Haryana

Ambala

CC/226/2018

Bhagwan Dass - Complainant(s)

Versus

Star Health and Allied Inss Co. - Opp.Party(s)

16 Jul 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

                                                          Complaint case No.: 226 of 2018.

                                                          Date of Institution         :  20.07.2018.

                                                          Date of decision   :  22.07.2019.

 

Bhagwan Dass, age about 49 years, son of Late Shri Doger Chand, r/o H.No.25, Sector-7, Urban Estate, Ambala City.

……. Complainant.

                                                Versus

 

1. Star Health and Allied Insurance Company Limited, Registered and Corporate Office 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600 034, through its authorized signatory.
2. Branch Manager, Star Health and Allied Insurance Company Limited, branch office at SCO 180, 1 to 3, 3^rd Floor, Minerva Complex, Rai Market, Ambala Cantt-133001, through its Branch Manager.

 

     ….…. Opposite Parties.

 

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.

Shri Vinod Kumar Sharma, Member.                 

                            

Present:       Shri B.B. Sehgal, Advocate, counsel for complainant.

Shri Mohinder Bindal, Advocate, counsel for the OPs.

 

Order:        Smt. Neena Sandhu, President

                   Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay the health claim as per the bills already submitted to the OPs alongwith interest @ 18% per annum w.e.f. 20.02.2018 till its actual payment.
2. To pay Rs.1,00,000/- as compensation for the mental agony and physical harassment suffered by the him.
3. To pay Rs.22,000/- as litigation charges.
   382.  

          Any other relief which this Hon’ble Forum may deem fit.

 

Brief facts of the case are that the complainant purchased Family Health Optima insurance policy bearing policy No.P/211117/01/2017/000713 on payment of premium of Rs.15790/- to the OP No.2. The said policy was again renewed upto 29.09.2018 by the OPs by receiving the premium amounting Rs.20077/- vide receipt No.1286001411 dated 26.09.2017. Before issuing the said insurance policy, the OP No.2 got medically examined the complainant from authorized doctor and after satisfying from the medical check-up, the OPs accepted the premium amount and then issued the policy to him. Unfortunately, on 19.02.2018, he suffered from heart problem and admitted in PGI, Chandigarh for treatment vide Admission No.2018.13494 dated 20.02.2018. The complainant was treated for his heart problem and discharged on 21.02.2018 from Cardiology department and incurred a sum of Rs.3,50,000/- on his treatment. He submitted his claim with the OPs alongwith original bills and treatment record and his claim was registered as CLI/2018/211117/0608862. However, the OPs vide letter dated 01.06.2018, repudiated his legal and valid claim on the ground that the present admission and treatment of insured patient is for the pre-existing heart disease, whereas, he suffered heart problem for the first time on 19.02.2018. Before that, he never remained admitted in any hospital nor he was under treatment of said disease at the time of purchasing the insurance policy.  Moreover, the OPs prior to accepting the premium and issuing the insurance policy, got him medically examined from the authorized doctor and at that time, no such disease ever diagnosed by its authorized doctor as well. By not paying the claim amount, the OPs have committed deficiency in service. Hence, the present complaint.

2.                Upon notice, the OPs appeared through counsel and filed written version and have raised preliminary objections regarding jurisdiction; cause of action and maintainability. On merits, it is stated that in the Outpatient record & discharge card of PGI Chandigarh, it is mentioned that the complainant was suffering from Diabetes Mellitus for the past 10 years and hypertension for the past 2 years and was chronic angina patient at the time of admission in PGI, Chandigarh on 20.02.2018. It is thus established that the complainant has been suffering from DM, HTN and heart disease for the past 10 years, prior to inception of the first medical insurance policy in 2016. The complainant was even asked for query vide letters dated 06.04.2018, 21.04.2018 & 06.05.2018 to submit all previous investigation reports, consultation papers, treat papers with regard to his coronary disease and all treatment record of his diabetes and hypertension, CAG report angioplasty report, discharge summary, biopsy report and ECG, Echo reports, but the complainant submitted ECG and Echo reports only. The insured has a duty to disclose each and every information and material fact about pre-existing ailment and about his health at the time of availing the policy, but the complainant intentionally and deliberately concealed and suppressed the material facts about pre-existing ailment to take illegal benefits of the policy from the OPs. At the time of inception of the policy from 30.06.2016 to 29.09.2017, the insured has not disclosed his above mentioned medical history/health details in the proposal form, which amounts to misrepresentation/non-disclosure of material facts. As per Waiting Period as 3(iii) of the policy, the company is not liable to make any payment in respect of expenses for treatment of pre-existing disease/condition, until 48 months of continuous coverage has elapsed, since inception of the policy i.e. from 30.09.2016. Hence, the claim of the complainant was rightly repudiated vide letter dated 30.05.2018 and prayer has been made for dismissal of the present complaint with costs.

3.                The ld. counsel for the complainant tendered affidavit of complainant as Annexure CX alongwith documents as Annexure C-1 to C-17 and closed the evidence on behalf of complainant. On the other hand, the learned counsel for the OPs tendered affidavit of Rajiv Jain, Chief Manager, Star Health Allied Insurance Co. Ltd., New Delhi as Annexure OPA alongwith documents as Annexure OP1 to OP6 and closed the evidence on behalf of the OPs.

4.                We have heard the learned counsel of the parties and carefully gone through the case file and the case laws referred by the ld. counsel for the parties.

5.                 The learned counsel for the complainant has argued that the OPs have wrongly repudiated the claim of the complainant vide letter dated 01.06.2018 on the flimsy ground that the insured was suffering from pre-existing disease, whereas, he suffered from the said heart problem for the first time on 19.02.218 and had taken treatment for the said disease from PGI, Chandigarh, for which, he had spent Rs.3,50,000/-. Before that, he had neither taken any treatment for the heart problem nor remained admitted in any hospital. He further argued that at the time of taking the policy in question, the age of the complainant was more than 45 years and as per IRDAI guidelines, the  OPs prior to accepting the premium and issuing the policy, got examined the complainant from their authorized doctor. Once the OPs have issued the policy in question after conducting the medical examination of the complainant, then at this stage, they cannot refuse to give the claim amount on the ground of pre-existing disease.

6.                On the contrary, the learned counsel for the OPs has argued that in the Outpatient Card of PGI Chandigarh (Annexure C-4/OP-6), it is mentioned that the complainant was suffering from Diabetes Mellitus for the past 10 years and hypertension for the past 2 years and was a chronic angina patient at the time of admission in PGI, Chandigarh i.e. 20.02.2018. From the said card, it is quite clear that the complainant was suffering from DM, HTN and heart disease for the last 10 years. However, the complainant at the time of taking the policy 30.09.2016, had not disclosed this fact and has violated the terms & conditions of the policy and no claim was payable under the policy. Accordingly, the claim filed by the complainant was rightly repudiated. In support of his contention, the ld. counsel for the OPs has placed reliance on the cases, titled as Sonu Vs. Birla Sun Life Insurance Co. Ltd. & Anr., 2017 (3) CLT, 271 (NC; Nori Venkata Ramana Vs. Reliance General Insurance Co. Ltd. & Others, 2018 (3) CLT, 302 (NC); Life Insurance Corp. of India Vs. Randhir Singh, 2017 (4) CLT, 318 (SC) and M/s Kotak Mahindra Old Mutual Life Insurance Co. Ltd. & others Vs. Naresh Kumar, 2017 (4) CLT, 84 (SC).

7.                 Admittedly, the complainant had purchased the policy in question from the OPs initially on 30.09.2016 and got it renewed upto 29.09.2018 vide policy documents Annexure C-1 & C2. The plea of the complainant is that during the subsistence of the policy, on 19.02.2018, he suffered from heart problem and admitted in PGI, Chandigarh and spent Rs.3,50,000/- on his treatment. He submitted his claim with the OPs alongwith original bills and treatment record, but the OPs repudiated his claim on the flimsy ground of pre-existing disease. From the perusal of repudiation letter dated 01.06.2018 (Annexure OP1), it is evident that the OPs repudiated the claim of the complainant on the ground “from the discharge summary of PGI, Chandigarh, it is observed that the insured patient is a known case of diabetes mellitus for the past 10 years and hypertension for the past 2 years. As per the submitted investigation report, the insured patient has chronic, longstanding heart disease. These findings confirm, the insured patient has diabetes mellitus, hypertension and heart disease prior to inception of the medical insurance policy. Hence, these are pre-existing diseases”. On perusal of copy of proposal Form (Annexure OP-2), it is revealed that the complainant had given answers in negative to all the questions and to the question, ‘Are you in good health and free from physical and mental disease or infirmity, if not, give details’, he had given answer ‘yes’. The plea of the OPs is that the complainant was suffering from diabetes mellitus for the past 10 years and hypertension for the past 2 years, but he did not disclose this fact while taking the policy in question. To corroborate this fact, the OPs produced Admission Card of the complainant Annexure OP-6. Under the said card, it is recorded that 48 years old diabetic, hypertensive, obist man p/w chest pain and breathlessness. It may be stated here that except this Admission Card, the insurance company has not produced any medical record of the complainant to prove that the complainant was taking treatment for the diseases, referred to above, prior to taking the policy in question. It was not proved on record as to who had disclosed that complainant was suffering from the said diseases. Further, affidavit of the treating doctor who had recorded the patient history, at the time of admission, has not been produced on record. The entire defence revolves around the said admission card, which is not supported by cogent document. In the case of Rajinder Singh Vs. The New India Assurance Co. Ltd. & Ors., 2018(3) CLT-187, the Hon’ble State Commission Haryana, has held that the treating doctor mentioned that the complainant was suffering from diabetes and hypertension for the last about three years without mentioning his source of knowledge in this regard and has not mentioned as to whether the patient had himself told him that he was suffering from the abovementioned ailments- Repudiation of the claim was not justified. Further, in the case of LIC of India Vs. Joginder Kaur, 2005, CPJ-78, the Hon’ble State Commission Haryana has held that the unproved case history recorded by some person on the date of admission of the patient, would not be cogent and convincing evidence to repudiate the case, unless it was coupled with medical record for the treatment prior to the submission of the proposal form. Furthermore, from the record, it is born out that the age of the complainant was more than 45 years at the time of taking the policy in question, therefore, as per IRDAI guidelines, it was incumbent upon the OPs, prior to accepting the premium and issuing the policy, got medically examined the complainant. As it has been held by the Hon’ble State Commission, U.T., Chandigarh, in the case of Manish Goyal Vs. Max Bupa Health Insurance Co. Ltd. and others, 2018 (2) CLT, 205 that If the opposite parties themselves, failed to adhere the instructions issued by Insurance Regulatory & Development Authority of India (IRDAI), by putting the insured to through medical examination, being her age more than 45 years, and were interested in collecting premium from the complainant, as such, now at this stage, they cannot evade their liability. Keeping in view the ratio of the law laid down by the superior Fora in the aforesaid cases and the facts and circumstances of the present case, we are of the considered opinion that the insurance company has not been able to prove the allegations, on the basis of which, they had repudiated the claim of the complainant. Thus, the repudiation of the claim done by the OPs is held to be unjustified and amounts to deficiency in services on their part. Hence, the OPs are liable to reimburse the amount which the complainant had incurred on his treatment. Now the question which arises for consideration is what should be the quantum of indemnification? In the complaint, the complainant had mentioned that he has incurred Rs.3,50,000/- on his treatment, but the complainant had placed on record only the bills Annexure C3, Annexure C5 to Annexure C-16 for a sum of Rs.1,29,450/-(1200+230+5500+500+3520+1489+94355+19017+2040+ 102+1497). Therefore, the OPs are liable to reimburse the said amount of Rs.1,29,450/- alongwith interest to the complainant. They are also liable to compensate the complainant for the mental agony and physical harassment suffered by him, alongwith litigations expenses.

8.                In view of the aforesaid discussion, we hereby allow the present complaint against the OPs and direct them in the following manner:-

1. To pay the amount of Rs.1,29,450/- alongwith interest @ 7% per annum w.e.f. 01.06.2018 i.e. the date of the repudiation of claim, till its realization.
2. To pay Rs.3,000/- as compensation for mental agony and physical           harassment suffered by the complainant.
3. To pay Rs.2,000/- as litigation expenses.

 

                   The OPs are further directed to comply with the aforesaid directions jointly and severally within the period of 30 days from the date of receipt of the certified copy of this order, failing which, the awarded amount shall carry interest @ 9% per annum for the period of default. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on :22.07.2019.

 

          (Vinod Kumar Sharma)           (Ruby Sharma)     (Neena Sandhu)

              Member                                  Member             President