THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR
Consumer Complaint No. 599 of 2014
Date of Institution : 17.11.2014
Date of Decision : 6.10.2015
Gurinder Singhh s/o S. Gurbax Singh, R/o House No. 54-55, Kot Atma Ram, Gali No.4, Sultanwind Road, Amritsar.
...Complainant
Vs.
Star Health and Allied Insurance Company Limited Regional Office at 1, New Tank Street Valluvar Kottam High Road, Nungambakkam, Chennai 600034
Star Health And Allied Insurance Company Limited Branch Office at SCO 25, First Floor, Ranjit Avenue, District Shopping Complex, Amritsar 143001
....Opp.parties
Complaint under section 12/13 of the Consumer Protection Act, 1986
Present : For the complainant : Sh. B.S. Rajput, Advocate
For the opposite parties : Sh. S.S. Salaria, Advocate
Quorum : Sh. Bhupinder Singh, President ,Ms. Kulwant Bajwa,Member
Order dictated by :-
Bhupinder Singh, President
1 Present complaint has been filed by Gurinder Singh under the provisions of the Consumer Protection Act alleging therein that he obtained a mediclaim Insurance Policy for himself as well as his family members i.e his wife Darshan Kaur sons Harsimran Singh and Hardil Singh on 17.1.2014 from opposite party No.1 with policy No. P/211111/01/2014/003066 for the period from 17.1.2014 to 16.1.2015 with sum assured Rs. 3 lacs. Complainant has alleged that at the time admission in hospital, he is fully insured as per policy period w.e.f. 17.1.2014 to 16.1.2015. Complainant has paid all the expenses during hospitalization to the tune of Rs. 1,56,000/- as per hospital and medical bills. The complainant visited the opposite party No.2 many times and requested them regarding settlement of claim, opposite party No.2 did not pay any heed to the requests of the complainant. Alleging the same to be deficiency in service, compliant was filed seeking directions to the opposite party to the settle the claim to the tune of Rs. 1,56,000/-. Compensation of Rs. 2,00,000/- alongwith litigation expenses were also demanded.
2. On notice , opposite parties No.1 & 2 appeared and filed written version in which it was submitted that complainant had obtained the policy under Family Health Optima Insurance Plan vide Policy No. P/211111/01/2014/003066 for the period from 17.1.2014 to 16.1.2015. During the currency period of the policy, complainant admitted in EMC Hospital on 24.6.2014 and on receipt of the pre-authorization request, the opposite party called certain documents to process the claim vide letter dated 27.9.2014. Thereafter the opposite party perused the claim for seeking reimbursement of the medical expenses for treatment of Coronary Artery Disease, Unstable Angina and it was observed that as per discharge summary and the treating doctor certificate dated 19.9.2014 which forms part of the claim from states, the insured/complainant had a past history and a known case of Diabetes Mellitus of past one year. The history sheet also reveals that the insured/complainant is a known case of Diabetes Mellitus and had a past history of Angina on Exertion (AOE) and Dysponea on Exertion (DOE) for past one year. Thus all the findings indicate the present ailment is a longstanding and existing prior to the inception of the policy. The complainant had not disclosed the above mentioned medical history/health details in the proposal form wich amount to mis-representation/non-disclosure of material facts. It was submitted that as per condition No. 7, of the policy, if there is any mis-representation or non disclosure of material facts whether by the insured person or any other person acting on his behalf, the opposite party is not liable to make payment in respect of any claim. As such the claim of the complainant has rightly been repudiated as per policy terms and conditions and there is no deficiency of service on the part of the opposite party qua the complainant. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence his affidavit Ex.C-1 & C-2 alonwith documents Ex.C-3 to C-14.
4. Opposite parties tendered affidavit of Sh. Rajnish Kohli. Asstt. Vice President Ex.OP1,2/1 alongwith documents Ex.OP1.2/2 to Ex.OP1/2/12.
5. We have carefully gone through the pleadings of the parties, arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e.pleadings of the parties and the evidence produced on record by both the parties, it is clear that complainant got mediclaim Insurance policy for himself as well as his family members including wife Darshan Kaur, sons Harsimran Singh and Hardil Singh on 17.1.2014 from opposite party No. 1 with policy No. P/211111.01/2014/003066 for the period from 17.1.2014 to 16.1.2015 with sum assured Rs. 3 lacs. On 25.6.2014 complainant suffered pain in his ches and was admitted in EMC Super Speciality Hospital, Amritsar on 25.6.2014 and was discharged on 28.6.2014. Opposite parties were duly informed. The complainant spent a sum of Rs. 1,56,000/- on his medical treatment. Claim was lodged with the opposite party vide claim form dated 19.9.2014 but the opposite party did not settle the claim of the complainant. Ld.counsel for the complainant submitted that all this amounts to deficiency of service on the part of the opposite party qua the complainant.
7. Whereas the case of the opposite party is that on receipt of information regarding the admission of the complainant in EMC Hospital on 24.6.2014, the opposite party called various documents/information from the complainant vide letter dated 27.9.2014. Thereafter the opposite paties perused the claim case of the complainant regarding treatment of Coronary Artery Disease, Unstable Angina and it was observed that as per discharge summary and the treating doctor certificate dated 19.9.2014 which forms part of the claim form submitted by the complainant himself, the complainant insured had a past history as a known case of Diabetes Mellitus for the past one year. He had history of Angina on Exertion (AOE) and Dysponea on Exertion (DOE) for the past one year. Thus all the findings indicate the present ailment is a long standing and existing prior to the inception of the policy. At the time of inception of the policy from 17.1.2014, the insured/complainant had not disclosed the above mentioned medical history/health details of the insured in the proposal form Ex.OP1,2/5 which amounts to mis-representation/non disclosure of material facts. As per condition No. 7 of the tems and conditions of the policy Ex.OP1,2/2, if there is any mis-representation or non disclosure of material facts, whether by the insured or any other person acting on his behalf, the opposite party/Insurance company is not liable to make any payment in respect of any claim. So the claim of the complainant was repudiated by the opposite party as per terms and conditions of the policy. Ld.counsel for the opposite party submitted that under these circumstances, there is no deficiency of service on the part of the opposite parties qua the complainant.
8. From the entire above discussion, we have come to the conclusion that complainant obtained mediclaim policy Ex.OP1,2/2 from opposite party No.1 on 17.1.2014 for the period from 17.1.2014 to 16.1.2015. The complainant suffered pain in the left side of his chest and he was admitted in EMC hospital, Amritsar on 25.6.2014 and was discharged on 28.6.2014 as per discharge card Ex.C-4 with treatment slips Ex.C-5 to Ex.C-7. The complainant alleges that he spent a sum of Rs. 1,56,000/- as per hospital and medical bills of his treatment. Claim was lodged with the opposite parties vide claim form Ex.OP1,2/5. On receipt of the claim from the complainant, opposite parties perused the record of the complainant regarding expenses for treatment of Coronary Artery Disease, Unstable Angina as per the treating doctor's certificate dated 19.9.2014 submitted by the complainant himself with the claim form Ex.OP1,2/4, the doctor has verified that the complainant was a known case of Diabetes Mellitus for the past one year. He also reveals that the complainant had a past history of Angina on Exertion (AOE) and Dysponea on Exertion (DOE) for the past one year and all these diseases indicate th present ailment of Coronary Artery Disease/Unstable Angina is a long standing and existing prior to the inception of the policy. The complainant while filling in the proposal form Ex.OP1,2/5 has not disclosed the aforesaid medical history/health details of the insured rather he has categorically stated that he was not suffering from any disease and he stated himself to be quite good in health and free from physical and mental diseases or infirmity. The medical certificae duly given by the doctor treating the complainant and produced by the complainant himself with the claim form Ex.OP1,2/4 fully proves that the complainant had disease of Diabetes Mellitus for the last one year and had also history of Angina on Exertion (AOE) and Dysponea on Exertion (DOE) for the last one year. But he has not disclosed these facts in the proposal form filled in by the complainant Ex.OP1,2/5. All this amounts to mis-representation/ non-disclosure of material facts at the time of taking the policy by the complainant from the opposite party. As per clause 7 of the terms and conditions of the Insurance Policy Ex.OP1,2/2, if there is any mis-representation or non disclosure of material facts whether by the insured or any other person acting on his behalf, the opposite party is not liable to make any payment in respect of any claim of the insured. Opposite party was, therefor, justified in not allowing the claim of the complainant. It has been held by the Hon'ble National Commission in case Life Insurance Corporation of India Vs. Mansa Devi 2003(1) Judicial Reports Consumer 501 that where the insured has suppressed the material facts of existence of any pre-existing disease and had undergone treatment for that, the suppression of such a material fact renders the contract of insurance illegal, invalid, void abinitio and unenforceable. Hon'ble National Commission further held that he contract of insurance is of utmost good faith i.e. Ubremma Fidae and the life assured is bound to disclose honestly, truthfully and correctly all the answers in the proposal form concerning the state of his health. The same view has been taken by the Hon'ble National Commission in case Sr. Divisional Manger, LIC of India Vs. Smt. Satwant Kaur Sandhu Legal Digest April 2011 page 85 as well as in case Panchal Ramabhai Motibhai Vs. LIC of India Legal Digest April 2011 page 83. So the concealment of this material fact by the complainant while obtaining the present policy from the opposite party renders this contract of insurance illegal and void. Hon'ble Supreme Court of India in case Satwant Kaur Sandhu Vs. New India Assurance Company Ltd IV (2009) CPJ 8 (SC) has held that in case of mediclaim policy, where the policy holder suffering from chronic diabetes and renal failure not disclosed while obtaining the mediclaim insurance policy, this suppression of material fact has been fully proved by the opposite party. It was held that claim of the life insured has been rightly repudiated by the insurer .
9. Consequently we hold that complaint is without merit and the same is hereby dismissed with no order as to costs. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
6.10.2015 ( Bhupinder Singh )
President
/R/ ( Kulwant Kaur Bajwa) Member
