Punjab

Sangrur

CC/512/2018

Arun Kumar - Complainant(s)

Versus

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

Sh.Yogesh Gupta

01 Feb 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

 

                                                                         Complaint No. 512

 Instituted on:   13.12.2018

                                                                         Decided on:     01.02.2021

Arun Kumar S/o Sh. Pushpinder Kumar, R/O H.No.213/3, W.No.8, Near Gandhi Chowk, Ahemdgarh, Distt.Sangrur.

                                                          …. Complainant.     

                                                 Versus

1.     Star Health and Allied Insurance Co. Ltd. No.15, Sri Balaji Complex, 1^st Floor, Whites Lane, Royapettah, Chennai-600014 through its M.D.

2.     Star Health and Allied Insurance Co. Ltd. Area Office, Ludhiana No.3369, 4^th Floor, Sandhu Tower-II, Ferozpur Road, Ludhiana 141001 through its Manager.

             ….Opposite parties. 

For the complainant:             :Shri  Yogesh Gupta, Adv.              

For the OPs                         :Shri Rohit Jain, Adv.

 

Quorum:    Shri Jasjit Singh Bhinder, President

                Shri V.K.Gulati, Member   

ORDER:   

Shri Jasjit Singh Bhinder, President

1.             Shri Arun Kumar,  complainant has filed this complaint pleading that the complainant has taken Health Insurance policy bearing  No.P/211200/01/2018/002947 from the OPs for the assured sum of Rs.5,00,000/- on 6.11.2017.  This policy was also renewed subsequently after paying premium of Rs.21,240/-.  Further it is averred that Shri Pushpinder Kumar father of the complainant is also insured under this policy.  Further it is averred that father of the complainant suddenly fell ill and was got admitted in PGI Hospital Chandigarh on 23.12.2017 and was discharged on 12.1.2018 where he spent an amount of Rs.3,30,000/- on his treatment.  The complainant gave intimation to the OPs and submitted all the documents to the OPs, but the OPs after inordinate delay repudiated the claim unilaterally on 16.6.2018.  The complainant and his father has no knowledge about the disease as the same was not an existing disease as his father had not earlier taken treatment for Calcific Aortic Steosis. It is further averred that the OPs have wrongly and illegally repudiated the rightful claim of the complainant.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the Opposite parties be directed to pay to the complainant the amount of Rs.3,30,000/- along with interest @ 12% per annum from 1.4.2018 till realization and further to pay Rs.50,000/- as compensation on account of mental agony, tension and harassment and an amount of Rs.11,000/- on account of litigation expenses.

2.             In reply filed by the OPs, preliminary objections are taken up on the grounds that the complainant has no locus standi to file the present complaint, that the complaint is not maintainable, that the complainant has not come to the Forum with clean hands and that the complainant has suppressed the material facts from this Forum.  On merits it is admitted that father of the complainant Shri Pushpinder Kumar remained admitted in the PGI Chandigarh from 23.122017 to 12.1.2018 and intimation was given to the opposite parties after discharge and claim form along with some documents was submitted to the OPs. It has been denied that the OPs have wrongly repudiated the claim vide letter dated 16.6.2018. It has been denied that the complainant or his father had no knowledge about the disease.  Further it is stated that Ludhiana branch of the OPs had issued the policy in question and the terms and conditions of the policy were explained to the complainant at the time of proposing the policy and the same was served to the complainant along with policy schedule.  It is further stated that the Senior Citizen Red Carpet policy coverage with suitable co-payment, 50% of each and every claim arising out of all pre-existing diseases as defined and 30%  in case of all other claims which are to be borne by the insured.  It is stated further that the policy is contractual in nature and the claim arising therein are subject to the terms and conditions of the policy.   The claim has been reported on the 46^th day of the policy and the insured claimed an amount of Rs.3,29,017/-. It is further averred that on scrutiny of the claim record, it was found that as per the consultation report slip of Saron Medical Clinic dated 29.12.2017, the insured was advised for admission and referred to higher centre, as per ICP dated 29.12.2017 and 31.12.2017, the insured is a known case of HTN since four years and as per the ICP the insured is a known case of HTN since 15 years and was on medication.  It is further averred that after all it was found that the insured has pre existing hypertension and long standing cardiovascular disease.   As such the claim of the complainant has rightly been repudiated.   

3.             The learned counsel for the parties produced their respective evidence.

4.             The learned counsel for the complainant has argued that father of the complainant suddenly fell ill and he was got admitted in the PGI Hospital Chandigarh on 23.12.2017.  The learned counsel for the complainant has further argued that his father was discharged on 12.1.2018 and after discharge the claim of Rs.3,30,000/- along with all the documents was submitted to the OPs, but the OPs repudiated the claim of the complainant vide letter dated 16.6.2018.  The learned counsel has further argued that the disease was not exiting at the time of taking the insurance policy.  Further the learned counsel has argued that the OPs have wrongly mentioned that the disease is pre existing one. The learned counsel for the complainant has further argued that the complainant requested the OPs to make the payment of the claim but the OPs wrongly repudiated the claim of the complainant.  The learned counsel for the complainant has relied upon Rajesh Singla versus Max Bupa Health Insurance Co. Ltd. and another 2018(3) CPJ 172 (Punjab State Commission) wherein it has been held that “Consumer Protection Act 1986 Section 17 Health Companion Health Insurance policy- Reimbursement denied on ground of suppression of pre-existing disease- Alleged deficiency in service- Thus, the complaint –Held, mere reference in the record mentioned by the Doctor that he was suffering from hypertension for the last 5 years is not sufficient to say so. Moreover, hypertension is not a disease, which is required to be referred in the proposal form. Ops have not been able to collect any evidence that before taking policy, complainant/insured was suffering from hypertension or his liver disease was complication arising on account of misuse of substance therefore, claim cannot be repudiated on basis of any complication of hypertension. OPs are directed to pay Rs.22,22,352 to complainant along with interest @ 9% per annum. Hence, complaint disposed of.”   The learned counsel for the complainant has further relied upon Oriental Insurance Company Ltd. versus K. Anandam 2005(1) CPJ 571 (Karnataka State Commission), wherein it has been mentioned “Insurance-Mediclaim policy-Repudiation of claim- Reimbursement of bypass surgery refused under exclusion clause. Insured was subjected to medical examination before issuance of fresh policy. ECG found normal, complainant could not have known existence of any disease relating to heart on date of filling of proposal form. Cardiac arrest could not be anticipated as no symptoms of cardiac arrest exist. Complainant had to undergo bypass surgery within 30 days from date of policy due to sudden cardiac arrest. Exclusion clause not applicable. Repudiation unjustified. Complaint allowed.”   The learned counsel has further relied upon  Life Insurance Corporation of India versus Surjan Singh Saini 2001(1) CPJ 278 (Punjab State Commission), wherein it has been held  that “Insurance Claim- concealment of disease- claimant- insurance claim was repudiated on the ground that insured deceased had not stated the real state of her health at the time of submitting the proposal form.  From the evidence on record it is well established that deceased had some pain in abdomen at the time when form was submitted. She was not bound to inform about every minor ailment.  Death occurred due to disease of Gall Bladder and defect in kidney which has no nexus with pain in abdomen.  Repudiation of claim unjustified. Order of District Forum accepting claim of Rs.one Lac with interest at the rate of 18% upheld.”

5.             On the other hand, the learned counsel for the OPs has argued that the insurance policy was issued by Branch Office Ludhiana and only the District Commission at Ludhiana has the jurisdiction and the District Commission at Sangrur has no jurisdiction.  Learned counsel for the OPs further argued that at the time of filling the proposal form the father of the complainant not mentioned that he has pre existing disease.  Learned counsel for the OPs further argued that his father was suffering from hypertension for the last 5 years as such the claim has rightly been repudiated.  The learned counsel for the OPs has relied upon Sonic Surgical versus National Insurance Co. Ltd. IV(2009) CPJ 40 (SC)  and  Darshan Singh versus HDFC Standard Life Insurance Company Limited and another  II (2019) CPJ 243 (NC) and Branch Manager, Bajaj Allianz Life Insurance Company Limited and others versus Dalbir Kaur 2020(4) Civil Court Cases 142 (SC)

6.             To prove his case, Arun Kumar complainant has tendered affidavit Ex.C-1 and he has deposed as per his complaint.  Affidavit  of Shri Pushpinder Kumar is Ex.C-2 and he has also deposed that he suddenly fell ill and was got admitted in PGI Chandigarh on 23.12.2017 and was discharged on 12.1.2018 and after discharge claim of Rs.3,30,000/- was submitted to the OPs and the OPs after the inordinate delay repudiated the claim.  Ex.C-3 is the copy of insurance policy of Star Health and Allied Insurance Company Limited which is in the name of Arun Kumar and Shri Pushpinder Kumar is also insured in the policy. Ex.C-4 is copy of document of Star Health Insurance, Ex.C-5 is the copy of Senior Citizen Red Carpet Health Insurance Policy of Star Health, Ex.C-6 is copy of letter of Star Health, Ex.C-7 is the copy of document of Star Health, Ex.C-8 is the copy of repudiation letter dated 16.6.2018, Ex.C-9 is record of PGI Chandigarh,  Ex.C-10 to Ex.C-41 are the copies of medical bills of PGI Chandigarh.  Ex.C-42 is the copy of letter of Star Health Insurance.

7.             On the other hand, Shri Rajiv Jain has tendered his affidavit Ex.OPs/1 and deposed as per written statement.  Ex.OPs/2 is the copy of power of attorney. Ex.OPs/3 is the proposal form of Star Health Insurance. Ex.OPs/4 is Senior Citizen Red Carpet Health Insurance policy, Ex.OPs/5 detail of policy, Ex.OPs/6 and Ex.OPs/7 is claim form, Ex.OPs/8 is copy of prescription slip dated 22.12.2017. Ex.OPs/9 and Ex.OPs/10 are also letter of Star Health Insurance.

 8.            In the present case, Shri Pushpinder Kumar who was also covered under the mediclaim policy issued by the OPs  was operated in PGI Chandigarh and he submitted the bills of Rs.3,30,000/- to the OPs but the Ops vide letter Ex.C-8 repudiated the claim on the ground that hospital record shows that the insured patient has hypertension for the past 4 years which confirms the insured patient has hypertension prior to inception of the medical insurance policy.

9.             The complainant has attached the Judgment of Hon’ble Punjab State Commission titled as Rajesh Singla versus Max Bupa Health Insurance Co. Ltd. (supra) wherein it was mentioned by the Hon’ble State Commission that the report of doctor is not sufficient to say  that he was suffering from hypertension for the last five years.  Moreover hypertension is not a disease which is referred in the proposal form.   The complainant has also attached the judgment of the Hon’ble Karnataka State Commission  titled as Oriental Insurance Company Ltd. versus K. Anandam (supra) wherein it has been mentioned that cardiac arrest could not be anticipated as no symptoms of cardiac arrest exist.     Further it  was also held by Hon’ble Punjab State Commission in another judgment titled as Life Insurance Corporation of India versus Surjan Singh Saini (supra) that insured is not bound to inform every minor ailment.  The complainant has also attached the judgment  of Religare Health Insurance Company Limited versus Subhash Chander Aggarwal 2017(3) CLT 140 (Punjab State Commission) decided on 26.4.2017, wherein it was held by the Hon’ble State Commission that in year 2011 the patient was found problem of hypertension, therefore, it was held that it is not  a pre-existing disease and the claim was allowed.  On the other hand, the law produced by the OPs is not at all helpful to them.

10.            As per the record of PGI Chandigarh Ex.C-9, the patient Pushpinder Kumar was operated and he was admitted on 23.12.2017 and discharged on 12.1.2018.  All the bills have been attached by the complainant in support of his claim.  Shri Pushpinder Kumar in his affidavit Ex.C-2 has clearly stated that he has taken Health insurance policy from the OPs and the policy was renewed after paying premium of Rs.21246/- for one year.  He has further mentioned that suddenly he fell ill and was admitted in PGI Chandigarh on 23.12.2017 and discharged on 12.1.2018 and after discharge claim of Rs.3,30,000/- was submitted to the OPs, but the claim was repudiated.  In the written statement filed by the Ops, they have admitted that Shri Pushpinder Kumar was admitted in PGI Chandigarh on 23.12.2017 and discharged on 12.1.2018 and submitted the claim of Rs.3,30,000/- to the OPs, so the admission and surgery of Pushpinder Kumar is admitted by the OPs.  

11.            The other point is that the policy was taken at Ludhiana and Arun Kumar is resident of Sangrur.  It is mentioned in the complaint that the complainant was residing in Sangrur, so this Commission has the jurisdiction to decide the case.

12.            After taking the legal position and circumstances of the case, we allow the complaint and direct the OPs to pay to the complainant the amount of Rs.3,30,000/-  along with interest @ 6% per annum from 16.6.2018 i.e. the date of repudiation of the claim till realization in full.  We further direct the OPs to pay to the complainant an amount of Rs.5,000/- on account of litigation expenses.  This order be complied with by the opposite parties within 60 days from the date of receipt of certified copy of this order. A certified copy of this order be issued to the parties free of cost as per rules. File be consigned to records.

Pronounced.

                        February 1, 2021.

 

(Vinod Kumar Gulati)  (Jasjit Singh Bhinder) 

           Member                  President