Delhi

New Delhi

CC/148/2018

Mahabir Parshad - Complainant(s)

Versus

The Manager/ Authorised Signatory Star Health & Allied Insurance Co. Ltd. - Opp.Party(s)

19 Nov 2019

ORDER

 

 

 CONSUMER DISPUTES REDRESSAL FORUM-VI (DISTT. NEW DELHI),

 ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN,

         I.P.ESTATE, NEW DELHI-110002.

 

Case No.C.C.148/2018                                          Dated:

              In the matter of:

Mahabir Parshad,

S/o late Sh. Ram Kumar,

R/o FC-115, 1^st Floor,

Tagore Garden,  New Delhi-27.

            ……..COMPLAINANT

VERSUS

The Manager/authorized Signatory,

Star Health & Allied  Insurance Co. Ltd.

First  Floor, Himalaya Marg,

23, Kasturba Gandhi Marg, New Delhi-110001.

 

Opposite Party.

                

                                                                                

NIPUR CHANDNA, MEMBER

ORDER

The complainant has filed the present complaint against the OP. The gist of the complaint is that the  complainant is insured in the subject policy and his daughter is proposer thereon  and she had paid a payment of Rs.69,798/- and Rs.71,127/- as premium of the said policy for two successive years.  The representative of OP, Sh. Kuldeep Singh contacted the complainant and obtained the entire relevant information in paper form along with medical prescriptions of doctors.  Thereafter, one Vishabh gupta, from OP Co. contacted the complainant for premium of the next year and after receiving the premium of Rs.71,127/-.  It is stated that while filling the proposal form, the complainant has declared to the OP that he is suffering from diabetes and kidney disease and has also handed over the medical record pertaining to the said disease to the agent of the OP namely, Sh. Kuldeep Singh, who after going through the medical record issued the policy in question and assured that the treatment of dialysis is covered under the policy.  On 8.7.2016, the complainant lodged the reimbursement claim for dialysis and artificial kidney with the OP, instead of making the reimbursement, OP asked for certain documents vide letter dt.27.7.2016 which was duly replied on 11.8.2016 along with required documents. Vide letter dt. 26.10.16, OP Co. cancelled the policy by giving the reasons of non-disclosure of material facts and the same is confirmed by the OP vide letter dt. 3.12.2016 along with a DD NO. bearing No.771706 dt. 2.12.2016 for a sum of Rs.71,127/- deposited against the premium for the policy w.e.f. 23.5.2016 to 22.5.2017.  It is further stated that he complainant never encashed the DD issued by the OP.  He served two notices to the OP, the same was not replied by the OP.  It is further alleged that the OP Co. repudiated the claim of the complainant on gospel truth which was unjustified, hence this complaint.

2.         Complaint has been contested by OP.  In its written statement,   OP has not disputed that complainant had taken policy referred above. OP has stated that there is no deficiency in service on its part as alleged by the complainant.  It has been further stated that the insured has now claimed an amount of Rs.87,900/- for kidney dialysis on regular basis for the period from 21.12.2016 to 20.5.2017 which falls subsequent to the cancellation of the policy w.e.f. 5.12.2016, hence, the same is not payable.   He further prayed for  dismissal of present complaint.       

        3.         Both the parties have filed their evidence by way of affidavits.

4.         We have heard argument advance at the Bar and have perused the record.

5.        Ld. counsel for the OP has contended that as per the consultation slip of Bhatia, Dentopulse dt. 15.5.2015, the insured has a history of hypothyroidism since 7-8 years and CKD 2 years,  for which he was on medication prior to the solicitation of the policy. It was argued that the insured had given false replies in the application for insurance as such the policy was obtained by concealment and suppression of material facts. In support of its contention counsel for OP has drawn our attention towards the proposal form as well as the copies of consultation report dt.8.4.2015 of Dr. Ashish Kalra and consultation slip of Bhatia, Dentopulse dt. 15.5.2015. It was further argued that the first claim was rightly repudiated as the policy was obtained by concealment and suppression of material facts and thereafter vide letter dt. 3.12.2016 the policy pertaining to the period 23.5.2016 to 22.5.2017 was cancelled and the DD of the premium amount was already refunded to the complainant.  The present claim pertaining to the amount of Rs.87,900/- for kidney dialysis on regular basis for the period from 21.12.2016 to 20.5.2017 which falls subsequent to the cancellation of the policy w.e.f. 5.12.2016, hence, the same is not payable

6.         On the other hand, ld. counsel for the complainant has contended that there is no concealment of material facts by the insured and  he had already submitted the medical history to the OP before inception of the policy.  It is further stated that the DD sent by the OP against the cancellation was never encashed, hence, he is entitled for the relief claims.  

7.        Perusal of the file shows that the complainant in the present complaint has claimed the reimbursement of the claim pertaining to the period from 21.12.2016 to 20.5.2017.It is admitted position that the policy of the insured  was cancelled by the OP on 3.12.2016 and the DD of the premium amount was already refunded to the complainant.  However, as per the statement of the complainant, he had never encashed the same DD but non-encashment of DD by the complainant does not held OP liable for reimbursing the claim which falls subsequent to the cancellation of the policy w.e.f. 5.12.2016.

 

8.     In the present case, the material on record discussed above clearly establishes that the insured had concealed material facts about his health as well as life style in the proposal form, as such the policy was cancelled by the OP w.e.f. 5.12.2016. Insured has now claimed an amount of Rs.87,900/- for kidney dialysis on regular basis for the period from 21.12.2016 to 20.5.2017 which falls subsequent to the cancellation of the policy w.e.f. 5.12.2016, hence, the same is not payable.

9.     In view of the above facts and circumstances of the present case, we are of the  considered view that the OP was justified in repudiating the claim, however, we direct OP to sent a fresh DD of premium amount to the complainant in case of non-cashment of the DD  bearing No.771706 dt. 2.12.2016 for a sum of Rs.71,127/- by the complainant.

The order shall be complied within 30 days of the receipt of the copy of the order. If the said amount is not paid by the OP within a period of one month from the date of receipt of this order, the same shall be recovered by the complainant along with simple interest at the rate of 10% per annum from the date of this order till recovery of the said amount. A copy each of this order each be sent to both parties free of cost by post. Orders be also sent to www.confonet.nic.in. File be consigned to record room.

Pronounced in open Forum on 19/11/2019

 

 

ARUN KUMAR ARYA)

          PRESIDENT

(NIPUR CHANDNA)                                                  (H M VYAS)

       MEMBER                                                                MEMBER