Delhi

West Delhi

CC/15/26

Suresh Kumar - Complainant(s)

Versus

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

09 Oct 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (WEST)

150-151; COMMUNINTY CENTER ; C-BLOCK; JANAK PURI; NEW DELHI

 

CASE NO.  26/15

Suresh Kumar Sareen     

Through  LRs

1. Sanjay Sareen
2. Vineet  Sareen
3. Ajay Sareen

All S/o Late Shri Suresh Kumar Sareen

All R/o  R-Block , 40 G, Dilsahad Garden,  Delhi.                                  

4. Sakshi Arora  D/o Late Sh. Suresh Kumar R/o H.No. 53,     2^nd  Floor,  Sartita Vihar,   Delhi      

As legal heir of their deceased father

Sh. Suresh Kumar Sareen Complainants.                                                                                                                                                 

 

VERSUS

The  Star Health And Allied Insurance Co. Ltd. Through Its Director/Manager  

Branch Office:-

C-8, Third Floor, New Krishna Park Janak Puri,   West New Delhi.

Regd. Office At

1, New Tank Street,   Valluvar Kittam High Road  Nangambakkam  Chennai-600034                      ....…. Opposite party

O R D E R

 

 

K.S. MOHI, PRESIDENT

 

The complainant has filed the present complaint against the O.P under section 12 of Consumer Protection Act, 1986.  The facts as alleged in the complaint are that the complainant had taken  medi-claim  policy  known as Star health  & Allied  Insurance vide its  policy No. P/161127/01/2014/002639 for the period  from 15.03.2014 to 15.03.2015 of total premium  of Rs. 9500/- .  All of a sudden  the complainant  who is senior citizen fell ill  and  was immediately  taken to Deepak  Memorial Hospital on  16.09.2014 where he remained admitted till 20.09.2014  and incurred medical  expenses  of Rs. 75,960/-. He  submitted  all the relevant  documents alongwith medical  bills were submitted  to the respondent  for reimbursement of Hospital  expenses. But  he was shocked  to receive letter dated 04.11.2014 from respondent whereby his medical claim was repudiated on the ground of; disease of  fever, increase of  urination, incontinence of urine  and  motion  and insured  patient had motion  and patient had a fall  3 years back and MRI shows  D11 Vertibra  collapse  which is the cause of LL weakness  and inability to walk thus not covered   by policy.  The complainant  thereafter served the OP with legal notice through his counsel  but OP did not  reply  the same despite  service hence the present complaint. 

2.     OP  filed  written statement  taking preliminary objection inter-alia  that the  present complaint is  false, baseless and   mis-conceived  and deserves to be dismissed.  The OP  perused  the claim records and  as per discharge summary  the insured  was a known case of  Diabetes Mellitus with anemia  with  cholelithiasis with D-11 collapse. The patient  had history of  diabetes mellitus  for 3 years and  previous admission before 5 years  back, therefore, was not entitled  to reimbursement   of claim.  It is further stated by  OP on merits that OP concealed the material facts while  filling proposal form and as such he is not entitled   the  relief claimed.    

3.     Complainant has filed replication denying contents of written statement  and re-affirming the contents of complaint.  He has filed his affidavit in evidence testifying all the facts stated in the complaint. On the other hand Sh.Rajnish  Kohli, Assistant  Vice President, Claims  has filed his affidavit in evidence on behalf of O.P. he mentioned documents EXBT  AS OP-1 to EXBT AS OP-5.  Written submissions have also been filed by both the parties.

4.     We have heard  Counsel for parties  and perused the record.

5.     Suffice  it to say  that OP repudiated the claim  on the basis of pre existing  disease  which was not disclosed  by complainant in the  proposal form filled in up at the time of  inception of insurance policy.  To conclude whether the repudiation  letter  was  justified or otherwise we need to scrutinize  discharge summary.   The discharge Summery  filed on record would show  that complainant  remained admitted  in Deepak Memorial Hospital from 16.09.2014 to 20.09.2014  with complaints  of ghabrahat , decreased oral intake,  generalized weakness, vomiting and  increased frequency  of urine and stool  incontinence since last 3-4 days and  weakness B/L lower limb with  backache. Known as case of DM since last 2-3 months with  cholelithiasis with D-11 collapse. History of fall 3 years back.  The policy in   this case has was taken  on 15.03.2014 and insured  was admitted  in hospital 16.09.2014  that is  almost  six months after taking  the policy.  The insured is stated to be  known case of    DM for the last  2/3 months with anemia.  Now it is  well settled  law that hypertension  and diabetes  can never be termed as pre existing disease  because these  ailments  are  life style disease  which can be controlled by conventional methods. In case titled  Aviva  Life  Insurance  Claim Department Vs  Sharanjit Kaur V(2014) CPJ 124 Punj it was held as under :

Death claim-  Suppression   of pre existing  disease –claim repudiated – Hypertension is a life-style  disease easily  controllable  with conservative medicine insured  not deliberately concealed  material fact-Repudiation unjustified.

Insurer cannot repudiate the  contract  unless the fact is actually material.     Insurer can avoid policy only by proving that the statement is false, fraudulent.   The duty to disclose  is limited to the facts  within the knowledge of the insured alone.

 

            Even otherwise  the  pre existing disease is  one  which  happened to the insured soon before taking the policy for which the insured  was hospitalized  or had undergone some surgery,  where the insured suffered disease 10 years  back  before taking  the policy,  such a disease can not  be termed  as pre-existing  disease  and need not to be mentioned in the proposal form. In case titled National insurance CO. Ltd. Vs  Smt. Krishna Avtar Aggarwal II  (2005) CPJ 747 it was held as under:

Mediclaim policy –Repudiation of claim  - Concealment of pre-existing  decease alleged- complaint allowed   by Distt. Forum – Non discloser  for which  injured was  treated  15/20 years before, not  amounts  concealment of fact – word “ existing”  means disease  which  exists at time of taking the policy-OP   should  have ensured that person in whose favour  policy  was being  given  was entitled to same or not .  Contributory  negligence on part of OP cannot be   ruled out .  OP liable under policy. Order of Forum  upheld .

                  

5.    Keeping in view  the above discussion  we are  of the considered view  

that repudiation of claim of complainant was unjustified and unwarranted , therefore, it amounted to deficiency on part of the OP.  We thus  direct  the OP to pay a sum of Rs. 75,960 /- with interest  @ 6% from the date of institution  of complaint till realization.  The complainant is also awarded  a sum of Rs. 20,000/- towards  mental agony and litigation expenses.

Copy of this order be sent to the parties as per rules.

File be consigned to the record room. 

  Announced this___  ___ day of __October _____ 2018.

 

                                                                                                                       ( K.S. MOHI )                                                    (PUNEET LAMBA)                                                                                    PRESIDENT                                                                       MEMBER