Haryana

Karnal

CC/182/2017

Vijay Kumar - Complainant(s)

Versus

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

Pawan Gahlot

11 Oct 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No.182 of 2017

                                                         Date of instt. 30.05.2017

                                                         Date of decision:11.10.2018

 

Vijay Kumar, son of Shri Om Parkash resident of house no.411/A, Gali no.5, Indira Colony, Tehsil Camp Panipat District Panipat, Haryana.                                                                                                                                                 …….Complainant       

                                        Versus             

 

1.Star Health and Allied Insurance Company Limited, branch office at SCO 242, 1^st floor, Sector-12, opposite Mini Secretariat Karnal-132001, through its Branch Manager.

2. Star Health and Allied Insurance Company Limited, branch office at Kasturba Marg, Himalaya House, New Delhi, through its Branch Manager.

3. Star Health and Allied Insurance Company Limited, Regd. & Corporate office at 1-New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600 034, through its chief Manager.

 

                                                               …..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 Pawan Gahlot Advocate for complainant

               Shri Gaurav Gupta Advocate for opposite parties.

               

                (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 in the month of February, 2016 he purchased a policy no.P/211114/01/2016/004378 (previous policy no.P/211114/01/ 2015/002696) from OP by paying the premium amount of Rs.6389/-which was valid w.e.f.27.02.2016 to 26.02.2017 under plan “Family Health Optima Insurance Plan”.  The said policy covered himself, his wife Smt. Promila Rani and child namely Aarav. It is alleged that on 4.9.2016 the wife of the complainant was in physical problem and was not feeling well and on account of said disease she was taken to Sir Ganga Ram Hospital New Delhi (herein after referred as SGRH) and where she got admitted from 4.9.2016 to 8.9.2016. The complainant spent Rs.66,946/- upon the treatment of his wife. The complainant spent the said amount from his own pocket, because the management of SGRH sent the bill to the OP no.1 for encashment because the said hospital is on the panel of the OPs for providing cashless treatment to the policy holder. The complainant deposited all the required document with the OPs for getting claim. But OPs rejected the claim of his wife through a letter dated 5.9.2016 on the ground that “the patient was suffering from the disease of disorder seizure since the last 10 years.” Whereas Dr.(Prof.) Rajesh Acharya, SGRH who treated his wife has given her opinion and has made clear that “Patient Promila 29 years female is suffering from this disease since the last 15 days and not since last 10 years.” It is further alleged that the abovesaid policy is cashless and the authorized agent of the policy as well as the OPs had assured the complainant for the full payment of the treatment at the time of purchase of the policy. It is very surprisingly that after the treatment, OP refused to pay the treatment expenses. The complainant requested the OPs several times to make the aforesaid payment to the complainant but OPs always prolonged the matter on one pretext or the other knowingly, intentionally and without any reason. 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 concealment of true facts; barred by limitation; mis-joinder and non-joinder of necessary parties; complainant is estopped by his own act and conduct and complainant is bound by terms and conditions of the policy. On merits, it is pleaded that insured patient, Mrs. Promila Rani was hospitalized at SGRH on 04.09.2016 for the treatment of Seizure disorder and submitted pre-authorization request for cashless treatment. On perusal of the documents submitted by the treating hospital, it is observed that as per the consultation report Dr. Rajesh Acharya, the patient is a known case of seizure disorder for 10 years which is not disclosed in the proposal form and the present admission is for the pre-existing disease i.e. seizure disorder. Hence the cashless authorization was denied and the same was communicated to the treating hospital and the complainant, vide letter dated 08.09.2016. Subsequently, complainant has submitted claim records for reimbursement of medical expenses. On scrutiny of the claim records, it is observed that:

. As per Discharge Summary, the insured was admitted on 04.09.2016 and diagnosed as Carpo-Pedal Spasm, Hypovitamins D & B-12 and Seizure Disorder.

.  The prescription dated 03.09.2016 of Dr Rajesh Acharya that the insured patient has recurrent seizure for the past 10 years.

        OP further alleged that from the above findings, it is observed that the present admission and treatment of the insured patient is primarily for the pre-existing seizure disorder. Based on the declaration made in the proposal form, the policy was served to the insured. As an underwriting practice, only the person aged above 50 years is put to pre medical examination. In the instant case, the insured was aged 25 years and 6 months. Hence, without any pre medical screening, the policy was served to the insured. The complainant has signed the declaration has deliberately answered “No” to the query raised the proposal form column meant for his wife, which is reproduced as is under:

        “Have suffered/suffering any stroke, epilepsy fainting attack, chronic headache, -No.”

Pre-existing Disease means, any condition, ailment or injury or related condition(s) for which the insured person had signs or symptoms and/or were diagnosed and/or were received medical advice/treatment within 48 months prior to the policy. As per exclusion clause no.1 of the policy, the company is not liable to make any payment, in respect of the pre-existing disease until 48 months of continuous coverage has elapsed. Hence, the claim was repudiated and the same was communicated to the insured vide letter dated 20.10.2016. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C9 and closed the evidence on 3.5.2018.

4.             On the other hand, OPs tendered into evidence affidavit of N.Gopalan Ex.RW1/A and documents Ex.R1 to Ex.R23 and closed the evidence on 13.07.2018.

5.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

6.             The counsel for the complainant argued that complainant had purchased policy in the month of February, 2016 from the OPs by paying the premium amount of Rs.6389/-, which was valid w.e.f.27.02.2016 to 26.02.2017 under plan “Family Health Optima Insurance Plan.” The said policy covered the complainant, his wife Smt. Promila Rani and his child namely Aarav. On 04.09.2016 Smt. Promila was in physical problem and she was taken to Sir Ganga Ram Hospital New Delhi, where she was admitted from 04.09.2016 to 08.09.2016. The complainant spent Rs.66946/- upon the treatment of his wife from his own pocket. The complainant deposited all the required documents with the OPs for getting claim. But OPs rejected the claim on the ground that “the patient was suffering from the disease of disorder seizure, since the last 10 years.” But doctor who treated his wife has given the opinion and has made clear that “Patient Promila 29 years female is suffering from this disease since last 15 days and not since last 10 years” vide certificate Ex.C8. He further argued that at the time of admission, on enquiry by the treating doctor he told him that his wife is suffering from this disease from the last 10 days but doctor inadvertently wrote 10 years instead of 10 days in Ex.R1. This mistake was rectified by the treating doctor on 07.09.2016, vide Ex.C8. OPs had wrongly repudiated the claim of the complainant and prayed for allow the complaint with costs.

7.             On the other hand, the counsel for the OPs argued that the insured patient was hospitalized at SGRH on 04.09.2016 for the treatment of Seizure Disorder and submitted pre-authorization request for cashless treatment. On the perusal of the documents submitted by the treating hospital, it was observed that as per consultation report of Dr. Rajest Acharya Ex.R1, the patient is known case of Seizure Disorder for last 10 years, this fact was not disclosed by the complainant in the proposal form and Ex.R1 proved the pre-existing disease i.e. Seizure Disorder. The cashless authorization was denied and same was communicated to the treating hospital and complainant, vide letter dated 08.09.2016. The claim patient was rightly repudiated the claim as she was having pre-existing disease. The learned counsel for the OPs relied upon the following judgments:

Satwant Kaur Sandhu Vs. The New India Ins. Co. Ltd., Civil Appeal no.2776 of 2002, decided on 10.07.2009(SC); P.C.Chacko & another Versus Chairman, LIC & Ors, civil appeal no.5322 of 2007 decided on 20.11.2007 (SC); Surinder Kaur Versus National Ins. Co. Ltd. decided on 4.5.2016: NCDRC (New Delhi); United India Ins. Co. Versus Umrao Chand Daga decided on 14.09.2016: NCDRC (New Delhi); C.N. Mohan Raj Vs. New India Ins. Co. Ltd. decided on 08.10.2012 NCDRC (New Delhi); M/s Industrial Promotion & Investment Corporation of Orissa Vs. NIA & Anr. civil appeal no.1130 of 2007, decided on 22.08.2016 (SC); M/s Suraj Mal Ram Niwas Oil Mills (P) Ltd. Versus United India Ins. Cop. Ltd. civil appeal no.1375 of 2003 decided on 08.10.2010; United India Ins. Co. Ltd. Versus M/s Harchand Rai Chandan Lal civil appeal no.6277 of 2004, decided on 24.09.2004 and Aman Kapoor Vs. National Ins. Co. Ltd. decided on 17.04.2017: NCDRC New Delhi.

8.             Admittedly, the patient had purchased the “Family Health Optima Insurance Plan” in the month of February, 2016. The wife of the complainant Smt. Promila was admitted in SGRH from 04.09.2016 to 08.09.2016. According to the complainant, he spent Rs.66946/- on the treatment of his wife from his own pocket. The claim of the complainant was repudiated on the basis of Ex.R1, wherein mention that the patient was suffering from pre-existing disease for 10 years. Ex.R1 was issued by treating Dr. Rajesh Acharya on 03.09.2016. On 07.09.2016 treated doctor Rajesh Acharya issued a certificate Ex.C8, wherein he mention that patient Promila 29 years female is suffering from recurrent Seizures from last 15 days and not since last 10 years. Meaning thereby the mistake occurred in Ex.R1 was rectified vide certificate Ex.C8 by the treating doctor on 07.09.2016. Ex.R1 was issued on 03.09.2016 and Ex.C8 was issued on 07.09.2016 i.e. only within 5 days of issuance of Ex.R1. At that time the patient was still admitted in the hospital. The authorities produced by the learned counsel for the OPs related to pre-existing disease, mis-representing the material facts by a person at the time of obtaining the insurance policy, giving incorrect information about his health, death due to Coronary artery disease, suppression of pre-existing disease etc., all the above mentioned case laws are not application in the present complaint as OPs failed to prove pre-existing disease or mis-representing on the part of the complainant. The OPs failed to rebut the document Ex.C8 and they had an opportunity to rebut the same. OPs also failed to prove that  the wife of the complainant Smt. Promila was suffering from pre-existing disease of Seizure Disorder. Hence, the claim of the complainant was wrongly repudiated by the OPs.

10.           Thus, as a sequel to above discussions, we allow the present complaint and direct the OPs to pay Rs.66946/- to the complainant with interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant as compensation for mental agony, harassment and litigation expenses. This order shall be complied within 30 days from the date of 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:11.10.2018

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

                               

        (Vineet Kaushik)                (Dr. Rekha Chaudhary)

            Member                               Member