Haryana

Karnal

CC/278/2015

Ashok Kumar S/o Bal Kishan - Complainant(s)

Versus

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

Vineet Rathore

18 Dec 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No.278 of 2015

                                                         Date of instt. 10.11.2015

                                                         Date of decision:18.12.2017

 

Ashok Kumar son of Shri Bal Kishan resident of House no.2243, Sector-7, Urban Estate, Karnal.

                                                                                                                                                                        …….Complainant.      

                                        Versus

 

1. Star Health and Allied Insurance Company limited, situated at SCO no.242, Sector 12 (Part-1), Karnal through its Branch Manager Raman Kumar.

2. Puneet Arora, Branch Sales Manager, Start Health and Allied Insurance Company Limited, situated at SCO no.242, Sectgor-12 (Part-1), Karnal.

3. Smt. Raj Rani (Agent having intermediatory code no.BA0000064885) Star Health and Allied Insurance Company Limited, house no.590, Sector 13 ext. Urban Estate, Karnal.

                                         

                                                                     …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act.            

 

Before   Sh. Jagmal Singh……President.

      Ms. Veena Rani ………..Member.

      Sh. Anil Sharma………Member

             

 

 Present  Shri Vineet Rathore Advocate for complainant.

               Shri  G.P.Singh Advocate for opposite parties.

               

 

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that he purchased a health insurance policy from OPs by paying the premium amount of Rs.10,826/-.  The said policy covered himself , his wife Ms. Sudesh Singla and two sons namely Himanshu Singhla and Sayam Singla. The insurance policy came in force on 14.10.2014 under policy no.P/211114/01/2015/001426 for sum insured Rs.5,00,000/-. This policy was issued without medical examination of all the insured persons. Since it was convinced by the OP no.2 that our unique feature of the policy is that insurance is done without medical examination. The complainant is hale and hearty follow of 42 years and has no signs of any sort of medical complaints. Suddenly on 24.11.2014 he felt some unrest and he was rushed for medical services for chest pain before ARTEMIS. After tests, he was managed with optimize medicine and becomes stable and was discharged with follow up advise. Thereafter, on 25.11.2014 he visited Sir Ganga Ram Hospital, Delhi where it was advised for PTCA plus stent to LCx. Thereafter, he was discharged on 27.11.2014 after PTCA stenting LCx.  He spent to the tune of Rs.2,25,000/- on his treatment. He filed the claim for reimbursement of the amount with the OPs and also submitted all the medical bills and expenses statements. After waiting long period he approached the OP no.1 for knowing the status of the claim under the policy. OP no.2 came to renew the policy and obtained signatures of the complainant on renewal policy form, one white paper  by saying that the blank paper is required for processing the claim and took a blank signed cheque bearing no.637406 drawn on Corporation Bank. But OPs did not release the claim amount and also did not renew the policy. He sent a legal notice to the OPs in that regard, but to no effect. In this way there was deficiency in service on the part of the OPs and hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs. OP no.1 appeared and filed written statement raising preliminary objections regarding the complaint is premature; deficiency in service; complainant has not come with clean hands and suppressed the true and material facts and estopped from filing the present complaint by his own act and conduct. On merits, it has been submitted that as per the policy of insurance, the complainant is directed to furnish the relevant documents to enable the OPs to process his claim for compensation. It is denied that the complainant had no signs of medical complaint earlier to the issuance of the policy. Infact, the complainant was suffering from Heart ailment before the purchase of the policy. Complainant informed the OP no.1 regarding his treatment on 7.11.2015, he submitted his claim for decision alongwith certain documents. On scrutiny it was found that the following documents which are mandatory to produce have not been submitted by the complainant.(i) ECHO and ECG report (ii) Duration of Chest pain (iii) 1^st Consultation paper (iv) on set and duration of Hypertension (v) Indoor case paper of ARTEMIS hospital and Reason for late intimation. On submission of the claim records, the OP no.1 shall evaluate the claim and respond as per the terms and conditions of the policy. It is denied that the OPs obtained signatures of complainant on any white paper or obtained a blank signed cheque bearing no.637406 drawn on Corporation Bank. Infact, the policy proposal form was filled up in the presence of the complainant and he has signed the same. He had also given a cheque of Rs.8413 duly filled up towards the premium charges. It is mentioned that since the complainant had suffered from Cardiac problem, he opted to continue with the earlier Family Health Optima Policy for his other family members and opted to purchase a Cardiac policy for himself. When the cheque was presented for payment, the same could not be released as the complainant had stopped the payment of the same and the cheque was returned unpaid to OP no.1. The complainant had also sent a legal notice dated 9.11.2015 received by OP no.1 on 20.11.2015 asking for renewal of the policy alongwith a cheque of Rs.12,000/- dated 7.11.2015. Since in the meanwhile, the complainant had filed the present complaint, therefore, the said cheque of Rs.12,000/- was returned to the complainant through his counsel on 7.12.2015 in view of the pendency of the present complaint dated 18.11.2015. It has further submitted that the insured was admitted in Sir Ganga Ram Hospital, New Delhi on 25.11.2014 for the Coronary artery disease. Instead of submitting the documents for our valuation in reimbursement, the insured sent Advocate notice on 9.11.2015 before sending the reply of the said notice insured approached this Forum within 9 days of the Advocate notice. So, there is no deficiency in service on the part of the OP no.1. The other allegations made in the complaint have been denied. OPs no.2 and 3 filed no reply.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A, affidavit of Virender Rana Ex.CW2/A and documents Ex.C1 to Ex.C24 and closed the evidence on 3.6.2016.         

4.             On the other hand, OPs tendered into evidence affidavit of Rajnish Kohli Ex.OW1/A and documents Ex.O1 to Ex.O20 and closed the evidence on 12.8.2016.

5.             We have heard the learned counsel for both the parties and perused the case file carefully and have also gone through the evidence led by the parties.

6.             There is no dispute with regard to the fact that the complainant obtained health insurance policy no. P/211114/01/2015/001426 for a sum of Rs.5,00,000/- which came into force on 14.10.2014 for coverage of complainant, his wife Ms. Sudesh Singla and two sons Himanshu Singla and Sayam Singla. It is also not disputed that on 24.11.2014 the complainant went to ARTEMIS Hospital regarding chest pain. Thereafter, on 25.11.2014, the complainant visited Sir Ganga Ram Hospital, Delhi, where he was admitted and advised for PTCA plus stent to LCx and was discharged on 27.11.2014.

7.             According to the complainant, he incurred Rs.2,25,000/- on PTCA stenting LCx medical expenditure including transportation, special diet. The complainant also alleged that he informed the OP no.2 telephonically, who assured that claim will be processed within a short period. It is further alleged that after a long period, complainant ranged up OP no.2 on 8.10.2015 for renewal of policy and releasing of claim. It is further alleged that complainant was astonished to know that OP no.2 has neither filed the claim nor intimated to the company. It is further alleged that the complainant submitted all the documents in the branch on 14.10.2015 but OP no.1 has not lodged the claim with the head office till 29.10.2015. It is further alleged that the complainant issued legal notice for releasing the claim and renewal of policy as such a cheque bearing no.637411 dated 7.11.2015 of Rs.12000/- was also sent with the notice. But the OPs have not processed the claim hence this complaint.

8.             The OP no.1 contended that the complainant has not supplied all the relevant documents inspite of asking for the same and filed the present complaint. It is further contended that the complainant was suffering from heart ailment before the purchase of policy. The complainant had informed the OP no.1 regarding his treatment on 7.11.2015. The complainant submitted his claim alongwith certain document but on scrutiny it was found that some mandatory documents mentioned above in reply of the OP have not been submitted by the complainant. It is further contended that it is incorrect that OPs had obtained signed on white paper or signed blank cheque no.637406 but in fact the proposal form was filled up in his presence and signed by him and he gave the abovesaid cheque of Rs.8413/- duly filled up and signed towards the premium charges. The policy could not be renewed as the cheque was not cleared due to the reasons the insured Drawer instructed STOP PAYMENT. As the complainant had suffered from cardiac problem, so he opted to continue with earlier “Family Health Optima Policy” for his other family members and for himself he opted to purchase a Cardiac policy. It is further contended that instead of submitting the documents, the complainant sent the legal notice dated 9.11.2015 alongwith cheque of Rs.12000/-which was received on 20.11.2015/12.11.2015 and before reply to the notice by the OPs, the complainant filed the present complaint on 10.11.2015  so the cheque of Rs.12000/- was returned to the complainant through his counsel on 7.12.2015.

9.             From the pleadings and evidence of the parties, it is clear that the present complaint was filed in this Forum on 10.11.2015 and the same was registered on 16.11.2015.  The complainant issued the legal notice to the OPs on 9.11.2015 as is clear from the postal receipts Ex.C2. No doubt the complainant alleged that he informed the OP no.2 for the claim but he informed the OP no.2 telephonically. The complainant has neither mentioned any date nor proved the same by producing the evidence that he had submitted the documents with the OP no.2.  It is admitted by the complainant in his complaint that the complainant submitted the documents in the branch on 14.10.2015, whereas according to OP no.1, the complainant submitted claim form on 7.11.2015. If it is presumed that the complainant has given the claim form to the OP no.1 on 14.10.2015, even then the OP no.1 has not been provided sufficient time for the processing of the claim and the complainant issued legal notice on 9.11.2015. The contention of OP no.1 has force that the OP no.1 could not reply to the legal notice as the complainant filed the present complaint without affording any time for considering the legal notice because the present complaint was filed on 10.11.2015 after sending the legal notice through registered post on 9.11.2015. The OP no.1 has placed on the file claim closure letter dated 26.1.2016 Ex.O-7, vide which the claim was closed on the ground of non-submission of documents mentioned in it.

10.           It is pertinent to mention here that the complainant has made a request for renewal of the policy for which the complainant has also moved an application with the complaint. But on the perusal of zimni orders, it is clear that neither the reply of said application was filed by the OPs nor the complainant had stressed for the same at any stage. In these circumstances, at this belated stage the renewal from back date is not justified. Moreover, for future policy, it is for the complainant that if he agreed with the terms and conditions of the policy which he wants to obtain he can obtain the same after paying the requisite premium.

11.           It is further pertinent to mention here that para no.20 of the reply of OP no.1 is very relevant and material for the decision of the case which runs as under:-

“This opposite party further submits that the policy issued to the complainant under which the dispute has been raised is governed by Limits of Liability as per various clauses. That without any prejudice to whatever has been stated earlier in this written statement, even admitting without conceding that the company is liable to pay the claim in terms of the contract of insurance issued to the Claimant-petitioner. It is respectfully submitted that the maximum quantum of liability under the terms of the policy shall be Rs.159097/-.”  

        There is no dispute that liabilities for the claims are govern by the various clauses as well as the terms and conditions of the policies. Regarding the calculations of the liability for the claim of the complainant, the OP no.1 has placed a document Ex.O1 on the file. In this calculation document i.e. Ex.O-1, the OP no.1 has given the details of the bills amount, deduction, payable amount, if liable and reasons for deduction. The complainant has not given any evidence to rebut the same. The complainant placed on the file the documents Ex.C-5 to Ex.C-11 regarding the bills and receipts for payments made by the complainant and all these payments have been taken into consideration by OP no.1 while preparing the calculation is Ex.O-1. The complainant has not produced any other bill/receipt on the file. In these circumstances, we are of the considered view that the liability of the OP no.1 for the claim of the complainant is Rs.159097/-. As already stated above that the claim was closed by OP no.1 for non-submission of documents, so we are further of the view that the complainant is bound to complete the necessary formalities and to supply the documents required by the OP no.1.

12.           Thus, as a sequel of above discussion, we allow the present complaint and held that OP no.1 is liable to pay the amount of Rs.159097/- for the claim of the complainant subject to the condition that the complainant will submit the documents mentioned in letter Ex.O-7. However, it is hereby made clear that the complainant will submit the required document within 30 days from the date of order and thereafter the OP no.1 will make the payment of Rs.159097/- to the complainant within 30 days from the date of completion of formalities by the complainant, failing which the complainant is entitled interest @ 8% per annum from the date of submission of documents by the complainant. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 18.12.2017

                                                                  

                                                                  President,

                                                         District Consumer Disputes

                                                        Redressal Forum, Karnal.

 

 

                        (Veena Rani)       (Anil Sharma)

                          Member                Member