Haryana

Karnal

CC/393/2021

Yogesh Goel - Complainant(s)

Versus

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

Abhay Sahu

08 Oct 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.393 of 2021

                                                        Date of instt.10.08.2021

                                                        Date of Decision: 08.10.2024

 

Yogesh Goel son of Shri Ram Kishan Goel, resident of house no.196/12, Ram Gali, Patwar Mohalla, near Choura Bazar, Karnal, District Karnal, proprietor of Manu Trading Company. Aadhar no.7087 4185 6986.

                                                                        …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Company Ltd. Registered & Corporate office: 1, New Tank Street, Valluvar Kotlam High Road, Nungambakkar, Chennai-600034.
2. Star Health & Allied Insurance Company Ltd. Branch office at SCF-137, 2^nd floor, Sector-13, Urban Estate, Karnal-132001.
3. Vikas (Sales Manager), Branch office at SCF-137, 2^nd floor, Sector-13, Urban Estate, Karnal-132001.

                                                                  …..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

              Ms. Neeru Agarwal…….Member

      Ms. Sarvjeet Kaur…..Member

 

 Argued by: Shri Abhay Sahu, counsel for the complainant.

                    Shri Mohit Goyal, counsel for the OPs No.1&2.

                    OP no.3 exparte, vide order dated 13.05.2022.

 

                     (Jaswant Singh, President)

 

ORDER:   

                        The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant had purchased a Family Health Optima Insurance Plan from the OPs, vide renewal Endorsement no.P/211114/01/2021/0000479, on 20.04.2020 and the tenure of said policy was 22.04.2020 to 21.04.2021, vide proposer code no.2833356 and the complainant had given the total premium amount of Rs.21,642/- i.e. premium Rs.18,340/- and CGST/SGST of Rs.1651/- each. The said policy was commenced from 08.04.2013 and the complainant regularly paying the premium amount for its renewal. On 17.04.2021, complainant had issued a cheque to the agent of the OPs no.1 and 2 i.e. OP no.3 for the renewal of the abovesaid policy but due to merger of the banks, the said cheque was returned by the OP no.3 to the complainant and disclosed the said fact of encashment of cheque due to the merger of banks, then immediately complainant through RTGS transferred the premium amount to the OPs no.1 and 2 on 17.04.2021 but the NEFT has been cancelled due to the merger of bank stated by the OP no.3. Further, on 19.04.2021, the complainant tried to make the premium amount to the OPs no.1 and 2 through RTGS but again the NEFT has been cancelled due to merger of bank. Hence, on 23.04.2021, in the morning the OP no.3 approached to the house of the complainant and received the premium amount in cash from the complainant and OP no.3 assured to the complainant that the policy of the complainant would not be lapsed in any manner and the complainant also received a message from the OPs no.1 and 2 for receiving the payment for premium amount and policy has been renewed. After paying the premium amount, suddenly the complainant feel some problem in his heart and on 23.04.2021 at about 2.17 p.m., complainant was got admitted in Sanjiv Bansal Cygnus Hospital, Railway Road, Karnal, where the doctor operated to the complainant and further discharge on 24.04.2021 from the hospital and thereafter the complainant remained under observation of concerned doctors. At the time of admission, complainant submitted to abovesaid policy card to the concerned doctors but at the time of making the payment, OPs rejected the authorization for cashless treatment to the complainant. Due to this act of the OPs, complainant faced so much difficulties and during his ailing condition, the complainant arranged money and paid the bills of hospital i.e. Rs.1,23,620/-, Rs.10,000/- (discount)= Rs.1,13,620/- for hospital charges+ Rs.8322/- for medicines and tests. Total expenses Rs.1,21,942/-. Thereafter, the complainant filled the claim form part-B, for claiming the treatment expenses, but the OPs firstly postponed the matter on one pretext or the other and thereafter not passed the claim of the complainant and also not issued any letter in this regard in favour of the complainant. Aggrieved from the acts of OPs, complainant sent a legal notice dated 11.06.2021 but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence, complainant filed the present complaint seeking direction to the OPs to make the payment of treatment of Rs.1,21,942/- alongwith interest @ 24% per annum from the date of treatment till its realization and the OPs further directed to make payment of compensation to the tune of Rs.1,00,000/- on account of deficiency in service and unfair trade practice and also for causing mental pain, agony and harassment etc. and to pay Rs.21,000/- as litigation expenses.

2.             On notice, OPs no.1 and 2 appeared and filed its written version, raising preliminary objections with regard to maintainability; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that OP issued Family Health Optima Insurance Plan, vide policy no.P/211114/01/2022/000690 for the period 23.04.2021 to 22.04.2022 covering Mr. Yogesh Goel-self, Mrs. Renu Goel- Spouse for the sum insured Rs.4,00,000/-. On receipt of the claim intimation, the claim no.CIR/2022/211114/2509490 in regard to hospitalization of insured patient Yogesh Goel at Sanjiv Bansal Cygnus Hospital, Karnal on 23.04.2021 for treatment of CAD was registered. The above insurance policy is renewed after a break period from 21.04.2021 to 23.04.2021. As per hospital records, patient had chest pain since morning 11 a.m. on 23.04.2021, patient came to the hospital in wheel chair, Trop T report sample was collected at 12.45 p.m. on 23.04.2021, which means patient by 12.45 itself came to the hospital. As per the policy schedule, the policy was issued on 23.04.2021, 13.57. It is observed from submitted documents patient renewed policy on 23.04.2021 at 1.57 pm. And patient could to be trop positive on 12.45 p.m., at which is on break period that the onset of the above disease is during the break period of insurance and this was not disclosed at the time of renewal of this policy. Hence, the claim is not admissible. As per condition no.7, of the above policy, the company is not liable o protect the insured person between the policy expiry date and the date of payment of renewal premium. Hence, claim is not payable under policy term and conditions. The cashless was rejected and the rejection of cashless claim was conveyed to the insured, vide letter dated 24.04.2021. The questioned claims misrepresentation/non-disclosure of material fact was conducted by complainant insured thus his claims were not payable according to said policy condition no.6. As per contract of insurance, it is the duty of the proposer to disclose all the material facts to the insurer, so that the insurer evaluates the material facts and decides, whether to accept the proposal or not as the insurance contract is based on utmost good faith. In the case of health insurance contracts, disclosure of health details are the material facts. Insurance is based on utmost good faith. As the contract of insurance, the insured is expected to declare in the proposal form about the details of his ailments/sickness-past medical history and the reply for the same helps the insurer to evaluates the material facts and decides, whether to accept the proposal or not. In this case, the insured has not declared past health history/complications while requesting incorporation of insured patient’s name Yogesh Goel in the policy schedule, which is non-disclosure of material fact, hence repudiation of claim by the company is fully justified, as the same was  not payable/admissible, as per the condition no.6 of the policy. It is further pleaded that as per contract of insurance, the insured is expected to declare in the proposal form about the details of his ailments/sickness-past medical history and the reply for the same helps the insurer to evaluates the material facts and decides, whether to accept the proposal or not. In this case, the insured has not declared past health history/complications while requesting incorporation of insured patient’s name Yogesh Goel in the policy schedule, which is non-disclosure of material fact, hence repudiation of claim by the company is fully justified, as the same was not payable/admissible, as per the abovesaid policy condition. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             OP no.3 did not appear despite serve and opted to be proceeded against exparte, vide order dated 13.05.2022 of the Commission.

4.             Parties then led their respective evidence.

5.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of customer identity card Ex.C1, copy of insurance policy Ex.C2, copy of discharge summary Ex.C3 to Ex.C5, copy of medical bills Ex.C6, copy of receipt Ex.C7, copy of bills Ex.C8 to Ex.C13, copy of NEFT Ex.C14 and Ex.C15, copy of claim form Ex.C16, copy of legal notice Ex.C17, postal receipt Ex.C18, copy of reply of legal notice Ex.C19, copy of Renewal Payment receipt Ex.C20, copy of latest policy Ex.C21, copy of bank statement Ex.C22, copy of GST number Ex.C23 and closed the evidence on 06.06.2023 by suffering separate statement.

6.             On the other hand, learned counsel for the OPs no.1 and 2 has tendered into evidence affidavit of Sumit Kumar Sharma Ex.OPW1/A, copy of insurance policy Ex.OP1, copy of terms and conditions of the policy Ex.OP2, copy of proposal form Ex.OP3, copy of field visit report Ex.OP4, copy of Pre-authorization request Ex.OP5, copy of query letter on authorization for cashless treatment Ex.OP6, copy of rejection letter on authorization for cashless treatment Ex.OP7 and Ex.OP8, copy of emergency cum Triage Notes Ex.OP8, copy of progress sheet Ex.OP10, copy of lab report Ex.OP11 and closed the evidence on 18.07.2024 by suffering separate statement.

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

8.             Learned counsel the complainant, while reiterating the contents of complaint, has vehemently argued that on 08.04.2013, complainant purchased the Family Health Optima Insurance Plan from the OP. Complainant regularly renewed the said policy and last date of renewal was 22.04.2020. On 17.04.2021, complainant had handed over the cheque to the OP no.3 for renewal of the policy but due to merger of the bank, the cheque was returned to the complainant. Thereafter, complainant tried to make the premium amount to the OPs through RTGS but again NEFT was cancelled due to merge of the bank. On 23.04.2021, in the morning OP no.3 approached the complainant to his house and received the premium amount in cash and complainant. On 23.04.2021, complainant feels some problem in his heart and got admitted in Sanjiv Bansal Cygnus Hospital, Karnal and discharged on 24.04.2021. The intimation was given to the OP. Complainant has spent an amount of Rs.1,21,942/- on his treatment and submitted the claim for reimbursement of the said amount but the claim was repudiated by the OPs on the false and frivolous ground and lastly prayed for allowing the complaint.

9.             Per contra, learned counsel for the OPs no.1 and 2, while reiterating the contents of written version, has vehemently argued that complainant availed a Family Health Optima Insurance Plan from 23.04.2021 to 22.04.2022. The complainant submitted the claim for reimbursement of the amount regarding admission at Sanjiv Bansal Cygnus Hospital, Karnal on 23.04.2021 for treatment of CAD. It was observed from submitting document, complainant renewed the policy on 23.04.2021 at 1.57 p.m. and complainant found to be trop positive on 12.45 p.m., at which was on break period that the onset of the above disease is during the break period of insurance policy and thus the claim of the complainant was rightly repudiated by the OPs and lastly prayed for dismissal of the complaint.

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

11.           Admittedly, complainant availed a Family Health Optima Insurance Plan from the OPs in the year of 2013 and the same was renewed upto 21.04.2021 without any break. It is also admitted that the sum insured under the policy was Rs.4,00,000/-.

12.           The claim of the complainant has been denied by the OPs on the ground, which is reproduced as under:-

“We refer to your request for cashless treatment at the above referred hospital for the above diagnosed disease of the insured patient.

The above insurance policy is renewed after a break period from 21.04.2021 to 23.04.2021.

It is observed from submitted documents patent renewed policy on 23.04.2021 at 1.57 p.m. and patient found to be trop positive on 12.45 p.m., at which is on break period that the onset of the above disease is during the break period of insurance and this was not disclosed at the time of renewal of this policy. Hence the claim is not admissible.”

13.           The claim of the complainant has been repudiated by the OPs on the above mentioned ground. The OPs have alleged that complainant found trop positive on 12.45 p.m. and the policy in question was got renewed on 1.57 p.m. As per discharge summary Ex.C3, the complainant got admitted in the hospital on 23.04.2021 at 2.17 p.m. and discharged on 24.04.2021 at 6.14 p.m.

14.           Undisputedly, the bank of the complainant was merged. On 17.04.2021 and 19.04.2021, complainant tried to deposit the premium amount for renewal of the policy but same was not got deposit due to merger of the bank and said facts have been proved from the documents Ex.C14 and Ex.C15.  On 23.04.2021, in the morning complainant handed over the premium amount in cash to the OP no.3 (agent of the OPs no.1 and 2). If the agent of the OPs no.1 and 2 had not deposited the premium amount in time for that complainant cannot be blamed.

 15.          Furthermore, if the sake of arguments, it is presumed that complainant got renewed his policy after receiving the result of TROPNINT POSITIVE, in that eventuality, the complainant can availed the grace period prescribed in guidelines of IRDAI. As per guidelines of IRDAI, the grace period is 30 days for yearly premium policies, from the date of the first unpaid premium, to pay the renewal premiums and keep the policy alive.  During the grace period, the insurance coverage will be available as per the terms and conditions of the policy. In the present case the premium of the policy was due on 21.04.2021. The complainant had taken the treatment on 23.04.2021 and renewed the policy on the same day and as per above guidelines, he could deposit the premium amount upto 20.05.2021, then the complainant would have availed the benefit of grace period for renewal of his policy and reimburse the amount spent by him in the hospital on his treatment. Hence, it has been proved on record that the act of OPs amounts to deficiency in service and unfair trade practice.

16.           Furthermore, now a days it has become a trend of insurance companies, they issue the policies by giving false assurances and when insured amount is claimed, they make such type of excuses. Thus, the denial of the claim of complainant is arbitrary and unjustified. In this regard, we place reliance on the judgment of Hon’ble Punjab and Haryana High Court titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, wherein the Hon’ble Punjab and Haryana High Court has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

17.           Keeping in view that the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, the act of the OPs while repudiating the claim of complainant amounts to deficiency in services and unfair trade practice, which is otherwise proved genuine one.

 18.          The complainant has spent an amount of Rs.1,21,942/- on his treatment and in this regard he has submitted bill Ex.C6, Ex.C8 to Ex.C13 and the said amount neither denied nor rebutted by the OPs.  Hence, the complainant is entitled for the amount of Rs.1,21,942/- alongwith interest, compensation for mental pain, agony harassment and litigation expenses etc.

19.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.1,21,942/- (Rs.one lakh twenty one thousand nine hundred forty two only) to the complainant alongwith interest @ 9% per annum from the date of denial of the claim i.e. 24.04.2021 till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs. 11,000/- towards the litigation expenses. This order shall be complied within 45 days from the date of receipt of copy of the order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated: 08.10.2024    

                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Neeru Agarwal)         (Sarvjeet Kaur)

                   Member                          Member