Haryana

Karnal

321/2013

Sunil Kumar S/o Suresh Verma - Complainant(s)

Versus

Star Heath & Allied Insurance Company Ltd - Opp.Party(s)

Shalrnder Rana

10 May 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                               Complaint No. 341 of 2013

                                                             Date of instt.22.07.2013

                                                               Date of decision 10.5.2016

 

Sunil Kumar son of Shri Suresh Verma, resident of village Matak Maajri, tehsil Indri, District Karnal.

                                                                   ……..Complainant.

                                      Versus.

1. Star Health & Allied Insurance Co. Ltd.SCO no.104, (1^st Floor), Mughal Canal, Karnal, through Branch Manager.

2. Star Health & Allied Insurance Co. Ltd., # 1, New Tank Street Valluvar Kottam High Road, Nangambakkam, Chennai-600034, through its MD/Concerned official

 

                                                                   ………… Opposite Parties.

                     Complaint u/s 12  of the Consumer Protection Act.

 

Before                   Sh.K.C.Sharma……….President.

                   Sh.Anil Sharma…….Member.

 

Present:      Sh. Shalender Rana Advocate for the complainant.

                   Sh. 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 and his wife Rani and children namely Anshul and Manish were insured by the opposite parties, vide policy no.P/211114/01/2013/000682 under family health plan covering all the family members. On 3.3.2013, he suddenly fell ill and was admitted to Max Super Specialty Hospital Mohali, Punjab. He was discharged from the hospital on 5.3.2013. Intimation was given to the opposite parties immediately within two hours and they assured that benefits of the policy would be granted. He submitted treatment record and medical bills to the opposite parties, but the opposite parties postponed the matter on one pretext or the other. It has further been pleaded that son of the complainant namely Anshul also fell ill and when his condition became serious he was also admitted to Max Super Specialty Hospital on 8.5.2013, where he remained admitted upto 11.5.2013. Relevant documents and medical bills of treatment of Anshul were also submitted to the opposite parties. However, the opposite parties postponed the matter on one pretext or the other. It has also been submitted that the opposite parties refused to give benefits of the policy to him without any reason. Therefore, a legal notice was served upon them on 19.6.2013 but the same also did not yield any result. In this way, there was deficiency in service on the part of the opposite parties, which caused him mental harassment and humiliation apart from financial loss.

2.                Notice of the complaint was given to opposite parties, who put into appearance and filed written statement controverting the claim of the complainant on various grounds. Objections have been raised that the complaint is not maintainable; that the complainant has not approached this forum with clean hands; that the complainant is estopped from filing the complaint by his own acts and conduct and that the complainant has no locus standi and cause of action to file the present complaint.

                   On merits, the issuance of the family insurance policy to the complainant has not been disputed. It has also been admitted that the complainant submitted record regarding his treatment in Max Super Specialty Hospital Mohali. It has been submitted that on the receipt of the pre-authorization request from the treating hospital, the medical team of the opposite parties perused the claim record and denied the cashless authorization, as there was violation of condition no.7 of the policy. This fact was communicated to the treating hospital, vide letter dated 4.3.2013. However, the claim form was sent to the complainant to approach for reimbursement of the medical expenses. As per discharge summary, the insured was known case of essential hypertension, obesity, Old Narcotic Substance Abuser since 1 to 1½ years and under treatment at PGIMER. Thus, the complainant was suffering from pre-existing disease at the time of inception of medical insurance policy, but he had not disclosed the said medical history/health details in the proposal form, which amounted to mis-representation/non-disclosure of material facts. Therefore, as per condition no.7 of the policy his claim was repudiated and communicated to him, vide letter dated 29.4.2013. It has further been pleaded that Anshul son of the complainant was also admitted in Max Super Specialty Hospital Mohali on 8.5.2013. On receipt of the preauthorization request from the treating hospital, the medical team of the opposite parties denied the cashless authorization on the ground that admission was primarily relevant for evaluation and investigation of fever and the same was communicated to the treating hospital as well as the insured, vide letter dated 9.5.2013. The opposite parties had denied the cashless authorization, but a claim form was sent to the insured to approach the company for reimbursement, however, till date the insured has not submitted the claim form alongwith medical records. On submission of the same, the case would be reviewed and decided on merits as per the terms and conditions of the insurance policy. Factum of receiving legal notice has been admitted. The other allegations made in the complaint have been denied.

3.                In evidence of the complainant, his affidavit Ex.CW1/A  and documents Ex.C1 to C8 have been tendered.

4.                On the other hand, in evidence of the opposite parties, affidavit of Rajnish Kohli Assistant Ex.O1 and documents Ex.O2 to Ex.O16 have been tendered.

5.                We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

6.                The complainant had obtained cashless family pension policy from the opposite parties covering the health risk of his entire family i.e. complainant, his wife and two sons namely Anshul and Manish. He remained admitted in Max Super Specialty Hospital Mohali from 3.3.2013 to 5.3.2013. The complainant submitted the claim to the opposite parties, but his claim was repudiated on the ground that as per the discharge certificate he was patient of essential hypertension, obesity, Old Narcotic Substance Abuser  1½ years ago and under treatment at PGIMER, but that fact was not disclosed by him in the proposal form.

7.                Learned counsel for the opposite parties laid stress on the contention that as per discharge summary the complainant was Narcotic Substance Abuser 1½ years  prior to his admission in the hospital and remained under treatment from PGIMER, but that fact was not disclosed by him in the proposal form, the copy of which is Ex.O3, therefore, his claim was rightly repudiated as per condition no.7 of the policy on account of non-disclosure of the material fact.

8.                To wriggle out of the aforesaid contention learned counsel for the complainant vehemently argued that the opposite parties have not produced any record of treatment of the complainant from PGIMER regarding Narcotic Substance Abuser. Star Health Super Specialty Hospital Mohali is also a sister concern of the opposite parties and the concerned doctor of the said hospital wrongly mentioned in the discharge summary that the complainant was drug abuser 1½ years ago and remained under treatment of PGIMER, without any basis, just in order to help the opposite parties to deny the genuine claim of the complainant.

9.                It is settled principle of law that contact of insurance is a contract uberrima fides and utmost faith must be observed by the contracting parties. Every material fact must be disclosed, otherwise there is good ground for rescission of contract.  If there is mis-statement or suppression of material fact, the policy can be called into question. Concealment of previous ailment is a suppression of material facts and complainant is not entitled for compensation. In this regard reference with advantage may be made the judgment of the Hon’ble Supreme Court in case Satwant Kaur Sandhu Versus New India Assurance company IV (2009) CPJ 8 (SC)  and the decision of the Hon’ble National Commission in Life Insurance Corporation of India and another Versus Bimla Devi revision petition no.3806 of 2009 decided by Hon’ble National Commission on 12.8.2015.

10.              The facts of the present case are to be analyzed keeping in view the aforesaid proposition of law, the copy of the proposal form is Ex.O3, wherein information was sought from the insured regarding some ailments and treatment if any, prior to submitting the proposal form. The complainant replied all the questions in negative. Meaning thereby, he denied that he was Narcotic Substance Abuser or took any treatment during the last one year for any disease other than hypertension and hyprothodism. The copy of the discharge summary of the complainant prepared by the concerned treating doctor of Max Super Specialty Hospital, Mohali is Ex.O8, according to which he was Old Narcotic Substance Abuser 1½ years ago and remained under treatment at PGIMER. The treating doctor must have mentioned the history as told by the complainant. The said discharge summary was prepared at the time of discharge of complainant from the hospital and the copy of the same must have provided to him at that time. If, he was not Narcotic Substance Abuser and did not get treatment from PGIMER, he could raise objection at the same time and ask the concerned doctor not to write such fact in the discharge summary. At this stage, the plea that doctor intentionally wrote such fact in the discharge summary in order to help the opposite parties, cannot be accepted. Mere non-production of documents of PGIMER regarding treatment of the complainant cannot be ground to disbelieve the facts mentioned by the treating doctor in the discharge summary of the complainant. Thus, it stands established that  prior to submission of the proposal form, the complainant was Narcotic Substance Abuser and remained under treatment at PGIMER, but he did not disclose such fact in the proposal form. In this way, he concealed the material fact while obtaining the policy, therefore, in such a situation repudiation of his claim by the opposite parties on the ground of violation of condition no.7 of the policy cannot be termed as illegal or unjustified in any manner.

11.              So far as the claim of the complainant regarding treatment of his son Anshul is concerned, only cashless benefit was denied by the opposite parties and claim for reimbursement was not denied. It has been submitted by the opposite parties that the claim for reimbursement regarding treatment of Anshul has not been submitted by the complainant so far and that would be considered after submission of the claim alongwith treatment and medical bills. The complainant has not been able to produce any document on record, which may show that the claim regarding reimbursement for treatment of Anshul has been submitted to the opposite parties. Therefore, in such a situation it would be justified to order that the opposite parties shall decide the claim of the complainant for reimbursement regarding treatment of his son Anshul within 30 days of submission of the claim.

12.              As a sequel to the foregoing discussion, the complaint of complainant is qua reimbursement regarding his treatment is dismissed. However, the claim of son of complainant will be decided by the opposite parties after submission of the claim form with the opposite parities, within 30 days. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 10.05.2016

                                                                                      (K.C.Sharma)

                                                                                         President,

                                                                             District Consumer Disputes

                                                                             Redressal Forum, Karnal.

                             (Anil Sharma)

                               Member