DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.208/2015
Neeraj Chandela
Mrs. Manju Chaudhary
Both at :
WZ-191, Khyala Village
New Delhi-110018.
….Complainant
Versus
Star Health & Allied Insurance Co. Ltd.
Through the Office concerned
C-11, Vista House, 1st Floor
SDA Commercial Complex
Near IIT Gate, Behind Canara Bank
New Delhi-110016.
Dr. Kali Datta Das
Sr. Consultant & Spine Surgeon
C/o Indian Spinal Injuries Centre
Sector-C, Vasant Kunj
New Delhi-110070.
Indian Spinal Injuries Centre
Sector-C, Vasant Kunj
New Delhi-110070.
….Opposite Parties
Date of Institution : 06.08.2015
Date of Order : 28.10.2022
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Sh. U.K. Tyagi, Member
ORDER
President: Ms. Monika A Srivastava
1. The complainant has filed the present complaint praying for refund of a sum of Rs.243219.85/- i.e. the amount spent on medical treatment directly along with interest at the rate of 24% per annum from the date of default till realisation. The complainant has also prayed for a compensation of Rs. 5,00,000/- towards damages for mental agony, harassment and Rs.55,000/- towards cost of litigation and proceedings.
2. It is stated by the complainant that he purchased an insurance policy for himself and complainant No.- 2 from OP-1 which was effective from 17.12.2010 for one year till 16.12.2011 initially and then continued thereafter till 2015.
3. It is also stated that OP no.1 after getting satisfactory medical examination handed over the policy documents after the receipt of due premium. The current policy was effective from the date 17.12.2014 till midnight of 16.12.2015.
4. It is further stated by the Complainant that since they maintained active lifestyle and there was no problem therefore they had no reason to lodge any claim against the policy in force from the beginning i.e 17.12.2015.
5. It is furthermore stated by the complainant that in January 2015 complainant No.2 felt some pain and approached Flex Medical Centre and on their advice got some physiotherapy done and were given some medicines. However, the said medicine and prescribed Physiotherapy did not bear any result therefore the complainant no.2 was advised to undergo MRI. Accordingly MRI was conducted on 18.12.2015. The report of the MRI revealed that there was diffused disc bulge with large central and right paracentral disc henination causing thecal sac, compression, bilateral foraminal nerve route compression (R>L) L5–S1 level and ligamenum flavum and facetal hypertrophy seen at L4-L5 and L5-S1 level causing bilateral and lateral recess stenosis.
6. The complainant then visited OP-3 i.e. Indian Spinal Injury Centre and started the treatment and underwent another MRI on 04.04.2015 for getting second opinion on the prescription of Dr Manoj Vats.
7. Complainant No.2 then approached Star Imaging and Path Lab (P) Ltd. and the report dated 08.04.2015 as compared to previous MRI done on 18.02.2015 stated there is no significant time interval change.
8. That on the advice of the doctor, another MRI report from City X-ray & Scan Clinic Pvt. Ltd. dated 09.04.2015 was taken which revealed the diffused disc bulge with annular tear posteriorly causing thecal sac compression and bilateral forminal nerve root compression at L3-L4 and L-4 L-5 levels. Diffuse disc bulge with large central and right paracentral disc henination causing thecal sac compression and bilateral foraminal nerve root compression (R>L) at L5-S-1 level. Ligamenum flavum and facetal hypertrophy seen at L4-L-5 and L-5-S1 level causing bilateral lateral recess stenosis.
9. It is further stated by the complainant that after getting of these reports scrutinised, operation was advised by OP-2 and 3 and accordingly complainant No.2 got admitted on 20.04.2015.
- It is the case of the complainant that as cashless treatment was refuted by OP-1 on 23.04.2015 on the ground that the documents submitted revealed that the complainant no.2 is known case of ulcerative colitis and this had not been disclosed to the OP No.1 prior to the inception of the policy.
- It is further stated by the complainant that complainant No.2 had not even disclosed that she was suffering from ulcerative colitis from such a long period i.e prior to policy.
- It is also stated by the complainant that the treatment undergone was entirely different than the prolapsed interverbrate disc L5 -S1 with secuestratel fragment and right S1 radiculopathy for which she was operated on 21.04.2015.
- It is also stated by the complainant that the discharge summary of the complainant no.2 revealed that on her admission, she had complained pain in both lower Limbs since past three months and that the problem diagnosed by OP-2 was not a simple problem which could have been avoided being treated after 5 years
- It is stated by the complainant that they have incurred a sum of Rs. 243219.85/- as per records available and indirect expenses of more than Rs.5,00,000/- on getting the complainant No. 2 treated while the policy with OP-1 was valid.
- It is stated that for the reasons provided for, repudiation is illegal and deep in malaise. The claim of the complainants have been rejected on illegally/ medically unsustainable grounds. It is stated that the repudiation of the claim is unreasonable and that OP-1 is liable and responsible for harassment, inconvenience and loss which has been suffered by the complainant.
- The complainants have made numerous visits of OP-1 but all went in vain.
- On the other hand, OP No.1 has admitted in their reply that the complainant along with his family which included spouse and its 2 dependent children were insured for sum of Rs.10,00,000/-vide policy numbers
- P/161200/01/2011/002593 17.12.2010 TO 16.12.2011
- P/161200/01/2012/002946 17.12.2011 TO 16.12.2012
- P/161200/01/2011/003543 17.12.2012 TO 16.12.2013
- P/161200/01/2011/003773 17.12.2013 TO 16.12.2014
- P/161200/01/2011/004441 17.12.2014 TO 16.12.2015
- It is stated by the OP that its liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured per family mentioned in the schedule and is ‘subject to terms, conditions, exclusions and definitions contained herein … the company will pay to the insured person the amount of such expenses as our reasonably and necessarily incurred in respect by, or on behalf of the insured person upto limits indicated’.
- It is further stated by the OP that the complainant has not approached this Commission with clean hands as he is a known case of coeliac disease and ulcerative colitis for 7-8 years and this fact was suppressed by the complainant while they were taking insurance from the OP and on the basis of doctored documents in order to extract undue care.
- It is further stated by the OP that though the complainant had obtained the policy in 2010 but he opted not to disclose the aforementioned disease. This fact was disclosed during the treatment by the complainant himself to the hospital and is duly recorded in the case sheets of the hospital.
- It is further stated that the complainants were not put to any pre medical screening as they were less than 50 years of age at the time of inception of policy. Therefore, the contract of policy gives a right to the OP to reject claims which are based on suppression of material facts and to cancel the policy.
- Condition number 7 of the policy runs as under, ‘the company shall not be liable to make any payment under the policy in respect of any claim if such claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation/ non -disclosure whether by the insured person/s or by any other person acting on his behalf’.
- Condition number 13 of the policy runs as under, ‘cancellation – the company may cancel this policy on grounds of misrepresentation, fraud, non-disclosure of material fact or non-cooperation by the insured person by sending the insured 30 days notice by registered letter at the insured person’s last known address…’.
- The OP has further placed reliance on the judgment of the Hon’ble National Commission titled Birla Sunlife vs Manjeet held on 23.02.15 wherein it was held ‘… thus it is obvious that life assured…obtained the insurance policy by concealment of material facts, which would have impacted the decision of the petitioner whether to accept the insurer’s proposal or not..’
- It is further stated by the OP that once the complainant received the cashless rejection, he obtained certificate from Dr. Kali Dutta Das in order to get the records collected. However, the truth is recorded in case sheets of the hospital.
- It is further stated by the OP no.1 that there is no deficiency in service on their part as the denial of the claim is on account of violation of vital terms and conditions. Since there is a misrepresentation on the part of the complainant, the OP has rightly repudiated the claim of the complainant.
- It is further stated by them that though not admitting, if the OP no.1 is liable to pay the claim of the complainant then in terms of the contract of insurance, the maximum quantity of liability under the terms of the policy shall be Rs.2,03,283/-
28. Vide order dated 22.02.2016 OPs 2 and 3 were proceeded ex-parte. Complainant has filed rejoinder, both the complainant as well as OP 1 have filed their respective evidence affidavits as well as written submissions.
29. The OP has stated that the complainant no. 1was suffering from ulcerative colitis for past 7-8 years and the said disease was not disclosed by the complainants in the proposal form. After having carefully gone through the proposal form as well as the medical record of the complainant, it is opined that the repudiation is not based on any cogent ground as the discharge summary of the complainant no.1 provided by Indian Spinal Injuries Centre records the said disease being suffered from 7-8 months. This fact also finds support by the prescriptions of other doctors filed on record pertain to November 2014 which clarifies that the complainant no. 1’s suffering from the said disease was a recent phenomenon. Apart from these, no other documents have been placed on record by the OP to controvert the medical record of the complainant no.2. The reliance of the OP no.1 on the form filled by their own person is not supported by any other evidence.
30. Further, this recent past disease of the complainant no.2 had no co-relation with the existing disease of the complainant no. 2for which she had to undergo surgery. The plea of the OP no.1 that their liability is limited to a certain extent under the policy is not correct as the policy is a floater policy and no particular amount is fixed for any one insured. Therefore, this Commission is of the opinion that the repudiation is not sustainable and the prayer of the complainants ought to be allowed.
31. The OP no.1 is directed to pay a sum of Rs.243219.85/- to the complainant along with a sum of Rs.50,000/- on account of mental harassment caused to the complainant. This compensation shall be payable by the OP within three months from the date of this order failing which the amount payable will carry an interest @ 5% p.a till realization.
File be consigned to the record room and order be uploaded on the website.
