person having severe pain in body specially in chest, he or she would never wait for any medical policy and immediately consult the doctor and to get the medical treatment. So, the observation of repudiation of insurance claim of complainant is not justified and liable to be rejected. In this way there is deficiency in service on the part of the OP. Hence this complaint.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; locus standi; jurisdiction and concealment of true and material facts. On merits, it is pleaded that the claim of the complainant was duly processed, considered on merits and the same was not found payable, hence the same was repudiated, vide repudiation letter dated 19.02.2020 due to the fact that the complainant is seeking reimbursement of hospitalization expenses for his treatment of coronary artery disease, acute coronary syndrome under family health optima insurance-2017 under the grab of policy number P/211114/01/2020/008157, covering the policy period from 05.11.2019 to 04.11.2020. The complainant was got admitted in Rama Super Specialty and Critical Care Hospital, Karnal on 29.11.2019 for the diagnosis of CAD, ACS. Complainant got renewed the said policy after a break period of 67 days i.e. from 30.08.2019 to 04.11.2019. On examination of reimbursement document, it is observed from the submitted consultation report dated 29.11.2019 of the above hospital that the complainant has complained of chest pain for the past 25 days which confirms the onset of the above disease is during the break in policy period. As per condition no.7 of the policy, the OP is not liable to protect the insured person between the policy expiry date and the date of payment of renewal premium. Thus the claim of the complainant has rightly been repudiated by the OP. It is further pleaded that as per discharge summary, the insured was diagnosed as CAD-ACS and CAG report shows LAD 95%. Within the short period of 14 days, the insured could not have developed 95% stenosis. It is further pleaded that complainant purchased the policy on 30.08.2018 for a sum of Rs.5,00,000/- for a period from 30.08.2018 to 29.08.2019. During this period the claim of the complainant was rejected on first year policy of 2018 for acute pancreatitis under first two year exclusion. Therefore, it was renewed after 2 months and 6 days delay from the day of expiry by giving good health declaration. There is no deficiency in service on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy Ex.C1, copy of claim form Ex.C2, copy of repudiation letter dated 06.03.2020 Ex.C3 and closed the evidence on 30.09.2021 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Rajiv Jain, Chief Manager Ex.OP1/A, copy of terms and conditions of the insurance policy Ex.O1, copy of policy schedule Ex.O2, copy of proposal form Ex.O3, copy of renewal of policy Ex.O4, copy of request for cashless Ex.O5, copy of Star Medical Officer FVR Ex.O6, copy of query of authorization for cashless treatment Ex.O7, copy of denial of pre-authorization request Ex.O8, copy of claim form Ex.O9, copy of discharge summary Ex.O10, copy of bills Ex.O11, copy of treatment history Ex.O12, copy of repudiation letter Ex.O13, cop of bills assessment sheet Ex.O14 and closed the evidence on 13.09.2022 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for the complainant, while reiterating the contents of the complaint, has vehemently argued that complainant had purchased a health insurance policy from the OPs. On 29.11.2019, complainant suffered from a severe pain in his chest and he got admitted in Rama Super Specialty and Critical Care Hospital, Karnal where the complainant medically treated as CAD, ACS (angiography) and complainant had spent an amount of Rs.1,50,000/- approximately on his medical treatment. After discharge from the hospital, complainant lodged the claim with the OPs for reimbursement of the amount but OP did not pay the claim and repudiated the same, vide repudiation letter dated 06.03.2020 on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that the claim of the complainant was duly processed and the same was not found payable. On examination of reimbursement document, it is observed that report dated 29.11.2019 of the Rama Super Specialty and Critical Care Hospital, Karnal, the complainant has complaint of chest pain for the past 25 days which confirms the onset of the above disease is during the break in policy period. Complainant got renewed the said policy after a break period of 67 days. As per condition no.7 of the policy, the OP is not liable to protect the insured person between the policy expiry date and the date of payment of renewal premium. Thus the claim of the complainant has rightly been repudiated by the OP and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant had purchased a health insurance policy from the OPs. It is also admitted that the said policy was renewed by the OPs for the period of 67 days and penalty were charged from the complainant.

11.           The covering period of the policy in question was from 05.11.2019 to 04.11.2020. The said policy was got renewed after the break period of 67 days i.e. from 30.08.2019 to 04.11.2019. The complainant got admitted in the Hospital on 29.11.2019. At that time the policy in question was in a lapse mode. The complainant has got renewed the said policy knowing that at the time of taking the treatment, the policy in question was not in force. The fact with regard to taking the treatment from the hospital has not been disclosed by the complainant at the time of renewal of the policy.  If the said fact had been disclosed, OPs would not renew his policy. Complainant cleverly got renewed his health policy just to get the claim the from OPs.

12.           Thus, present complaint is devoid of any merits and same deserves to be dismissed and the same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated:03.01.2023

 

                                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)

                    Member                         Member

 

Sushma

Stenographer