Haryana

Karnal

CC/181/2018

Gopal Singh - Complainant(s)

Versus

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

Narinder Sukhan

13 Nov 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 181 of 2018

                                                          Date of instt. 25.07.2018

                                                          Date of Decision 13.11.2019

 

Gopal Singh son of Shri Sher Singh resident of Arya Machinary Store, Novelty Road, Karnal.

                                                …….Complainant

                                        Versus

 

1. Star Health & Allied Insurance Co. Ltd. no.1, New Tank Street, Valluvarkottam High Road, Nungambakam, Chennai-600 034 through its authorized signatory.

2. Star Health & Allied Insurance Co. Ltd., situated SCO no.242, 1^st floor, Sector-12, Karnal through its authorized person.

3. Rajeev Gupta son of Devi Dayal Gupta, 107, Purani Mandi, Karnal agent of Star Health & Allied Insurance Co. Ltd., vide Intermediary Code no.BA0000177856, mobile no.94162-18812.

                                                                        …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

Before    Sh. Jaswant Singh……President. 

                Sh. Vineet Kaushik…..Member

                Dr. Rekha Chaudhary…….Member

 

 Present:  Shri N.K.Sukhan Advocate for complainant.

                   Shri Naveen Khaterpal Advocate for OPs.

                

                   (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant got insured himself medically from the OPs, vide policy no.P/211114/01/2018/001570 w.e.f.14.06.2017 to 13.06.2018. During the pendency of the policy, the complainant remained hospitalized in S.S. Hospital, 24/14 Urban Estate Karnal from 20.07.2017 to 25.07.2017 on account of CAD; Acute NSTEMS on emergency basis and discharged on 25.07.2017. Thereafter he remained admitted in Fortis Hospital, Mohali from 31.07.2017 to 06.08.2017 and further he remained admitted in Sir Ganga Ram Hospital, New Delhi from 06.08.2017 to 08.08.2017 for Bilaterla Pulmonary Thromboembolsism Non-Significant Coronary Artery Disease Normal Left Ventricular Function Bipaler Illness, he spent a sum of Rs.3,50,000/- approximately on  his treatment i.e. CADi Acute. As per terms and conditions of this policy, the complainant put his claim before the OPs alongwith original medical treatment records and other formalities as desired by the OPs and approached to the OPs for the settlement of his claim but instead of settling the claim the OPs start lingering the matter on one pretext or the other and finally repudiated the same, vide letter dated 19.01.2018 on the false ground. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written version raising preliminary objections with regard to limitation; cause of action; mis-joinder and non-joinder of necessary parties and concealment of true and material facts. On merits, it is pleaded that the insured availed Family Health Optima Insurance Policy covering Mr. Gopal Singh-self, Mrs. Suman Rani-Spouse, Nandani and Subham-dependent children for the sum insured, vide policy no.P/211114/01/2018/001570 w.e.f.14.06.2017 to 13.06.2018 for sum insured of Rs.3,00,000/-. It is further pleaded that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. The insured submitted three claims for reimbursement vide claim nos.CLI/2018/211114/0213135, CLI/2018/211114/0243423 and CLI/2018/211114/0192348 and the details of which are:

a. CLI/2018/211114/0213135

    The insured was admitted in the Fortis Hospital, Mohali-Bhabat (CT) on 31.07.2017 and discharged on 06.08.2017 for the treatment acute pulmonary thromboembolism-thrombolysed with TNK (02/08/2017) CAD-SVD (adv: medical management) LVEF-normal bipolar disorder. For the above mentioned hospitalization, the insured submitted pre authorization request and the same was denied due to non-disclosure of material facts, vide letter dated 02.08.2017. Subsequently, insured submitted claim for reimbursement of medical expenses of Rs.2,16,079/-.

b. CLI/2018/211114/0243423

        The insured was admitted in Sri Ganga Ram Hospital on 06.08.2017 and discharged on 08.08.2017 for the treatment Bilateral Pulmonar Thromboembolism Non-Significant Coronary Artery Disease Normal Left Ventricular Function. The insured submitted claim for reimbursement of medical expenses for an amount of Rs.44,908/-.

c. CLI/2018/211114/0192348

        The insured was admitted in S.S. Hospital on 20.07.2017 and discharged on 25.07.2017 for the treatment CAD, Acute NSIEMI (Trop-1) Depression. The Insured submitted claim for reimbursement of medical expenses for an amount of Rs.34,903/-.

On scrutiny of all the 3 claims documents, it is observed that:

i. As per the medical certificate dated 01.08.2017, the insured has bipolar disorder since 3 years and was on medication for 3 years for the same.

ii. As per the self declaration letter dated 01.08.2017, the insured state that Mr. Gopal Singh is having medicine since 3 years and it was diagnosed in 2014.

        The above findings confirm that the insured (patient) has Bipolar disorder from the inception of the policy and the same was not disclosed at the time of taking of the policy. Although the present admission is not concerned with the previous non-disclosure, the insured has to disclose the health history in the proposal form, but the insured has not disclosed the material facts. As per condition no.8 of the policy, if there is any misrepresentation whether by the insured or any person acting on his behalf, the company is not liable to make any payment in respect of any claim.

Thus, all the three claims were repudiated and the same were informed to the insured.

            Subsequently, the insured submitted representation to reconsider the claim, the same reviewed and observed that the rejection is in order and the same was informed to the insured vide letter dated 04.12.2017. As per condition no.15, the policy is also liable to be cancelled, thus the policy was cancelled with respect to Mr. Gopal Singh.

            As per the Contract of Insurance, the medical history/health details of the person(s) proposed for insurance are to be disclosed in the proposal form at the time of porting of the policy. It is further pleaded that as per the Regulation of the Insurance Regulatory and Development Authority Regulation, 2002 provides for the term Proposal Form: “A form to be filled in by the proposer for insurance, for furnishing all material information required by the insurer in respect of a risk, in order to enable the insurer to decide whether to accept or decline, to undertake the risk, and in the event of acceptance of the risk, to determine the rates, terms and conditions of a cover to be granted “All the questions the proposal are extremely relevant and they help the insurance company in deciding whether to accept the proposal or not and if yes, then at what rates, advantages, terms and conditions of a cover to be granted.

        Explanation: “Material” for the purpose of these regulations shall mean and include all important, essential and relevant informations that enable the insurer to take informed decision in the context of underwriting the risk.

Insurance is a contract based on Utmost Good Faith. There is a need and requirement and compulsion on the part of the insured to be truthful and transparent in the proposal to enable the insurer to take and make a conscious decision to underwrite the risk or not. Failure on the part of the insured, in this regard, would vitiate the very contract of insurance.  There is no deficiency in service on the part of the OPs and prayed for dismissal of the complaint.

3.             Learned counsel of OP no.3 has made a statement that the written statement of OPs no.1 and 2 be read as written statement of OP no.3.

4.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C16 and closed the same on 22.04.2019.

5.             OPs tendered into evidence affidavit of Rajiv Jain Ex.RW1/A and documents Ex.R1 to Ex.R27 and closed the same on 10.10.2019.

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

7.             The case of the complainant, in brief, is that complainant had taken a medical policy bearing no. no.P/211114/01/2018/001570 w.e.f.14.06.2017 to 13.06.2018. During the pendency of the policy, the complainant remained hospitalized in S.S. Hospital, 24/14 Urban Estate Karnal from 20.07.2017 to 25.07.2017 on account of CAD; Acute NSTEMS on emergency basis and discharged on 25.07.2017. Thereafter he remained admitted in Fortis Hospital, Mohali from 31.07.2017 to 06.08.2017 and further he remained admitted in Sir Ganga Ram Hospital, New Delhi from 06.08.2017 to 08.08.2017 for Bilaterla Pulmonary Thromboembolsism Non-Significant Coronary Artery Disease Normal Left Ventricular Function Bipaler Illness and he spent a sum of Rs.3,50,000/- approximately during this period on  his treatment i.e. CADi Acute. Thereafter, as per terms and conditions of this policy, the complainant put his claim before the OPs alongwith all the original medical treatment records and other formalities as desired by the OPs. The complainant approached to the OPs many times for the settlement of his claim but OPs did not settle and repudiated the same, vide letter dated 19.01.2018. Learned counsel of complainant relied upon the authorities in case Oriental Insurance Company Ltd. and Anr. Versus Mohinder Singh (DR.) 2008(4) CPJ 511 Hon’ble State Commission New Delhi, National Insurance Company Limited Versus Rajan Kumar and Anr. 2011(4) CPJ 11, LIC of India Vs. Joginder Kaur 2005, CPJ 78 of our own Hon’ble State Commission and New India Assurance Co. Ltd. Versus Commander (X) (P) Kamaldeep Singh Sandhu 2008(1) CPJ 34 of Hon’ble State Commission.

8.             The case of the OPs is that The insured submitted three claims for reimbursement vide claim nos.CLI/2018/211114/0213135, CLI/2018/211114/0243423 and CLI/2018/211114/0192348 As per the medical certificate dated 01.08.2017, the insured has bipolar disorder since three years and was on medication for three years for the same. As per the self declaration letter dated 01.08.2017, the insured state that Mr. Gopal Singh is having medicine since three years and it was diagnosed in 2014. The insured (patient) has Bipolar disorder prior to the inception of the policy and the same was not disclosed at the time of taking of the policy. Although the present admission is not concerned with the previous non-disclosure, the insured has to disclose the health history in the proposal form, but the insured has not disclosed the material facts. As per condition no.8 of the policy, if there is any misrepresentation whether by the insured or any person acting on his behalf, the company is not liable to make any payment in respect of any claim. Thus, all the three claims were repudiated and the same was informed to the insured.

9.             Admittedly, the complainant availed Family Health Optima Insurance Policy covering himself, Suman Rani-Spouse, Nandani and Subham-dependent children for the sum insured of Rs.3,00,000/-. The complainant got admitted in various hospital during the subsistence of the policy and submitted claims for reimbursement of medical expenses of Rs.2,95,890/- i.e. (Rs.2,16,079, Rs.44908/- and Rs.34908/-) for the expenses incurred in the Fortis Hospital Mohali, Sir Ganga Ram Hospital Delhi and S.S. Hospital Karnal respectively. All the three claims were scrutinized by the OPs and on the scrutiny of the all claim documents, it was observed that:

i. As per the medical certificate dated 01.08.2017 Ex.R6,  the insured has bipolar disorder since three years and was on medication for three years for the same.

ii. As per the self declaration of daughter Nandini of insured that her father had been taking these medicines since last three years. It was diagnosed in 2014.

All three claims of the complainant were repudiated by the OPs, vide repudiation letter Ex.R14, Ex.R15 and Ex.R16 on the only ground that the insured patient is a known case of bipolar disorder for the past three years and insured has bipolar disorder prior to inception of medical insurance policy and this facts have not disclosed in the proposal form which amounts to misrepresentation/non-disclosure of material facts.

10.            It is admitted case complainant-insured had purchased first policy Ex.R23 in the year 2014 and renewed vide policy Ex.R24 and Ex.R25 till 13.06.2018. As per first policy age of the insured was 46 years at the time of inception of the policy. As per IRDAI instructions it is duty of the insurance company, in case of issue of mediclaim policy in the favour of a person more than 45 years of age, to put him thorough medical examination. Similarly, view was taken by Hon’ble State Commission, Punjab in the case of M/s Max Bupa Health Insurance Co. Ltd. Versus Rakesh Walia, appeal no.191 of 2016 decided on 18.08.2016 wherein it was held that if contrary to the instructions issued by IRDAI, an insured above the age of 45 years, was not put to through medical examination, claim raised after issuance of insurance of policy cannot be rejected on account of non-disclosure of the fact of pre-existing disease when the policy was obtained. The case law cited by the complainant is fully applicable to the present case. The claim of the complainant cannot be repudiated on account of non-disclosure of the fact of pre-existing disease when policy was obtained.

11.            Moreover, as per medical certificate Ex.R6, the issuing Doctor has especially mentioned that :Bipolar disease has nothing to do with CAD or present ailment. The complainant has continuously renewed the policy in question. The insured has taken the treatment after passing the time of more than three years for taking the policy. Moreover, on page 50 of the treatment record Ex.C4 Dr. G.S. Kalra MD, DM(Cardiology) Director-Cardiology Fortis Hospital Mohali (Pb) specifically mentioned that patient has no prior history of Cardiac disease.

12.            In Mohinder Singh’s case (supra) the Hon’ble State Commission Delhi held that Medi-Claim policy-Reimbursement claim repudiated-Contention that factum of pre-existing disease not disclosed-Complaint allowed by District Forum-Appeal against-Insured leading healthy and normal life, not supposed to disclose factum of treatment/operation undertaken for particular disease 10-12 years earlier-Deceased living ordinary life, subjected to basic medical test by panel doctors of insurer-Onus on insurer to prove concealment of pre-existing disease at that time of obtaining policy, not discharged-Appeal devoid of merits, dismissed. In Rajan Kumar’s case (supra) our own Hon’ble State Commission has held that Insurance Mediclaim Policy-Claim repudiated-District Forum allowed the complaint-Hence appeal-Contention that life assured concealed her disease in the proposal form and also disease suffered by her was not cover under policy-Rejected-Opinion of doctor is not sufficient about pre-existence of disease-Insurance Company has to prove that life assured was in full knowledge of disease having been suffered by her-No case of suppression or fraud made out-Insurance Company liable to reimburse the expenses-Appeal dismissed. In Joginder Kaur’s case (supra) the Hon’ble State commission Haryana has held that the unproved case history recorded by some person on the date of admission of the patient, patient would not be cogent and convincing evidence to repudiate the case, unless it was coupled with medical record for the treatment prior to the submission of the proposal form. In Commander(X)(P) Kamaldeep Singh’ case (supra) the Hon’ble State Commission Punjab held that Angioplasty done-Repudiation of claim-on ground of concealment of pre-existing disease-Deficiency in service alleged-Complaint allowed-Appeal by Insurance Company-Held, no evidence produced regarding any treatment prior to taking of policy-Complainant’s knowledge about disease not proved-Even ECG produced at the time of taking of policy did not show anything wrong with heart-Thus, Insurance Company rightly liable to pay claim amount with interest-Order upheld-Appeal dismissed.

13.            Keeping in view that the ratio of the law laid down in the aforesaid judgments and the facts and circumstances of the present complaint, we are of the considered view that the insurance company has failed to prove the allegations on the basis of which they have repudiated the claim of the complainant. Thus, the repudiation of the claim done by the OPs is held to be unjustified and amounts to deficiency in service and unfair trade practice. The complainant spent Rs.2,95,890/-on his treatment, which is not denied by the OPs. Hence complainant is entitled for the said amount.

14.            Thus, as a sequel to the abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.2,95,890/- to the complainant with interest @ 9% per annum from the date of repudiation till its realization. We further direct the OPs to pay Rs.25,000/- to  the complainant on account of mental agony and harassment suffered by him and Rs.11,000/- for the litigation expenses. This order shall be complied with within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:13.11.2019                                                                       

                                                                      President,

                                                              District Consumer Disputes

                                                               Redressal Forum, Karnal.      

 

 

         (Vineet Kaushik)         (Dr. Rekha Chaudhary)

            Member                         Member