DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .
Complaint No. 386
Instituted on: 18.09.2018
Decided on: 15.02.2021
Pawan Kumar S/o Kanwar Bhan, R/O #103, Adarsh Mohalla, Near Pandit Parmanand, Nabha Gate, Sangrur.
…. Complainant.
Versus
1. Star Health and Allied Insurance Co. Ltd. SCO-242, 1st Floor, Sector 12, Opp. Mini Secretariat, Karnal (Haryana) through its Manager.
2. Star Health and Allied Insurance Co. Ltd. Office No.1, New Tank Street, Valluvarkottam High Road, Nungambakkam, Chennai through its Managing Director.
….Opposite parties.
For the complainant: :Shri Ashish Grover, 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 Pawan Kumar, complainant has filed this complaint pleading that the complainant has taken a Health Insurance policy from the OPs for the assured sum of Rs.3,00,000/- for himself, his wife Kanchan Arora, son Vandan Jagia and daughter Vansika and this policy was valid for the period from 23.2.2016 to 22.7.2017. The complainant paid the premium of Rs.8817/- to the OP, but no terms and conditions of the policy were supplied to the complainant. Further it is averred that the complainant suffered with high fever on 5.10.2016 and he approached the civil hospital and took treatment of the disease from the doctor of Civil Hospital, Sangrur for almost 15 days but the health condition of the complainant deteriorated day by day, as such the complainant went to Fortis Hospital, Ludhiana and they examined the complainant and was admitted in the hospital on 22.10.2016 and the complainant told the OPs that he is insured with the OPs as such the hospital authorities sent the request to the OPs for cashless treatment but the OPs without any reason refused to give the cashless treatment. The complainant remained admitted in the hospital from 22.10.2016 to 26.10.2016 and spent an amount of Rs.54,396/- for the treatment provided by Fortis Hospital, Ludhiana. Thereafter the complainant approached the OPs and submitted the claim with the OPs for reimbursement of the amount, but the OPs on 1.2.2017 claim of the complainant was rejected. 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.54,396/- along with interest @ 18% per annum and further to pay Rs.25,000/- as compensation on account of mental agony, tension and harassment and an amount of Rs.20,000/- 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 the complainant obtained the policy in question from the OPs for the period from 23.2.2016 to 22.2.2017. It has been denied that the complainant suffered with high fever on 5.10.2016 and took treatment from Civil Hospital, Sangrur. However, it is admitted that the complainant remained admitted in Fortis Hospital, Ludhiana and they examined the complainant and admitted on 22.10.2016 and spent an amount of Rs.54,396/-. It is stated further that the claim was reported in the 8th month of the policy. The complainant patient was hospitalized in Fortis Hospital, Ludhiana on 22.10.2016 and discharged on 26.10.2016 and diagnosed as AFI with TCP case as per claim form. The complainant submitted the claim for Rs.54,396/- but the claim was approved for an amount of Rs.8000/-. It is further averred that subsequently the complainant submitted claim form for reimbursement of medical expenses, as such the claim documents were scrutinized and found that the complainant is a known case of seizure disorder from the age of 18 years and was on treatment with valproate for 3 years. The complainant at the time of commencement of policy on 23.2.2016 had not disclosed the above mentioned medical history/health details, as such it amounts to misrepresentation of material facts. As such as per condition number 8 of the policy, if there is any misrepresentation of material facts, then the company can reject the claim. 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 the complainant obtained one Health Insurance policy from the OPs for the assured sum of Rs.3,00,000/- for his family from the OPs for the period from 23.2.2016 to 22.7.2017. The complainant paid the premium of Rs.8817/- to the OP. Further the learned counsel for the complainant has argued that the complainant suffered with high fever on 5.10.2016 and he approached the civil hospital and took treatment of the disease from the doctor of Civil Hospital, Sangrur for almost 15 days but the health condition of the complainant deteriorated day by day, as such the complainant went to Fortis Hospital, Ludhiana on 22.10.2016 and the complainant told the Hospital authorities that he is having a medical insurance and the Fortis Hospital sent the request to the OPs for cashless treatment but the OPs refused the request. As such the complainant paid an amount of Rs.54,396/- to the Hospital authorities. Thereafter the complainant submitted the claim form along with documents to the OPs, but the claim was rejected.
5. On the other hand, the stand of the OPs is that the complainant has created false litigation. Further the learned counsel for the OPs has admitted that the complainant was insured with the OPs for one year along with his family members subject to the conditions and clauses. The learned counsel further argued that the complainant was admitted in Civil Hospital Sangrur on 5.10.2016. It is admitted further that the complainant was admitted in Fortis Hospital Ludhiana on 22.10.2016, The learned counsel for the Ops further argued that the policy in question is contractual in nature and the terms and conditions are part of the policy. The learned counsel for the Ops further argued that the complainant was diagnosed with acute febrile illness. The learned counsel for Ops further argued that the claim of the complainant was approved for Rs.8000/-. The learned counsel for the Ops further argued that the complainant was found a history of seizure disorder and has prayed that the complaint be dismissed.
6. To prove his case, the complainant has tendered Ex.C-1 affidavit and has deposed as per the complaint. Ex.C-2 is the policy where the address is shown of Sangrur and branch is of Karnal. The sum insured was Rs.3.00 Lacs. Ex.C-3 is the important document i.e. OPs slip dated 5.10.2016 of Punjab Health Systems Corporation, Sangrur. Ex.C-4 is the record of Fortis Hospital Sangrur where the complainant was admitted and discharged on 26.10.2016 and spent the amount of Rs.54,396/- and this bill is accompanied by the record of all the medicines given to him. Ex.C-5 is also an important document issued by Dr. Harminder Singh Pannu, wherein he has stated that Pawan Kumar was admitted to FHL via UHID 26.64573 and IPID-25016 on 22.10.2016 with chief complaint of fever for 20 days with Rigors and Chills a/w body aches. He was treated on the Lines of Acute Febrile Illness and was discharged on 26.10.2016 with the diagnosis of Acute Febrile Illness with Thrombocytopenia. During hospitalization, he had 1 episode of Seizure which was managed with Antiepileptics. This certificate is accompanied by record of internal medicines wherein platelet came to be 970000 and was discharged under stable condition. Ex.C-6 is the rejection letter of claim by the OPs and it is mentioned that it came to the knowledge of the OPs that the patient is a known case of seizure disorder from the age of 18 years and this fact has not been disclosed at the time of taking insurance policy, so the claim was rejected.
7. The Ops have tendered the affidavit Ex.OP1&2/1 of Shri Rajiv Jain wherein he has deposed as per the written version of the Ops. Ex.OP1&2/3 is the proposal form vide which he was insured for Rs.3.00 Lacs. Ex.OP1&2/4 is the policy schedule of the insurance policy. Ex.OP1&2/6 is the document of star health and in this document it is mentioned that the complainant was having bodyache for the last five days. Ex.OP1&2/7 is also prescription slip of the complainant of internal medicine team and remaining document is of Fortis Hospital wherein in one document it is mentioned that the complainant is old history of Epilepsy. This is record of Fortis Hospital and in this record seizure disorder is also mentioned, so it is clear from the record of Fortis Hospital that the complainant was a old patient of Epilepsy. Ex.C-5 is wrong certificate issued by Dr. H.S.Pannu. When the record of patient shows that the complainant is a patient of Epilepsy, so this certificate gets no meaning. Further the proposal form which is duly signed by Pawan Kumar complainant, there is no mention that he is suffering from Epilepsy. Another record is dated 25.9.2016, wherein it is mentioned that the patient was suffering from Epilepsy since the age of 18 years and this medicine record is Ex.OP1&2/8.
8. So from the above record of Fortis Hospital, Ludhiana, it is crystal clear that Pawan Kumar complainant was old patient of Epilepsy for the 18 years and this fact has not been mentioned in the proposal form, so he has deliberately concealed this ailment at the time of taking the insurance. Even otherwise, as per para number 3(b) of the complaint, the complainant has mentioned that he suffered from high fever on 5.10.2016 and he approached Civil Hospital Sangrur. The complainant took treatment of said disease from the doctor of Govt. Civil Hospital Sangrur for almost 15 days, but this fact is also not proved on the file. As per the receipt Ex.C-3 of Civil Hospital Sangrur dated 5.10.2016 and 7.10.2016 no medicine was prescribed and there is nothing on file to prove that the complainant was suffering from fever. There is another document Ex.OP1&2/14 produced by the OPs of Fortis Hospital wherein it is mentioned that the patient was old seizures history.
9. From the above discussion, we find that the complainant has concealed the old disease at the time of taking the insurance policy. As such, we dismiss the complaint of the complainant. However, the parties are left to bear their own costs. A certified copy of this order be issued to the parties free of cost as per rules. File be consigned to records.
Pronounced.
February 15, 2021.
(Vinod Kumar Gulati) (Jasjit Singh Bhinder)
Member President
