Delhi

East Delhi

CC/1020/2013

VINOD KR. ADLAKHA - Complainant(s)

Versus

STAR HEALTH & ALLIED - Opp.Party(s)

28 Jul 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO.  1020/13

 

Shri Vinod Kumar Adlakha

R/o K-76, 1^st Floor, Krishna Park Ext.

Near Vikas Puri, Out Ring Road

New Delhi                                                                    ….Complainant

 

Vs.

 

Star Health & Allied Insurance Co. Ltd.

Plot No. 4, 3^rd Floor, B-Block Community Centre

Janak Puri, New Delhi – 10 058                              ….Opponent

 

Date of Institution: 05.12.2013

Judgment Reserved on: 28.07.2017

Judgment Passed on: 31.07.2017

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari  (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By : Sh. Sukhdev Singh (President)

 

JUDGEMENT

          This complaint has been filed by Shri Vinod Kumar Adlakha against M/s. Star Health & Allied Insurance Company Limited (OP) under Section 12 of the Consumer Protection Act, 1986. 

2.       The facts in brief are that the complainant purchased a Health Shield Insurance Policy for self from M/s. Star Health & Allied Insurance Company Limited (OP) on 22.11.2012 for the period from 22.11.2012 to 21.11.2013 for a sum of Rs. 2,00,000/- and paid the consideration amount of Rs. 9,500/- to OP.

          In the month of May, 2013, the complainant was admitted in the Central hospital on 04.05.2013 for treatment.  He was discharged from the hospital on 12.05.2013, but on the same day, he was again admitted in the same hospital and finally discharged on 18.05.2013 with the advice to come again for check-up.  The complainant informed the   respondent regarding his hospitalization, immediately.  He was shocked to know that the company rejected the cashless facility.  He contacted the respondent and was assured that he may pay the amount and after some formalities, they will reimburse the claim of the complainant.  The complainant paid a sum of                 Rs. 1,44,461/- to the hospital.  He was again admitted in the hospital on 25.06.2013.  He submitted the claim form alongwith all necessary papers to the respondent for reimbursement, but respondent repudiated the claim vide letter dated 24.07.2013. 

          It was further stated that the exclusion clause referred by the respondent was never brought to the knowledge of the complainant.  Non settlement of the claim amounts to deficiency of service on the part of the respondent.  Hence, the complainant has prayed for direction to OP to pay an amount of Rs. 1,44,461/- being the bill of hospitalization alongwith 24% interest, Rs. 1,00,000/- on account of compensation  for mental agony, pain and suffering and Rs.15,000/- towards litigation cost.   

3.       In the written statement, filed by OP, it was admitted that      Shri Vinod Kumar Adlakha was insured with OP for the period from 22.11.2012 to 22.11.2013 vide Senior Citizens Red Carpet Insurance Policy no. P/161118/01/2013/005362 for a sum of Rs. 2,00,000/-. 

          It was stated that the present complaint was barred under Section 26 of the Consumer Protection Act.  As per the indoor case papers, the patient was admitted with CVA (Cerebral Vascular Disease).  The Field Visit Reports states that the patient was a known case of CVA for 15-20 years, therefore, the cashless authorization was denied and the same was communicated to the complainant as well as the treating hospital vide letter dated 08.05.2013.

          It was further stated that at the time of inception of the first policy, which was from 22.11.2012 to 21.11.2013, the complainant had not disclosed his disease (Cerebral Vascular Disease), which amounts to non-disclosure of material facts.  The present claim was rejected under condition no. 7 of the issued policy, which reads as follows:-

“The company shall not be liable to make any payment under the policy in respect of any claim is in any manner or supported by any means or device, misrepresentation whether by the insured person/s or by any other person acting on his behalf.”

          Hence, the claim was repudiated and the same was communicated to the complainant vide letter dated 29.06.2013.

          It was further submitted that the complainant was residing at Vikas Puri and the address of the OP mentioned as Janakpuri, therefore this Forum has no jurisdiction to entertain the present complaint. 

4.       The complainant in his rejoinder to the Written Statement has controverted the pleas made in the written statement and has reasserted his pleas made in the complaint.

5.       In support of its case, the complainant has examined himself on affidavit.  He has narrated the facts, which have been stated in the complaint. 

          In defence, OP have examined Shri Rajnish Kohli, Assistant Vice President, who have deposed on affidavit.  He has narrated the facts, which have been stated in the WS.  He has also got exhibited medical insurance (Ex.OPW1/A), authorization letter in favour of   M/s. Star Health (Ex.OPW1/B), discharge summary (Ex.OPW1/C), bill submitted by the complainant (Ex.OPW1/D), daily observation chart (Ex.OPW1/E), Star Health Medical Officer FVR (PAN India) Revised (Ex.OPW1/F), test reports alongwith ECG ((Ex.OPW1/G colly.), proposal form (Ex.OPW1/H), expert opinion (Ex.OPW1/I) and certified copy of the policy (Ex.OPW1/J).

6.       We have heard Ld. Counsel for the parties and have perused the material placed on record.  It has been argued on behalf of      M/s. Star Health & Allied Insurance Company Limited (OP) that the complainant did not disclose the pre-existing disease which he was suffering from 15-20 years back. 

          On the other hand, Ld. Counsel for the complainant have argued that the complainant was not aware with regard to any pre-existing disease. 

          To appreciate the arguments of Ld. Counsel for the parties, a look has to be made to the discharge summary as well as the field visit report on which Ld. Counsel for OP have heavily relied upon.  If the discharge summary coupled with MRI (brain) report is looked into, it is noticed that in the discharge summary as well as MRI (brain) report, it has been stated that the complainant Mr. Vinod Kumar Adlakha was having ‘Old ischemic infarcts in bilateral thalamogangliocapsular locations’.  This has been got strengthened on the basis of Field Visit Report (FVR) where under column 16, it has been stated “H/o Right side numbness / patient went to             Dr. Agrawal (family doctor) for treatment (15-20 years back)”.  If the field visit report is analysed, it is noticed that the words “patient went to Dr. Agrawal for treatment (15-20 years back)” have been added.  This cast doubt in respect of the field visit report. 

          No doubt, in the discharge summary, based on the MRI report, ‘Old ischemic infarcts in bilateral thalamogangliocapsular locations’ have been concluded as old history of CVA (Cerebral Vascular Disease), however, the patient cannot be expected to know with regard to internal condition of the brain.  Therefore, he cannot be expected to disclose the disease, when he got the policy.  The field visit report being doubtful and the complainant having not known in respect of CVA (Cerebral Vascular Disease), the rejection of the claim on the ground of non-disclosure of pre-existing disease was not justified.  Therefore, the rejection of claim by the insurance company was without any basis, which amounts to deficiency in service and also the complainant have suffered mental pain and agony for which he has to be compensated.

          In view of the above, we order that M/s. Star Health & Allied Insurance Company Limited (OP) shall pay a sum of Rs. 1,44,461/- with 9% interest from the date of filing the complaint.  They are further directed to pay an amount of Rs. 30,000/- towards compensation which includes the cost of litigation. 

          This order be complied within a period of 45 days. If not complied, the compensation amount of Rs. 30,000/- shall also carry interest @ 9% p.a. from the date of filing the case. 

          Copy of the order be supplied to the parties as per rules.

          File be consigned to Record Room.

 

(DR. P.N. TIWARI)                                              (HARPREET KAUR CHARYA)

Member                                                                                Member    

(SUKHDEV SINGH)

                                                          President