Punjab

Sangrur

CC/458/2018

Baljinder Kumar - Complainant(s)

Versus

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

Sh. Udit Goyal

05 Oct 2023

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

          

                                                                         Complaint No. 458

 Instituted on:  05.11.2018

                                                                         Decided on  :   05.10.2023      

 

1. Baljinder Kumar Mehta aged about 50 years son of Sh. Mohan Lal, resident of H.No. 7A/82, Pathshala Road, Dhuri, Tehsil Dhuri, District Sangrur.

                                                   …. Complainant.                                      Versus

1. Star Health and Allied Insurance Company Limited, Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai, through its Managing Director:600034
2. Star Health and Allied Insurance Company Limited, SCO 17-18-19, 2^nd Floor, Jhandu Tower, Miller Ganj, G.T. Road, Ludhiana, through its Branch Manager 141003.
3. Star Health and Allied Insurance Company Limited, Branch Office: Above IDBI Bank Limited, Sunami Gate, Sangrur, through its Branch Manager.

                                                               ….Opposite parties. 

QUORUM                                       

JOT NARANJAN SINGH GILL: PRESIDENT

SARITA GARG                           : MEMBER

KANWALJEET SINGH             : MEMBER

 

For the complainant  : Shri Udit Goyal, Adv.              

For the Ops              : Shri Rohit Jain,Adv.

 

ORDER BY

KANWALJEET SINGH, MEMBER.

1. Complainant has alleged in the complaint that in the month of February 2015, agent of the Ops approached the complainant for getting the health insurance policy and told that their company has launched a family health insurance under which all the family members are covered under one policy and there is also benefit of auto recharge of claim to the extent of sum assured. It was also told that in case no claim for the relevant period, then their company will also give the benefit of no claim bonus by adding the 10% of the sum assured on the same premium. Further, their company is also provided the cashless Hospitalization in 4000 Hospitals throughout India. Company is also giving the added benefits of medical expenses of 30 days prior to the hospitalization and 60 days after the hospitalization. The complainant proposed for the insurance policy of the Ops for an amount of Rs. 5 Laks under family health optima insurance plan  and paid a premium of Rs. 17742/- through cheque bearing number 653283 drawn on HDFC Bank Ltd. Branch, Sangrur to the said agent of the Ops. Thereafter the Ops issued policy bearing number P/161114/2015/007883 for the period from 14.02.2015 to 13.02.2016 in favour of complainant. Under the said policy, the complainant, his wife and three children were insured for an amount of 5,00,000/- on floater basis. The policy was received by complainant through registered post at his residential address. The terms and conditions of the policy were not supplied to the complainant by the Ops. The said policy was renewed and complainant paid Rs. 18159/- as premium in cash for the renewal of policy for a period of 12.03.2016 to 11.03.2017. Therefore the Ops given the bonus of Rs. 1,25,000/- and issued the policy with the sum insured of Rs. 6,25,000/-.
2. Unfortunately, on 24.01.2017 when the complainant was at home and reading the newspaper, then, suddenly newspaper fell from his hands. The daughter of the complainant namely staffy Mehta, who is doctor, immediately checked the complainant, but both the hands of the complainant were not working. The complainant was immediately taken to Dr. Jindal Charitable Hospital, Dhuri, where the doctor after giving first aid, advise the family to take the complainant to higher hospital. Complainant was immediately taken to SPS, Hospital, Ludhiana, where the doctor after conducting the numerous tests found that it is a case of cervical spondylosis with myelopathy. The doctor advised the immediate surgery of the complainant. The Ops were immediately informed for cashless treatment through agent. The complainant remained admitted in the hospital from 30.01.2017 to 01.03.2017 at SPS, Hospital, Ludhiana and the Hospital raised a bill of Rs. 9,00,000/-. But the Ops did not pay the amount and consequently the complainant paid Rs. 8,82,316/- from his own pocket under the compelled circumstances. After discharge from the hospital, the agent of the Ops again approached the complainant for the renewal of the policy, but, the complainant refused to renew the policy as the ops failed to fulfill their promise for cashless treatment. The agent of the Ops assured to honour the claim and consequently complainant again got renewed the policy by paying the premium of Rs. 18159/- in cash to the said agent. The Ops renewed the policy for the period 12.03.2017 to 11.03.2018. The complainant again admitted in the hospital for the period from 09.03.2017 to 15.03.2017 and spent about Rs. 1,15,026/- on his treatment. After discharge from the hospital, the complainant approached to Ops through their agent for releasing the claim amount. Complainant submitted all the documents as required by the agent of the Ops. The Ops assured to release the claim amount within 15 days. Complainant was shocked to receive a letter dated 08.07.2017, wherein the Ops wrongly and illegally repudiated the claim on the ground that the treatment taken by the complainant is not covered under the policy. At the time of taking the policy in month of February 2015, the complainant was heal and hearty and was not suffering from any ailment. The present ailment, for which the treatment was taken by the complainant is accidental one and has occurred suddenly. As such, there is deficiency in service and unfair trade of practice on the part of Ops. It is prayed the Ops may kindly be directed to release the claim amount of Rs. 9,97,342/- alongwith the interest @18% per annum from the date of payment to the hospital i.e. 15.03.2017 till realization and Rs. 50,000/- on account of mental tension, agony and Rs. 22,000/- as litigation expenses.
3. Upon notice, Ops has appeared and filed written reply by taking preliminary objections that complainant has no locus standi to file the present complaint. Complaint is not legally maintainable. Insurance policy was obtained by complainant from Ludhiana Branch of the Ops. So, the Forum has no jurisdiction to try and decide the present complaint. On merits, it is admitted to the extent that the complainant proposed for the insurance policy of Ops for an amount of Rs. 5 Lacs under the family health optima insurance plan and paid the premium amount of Rs. 17742/- through cheque No 653283 and the Ops issued policy bearing number P/161114/2015/007883 for the period from 14.02.2015 to 13.02.2016 in favour of the complainant, his wife and three children were insured. The said policy received by the complainant through registered post at his residential address.  Further it is admitted that in case no claim for the relevant period, then their company will also give the benefit of no claim bonus by adding 10% of the sum assured on the same premium and Ops have providing the cashless hospitalization in 4000 Hospitals throughout India. Company is also giving the added benefits of medical expenses of 30 days prior to the hospitalization and 60 days after the hospitalization. The terms and conditions of the policy were sent to the complainant alongwith policy and the complainant never lodged any complaint regarding non receipt of term and conditions of the policy. The complainant got renewed the policy from 12.03.2016 to 11.03.2017 and the complainant paid Rs. 18,159/- as premium in cash for the renewal of the policy and there was no claim under previous policy, therefore, the Ops given the bonus of Rs. 1,25,000/- and issued the policy with the sum insured of Rs. 6,25,000/-. It is submitted that the claim is reported in the second year of the policy. The insured patient was admitted in the SPS, Hospital on 30.01.2017 and discharged on 01.03.2017 and as per discharge summary the insured patient was diagnosed with Cervical myelopathy, PIVD C3-C4-05 and Cervical stenosis and the complainant claimed an amount of Rs. 9,97,342/-.It is observed that the insured patient was treated for PIVD, which falls under the 2 years exclusion of the policy. Thus, the pre authorization of the insured is rejected and the same was informed to the insured vide letter dated 30.01.2017. Complainant was fully satisfied with the service of the Ops due to this reason complainant again got renewed the policy by paying the premium of Rs. 18159/- in cash and the Ops renewed the policy for the period of 12.03.2017 to 11.03.2018.  The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Subsequently, the Ops have received claim for reimbursement of medical expenses. On scruting of the claim docuements it is observed that the insured patient underwent treatment for prolapsed intervertebral Disc, which falls under the two year exclusion of the policy terms and conditions. Thus, claim was not payable and the same repudiated and informed to the insured vide letter dated 08.07.2017. All the remaining allegations of the complaint are denied by Ops and prayed that the complaint may kindly be dismissed with special costs.
4. Both the parties has submitted their documents in evidence. The learned counsel for the complainant has also suffered a separate statement dated 14.06.2019 that he do not want to give any evidence in rebuttal.
5. We have heard the learned counsel of both the parties and gone through the record file carefully with the valuable assistance of the learned counsels for the parties. During arguments the contentions of the learned counsel of both the parties are similar to their respective pleadings. So, there is no need to reiterate the same to avoid repetition. Now come to major controversy, whether the complainant is liable for relief as claimed by him in his prayer or not?
6. It is not disputed that the complainant availed a service from Ops with regard to family health policy which is Ex.C-2 bearing number P/161114/01/2015/007883 from 14.02.2015 to 13.02.2016. Under the policy the complainant, his wife and three children  were insured for an amount of Rs. 5,00,000/-. Premium paid by the complainant of Rs. 17742/-. As per Ex.C3, the policy was renewed for the period of 12.03.2016 to 11.03.2017. Ops given bonus of Rs. 1,50,000/- and sum insured was Rs. 6,25,000/- as per Ex.C3. Further, the policy was renewed as per Ex.C4, for the period of 12.03.2017 to 11.03.2018. The complainant had paid Rs. 18,159/- as premium. The limit of coverage was 6,75,000/- and the recharge benefit was mentioned as 1,50,000/-. As per Ex.C5, retail invoice at page 4 dated 31.03.2017 net amount of Rs. 8,82,316/- was received from complainant by SPS hospital sherpur chowk, G.T. Road, Ludhiana On 08.07.2017, Complainant had received a repudiation letter which is Ex.C8.
7. On the other hand, the Ops relied upon Ex.Op4 family health optima insurance plan at page number 3 of 4 at policy schedule, it is mentioned as the insurance under this policy is subject to conditions, clauses, warranties, exclusion etc. attached. This Commission observed that from this angel, the stand of complainant with regard to separate terms and conditions were not supplied by the Ops as per para number 3(a) at page number 3 of complaint is not believable. However, complainant did not moved any complaint/representation with regard to terms and conditions were not supplied by Ops.
8. During arguments the leaned counsel for Ops more focused on Ex.Ops/6 at page number 5 clause 3.0 exclusions is reproduced as under "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 48 consecutive months of continuous coverage have elapsed ; Since inception of the first policy with any Indian Insurer. However, the limit of the company's liability in respect of claim for pre-existing diseases shall be limited to the sum insured under the first policy with any Indian Insurance Company.

3. During the first two years of continuous operation of insurance cover any expenses on

1. Contract, diseases of the Vitreous and Retina, Glaucoma, diseases of ENT, Mastoidectomy, Tympanoplasty, Stpedectomy, diseases related to Thyroid, Prolapse of intervertebral disc (other than caused by accident)…

e) Degenerative Disc and Vertebral diseases including replacement of bones and joints and degenerative diseases of the Musculo-Skeletal System.

9.  
10.  

11. Resultantly, Keeping in view the facts and circumstances of the complaint in hand and the above discussed decision of the Hon'ble Punjab And Haryana High Court as well as the decision of the Hon'ble Supreme Court of India, we partly allow the present complaint of the complainant and direct the Ops to reimbursement the Medi-claim of the complainant (as per Ex.C-4) of Rs. 6,75,000/- + 1,50,000/- total Rs. 8,25,000/- and Further the Ops are directed to pay a consolidated amount of Rs. 5000/- as compensation and litigation expenses.
12. This order be complied by Ops within a period of 45 days from the date of receipt of order.
13. The complaint could not be decided within the statutory time period due to heavy pendency of cases.
14. Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance.                                  

                                Announced.

                                5^th October, 2023.

 

( Kanwaljeet Singh)    (Sarita Garg)  (Jot Naranjan Singh Gill)

    Member                        Member                  President