Chandigarh

DF-I

CC/574/2023

AJAY SIKKA - Complainant(s)

Versus

STAR HEALTH & ALLIED INSURANCE COMPANY LTD - Opp.Party(s)

SANDEEP BHARDWAJ

01 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/574/2023
Date of Institution	:	14/12/2023
Date of Decision	:	01/08/2024

 

Mr. Ajay Sikka r/o H.No 1041, Sector 18C, Chandigarh

… Complainant

V E R S U S

1.     Star Health & Allied Insurance Company Ltd through its Managing Director SCO 5A, 2nd Floor Sector 7C (Madhya Marg) Chandigarh 160019 Through its Managing Director/Director/Manager/authorized signatory.

2.     The Managing director, Star Health & Allied Insurance Company Ltd, Registered Office: No 1, New Tank Street, Valluvarkottam High Road, Nungambakkam, Chennai 600034.

3.     The Branch Manager, Star Health & Allied Insurance Company Ltd SCO 5A, 2nd Floor Sector 7C (Madhya Marg) Chandigarh 160019.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                               

ARGUED BY	:	Sh. Sandeep Bhardwaj, Advocate for complainant
	:	Ms. Surabhi Grover, Advocate for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Ajay Sikka, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that on 30.11.2021, complainant had purchased a Family Health Optima insurance policy from the OPs on payment of premium of ₹27,164/- valid w.e.f. 30.11.2021 to 29.11.2022 (Annexure C-1). The aforesaid policy was renewed on payment of renewal premium of ₹33,134/- w.e.f. 30.11.2022 to 29.11.2023 (Annexure C-2) (hereinafter referred to as “subject policy”). The subject policy covered the complainant, his wife Smt. Neeraj Sikka, daughter Jagriti Sikka and son Aayush Sikka with basic sum insured of ₹10.00 lacs, limit of coverage ₹12,50,000/- and recharge benefit of ₹1,50,000/-.  The complainant had purchased the subject policy on the assurance of the OPs that hospitalisation of any of the insured family member was covered under the subject policy and none of the insured persons had any prior disability, sickness or injury which could lead to hospitalisation and the said fact was disclosed to the OP. The son of complainant namely Aayush Sikka (hereinafter referred to as “insured patient”) developed pain in his left knee and on diagnoses at PGI, Chandigarh, it was found that he had developed Pattelar Tendenopathy for which the doctors had decided to go ahead with PRP injection around knee patellar and for the same, hospitalisation was required.  Accordingly, the insured patient got admitted in orthopedics special male surgical ward of PGI, Chandigarh on 18.3.2023 and after giving him PRP injection he was discharged on 19.3.2023. Copy of the OPD card is Annexure C-3. For the aforesaid treatment, complainant had spent an amount of ₹15,645/- vide receipts/bills (Annexure C-4) and when he approached the OPs for reimbursement of the said medical expenses, OPs wrongly refused to reimburse the aforesaid mediclaim and as the complainant had already paid two premiums to the tune of ₹27,164 + ₹33,134 = ₹60,298/-, he is entitled for the refund of the aforesaid amount alongwith the mediclaim. Thereafter the complainant issued legal notice dated 27.6.2023 (Annexure C-5), but, with no success. In this manner, the aforesaid act of the OPs amount to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action and concealment of facts.  However, it is admitted that the complainant had obtained the health insurance policy from the answering OPs and the same was got renewed vide the subject policy valid w.e.f. 30.11.2022 to 29.11.2023.  It is further admitted that the complainant had lodged claim with the answering OP, but, the same was rightly repudiated by the OPs vide letter dated 30.3.2023 (Annexure OP-1/6) as the same was not permissible as per the terms & conditions of the subject policy, being fallen under the exclusion clause as the insured patient was suffering from pre-existing disease for which the claim could have been raised only after the expiry of 48 months from 25.3.2023. Since the complainant had not disclosed about the pre-existing disease from which the insured patient was suffering, his claim is not maintainable.  Even in the proposal form, insured patient had categorically stated that he has not suffered from any pre-existing disease. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had purchased a health insurance policy (Annexure C-1) from the OPs for himself and his family members including son, Aayush Sikka (i.e. the insured patient) and got the same renewed vide subject policy (Annexure C-2) w.e.f. 30.11.2022 to 29.11.2023 and the insured patient had taken treatment for Pattelar Tendenopathy from the PGI, Chandigarh where he was admitted on 18.3.2023 and was discharged on 19.3.2023, as is also evident from Annexure C-3 and for the said treatment complainant had spent an amount of ₹15,645/-, as is also evident from the receipts/bills (Annexure C-4) and when the complainant raised claim with the OPs, the same was repudiated by the OPs vide letter dated 30.3.2023 (Annexure OP-1/6) on the ground that the insured patient was suffering from pre-existing disease, the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in repudiating the genuine claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs have rightly repudiated the claim of the complainant and the consumer complaint of the complainant, being false and frivolous is liable to be dismissed, as is the defence of the OPs.
   2. The claim of the complainant was repudiated by OPs vide letter dated 30.3.2023 (Annexure OP-1/6) on the sole ground that the insured patient was suffering from a pre-existing disease and the factum of the same was not disclosed to the OPs at the time of inception of the first policy. The relevant portion of the repudiation letter is reproduced below for ready reference :-

        “We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of PATELLAR TENDINOPATHY.

It is observed from the medical records that the insured patient has the above disease and on treatment which is prior to inception of the first medical insurance policy. Hence it is a pre-existing disease. The present admission and treatment of the insured patient is for the pre existing disease.

As per Exclusion - Pre-existing disease - Code Excl-01 of the policy issued to you, the Company is liable to make payment for any pre-existing disease only after the expiry of 48 months from 25.03.2023.

We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.”

 

3. Annexure C-3 is the copy of out-patient card of the insured patient, which nowhere refers that he was suffering from the alleged pre-existing disease i.e. knee Pattelar Tendenopathy since long to show that he was suffering from the said pain before the inception of the first policy and thereby making it clear that the OPs have repudiated the claim of the complainant by forming their own opinion on the basis of surmises and conjectures by holding that the insured patient was suffering from pre-existing disease. 
4. Not only this, the OPD card (Annexure C-3) further clearly indicates that the insured patient had disclosed to the medical officer/treating doctor of the PGI, Chandigarh that he had been suffering from knee pain for two months, making it clear that he had suffered from the said pain when the subject policy had already been issued/renewed and not prior to inception of the first policy issued in the year 2021.
5. Moreover, when it has come on record that the insured patient was not suffering from any pre-existing disease, the exclusion clause of the terms and conditions of the policy schedule (Annexure OP-1/3) does not apply in the present case i.e. no claim can be raised within 48 months of the inception of the policy in case of pre-existing disease and it is safe to hold that the OPs were unjustified in repudiating the claim of the complainant and the present consumer complaint deserves to succeed.
6. Now coming to the quantum of relief to be granted in the present case, since the complainant did not press for refund of premium paid, as recorded in the order dated 4.6.2024 of this Commission, and further has proved payment of ₹15,645/- vide receipts/bills (Annexure C-4) spent on hospitalisation/treatment of the insured patient, it is safe to hold that the OPs are liable to pay the said amount to the complainant alongwith interest and compensation etc.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹15,645/- to the complainant alongwith interest @ 9% per annum (simple) from the date of repudiation of the claim i.e. 30.3.2023 onwards.
2. to pay ₹10,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs within a period of 45 days from the date of receipt of certified copy thereof, failing which the amount(s) mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

01/08/2024	Sd/- [Pawanjit Singh] President
	Sd/-
	[Surjeet Kaur] Member
	Sd/-
	[Suresh Kumar Sardana] Member