DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

(CENTRAL) ISBT KASHMERE GATE DELHI

CC No. 361/2015

No. DF/ Central/                                                                      Date

Sharda Shankar Verma

C – 4E, First Floor, 108, MIG Flat,

Janak Puri, New Delhi – 110058

(Through Son/ AR Mr. Rajiv Kumar Raj)

                                                                                                      .....COMPLAINANT

                                                     VERSUS

1. Star Health and Allied Insurance Company Limited

    (Branch Office – Karol Bagh)

    18, 2^nd Floor, Ashoka Chamber, 5 B Pusa Road,

    Near Rajindra Place Metro Station, New Delhi – 110060

2.  World Brain Center Hospital

     (Dr. Neelesh Tiwari)

     RZ – 2, Raghav Nagar, Pankha Road,

    Opp. Janak Cinema, Near Dabri Crossing, New Delhi

                                                                                          …..OPPOSITE PARTY

Ms. Rekha Rani President

Sh. Vikram Kumar Dabas, Member                                                                      Mrs. Manju Bala Sharma, Member

 ORDER                        Date:      .     .2018

Sh. Vikram Kumar Dabas

           The complainant purchased a policy of Insurance covering his father Sh. Sharda Shankar Verma, a senior citizen from OP 1 and paid a sum of Rs. 9500/- as premium.  The policy was valid for the period from 26/10/2013 to 25/10/2014.   It is alleged that on 28/05/2014 the insured was admitted with OP 2 hospital and was discharged on 30/05/2014.  It is further alleged that the insured was again admitted in Sir Ganga Ram Hospital on 02/07/2014 and was discharged on 09/07/2014.  It is alleged that in both the times of admission OP 1 refused to give cashless facility which was provided under the policy.   It is also alleged that the claims lodged by the complainant on account of reimbursement of the expenses incurred on the treatment of the insured was also repudiated.  The complainant has alleged that the repudiation of the claim was unjust and was an act of deficiency on the part of OP 1.  It has therefore approached this Forum with the following prayers : 

1. Direct the respondent No. 1 for the reimbursement of the medical expenses to the tune of Rs. 1,31,959/- (18,990 + 1,13,769/-) along with interest.
2. Direct the respondent no. 1 for the reinstatement of the policy in question which bearing no. P/161213/01/2014/000222 in the name of Sh. Sharda Shankar Verma.
3. Award compensation to the tune of Rs. 2,00,000/- for mental harassment, mental pain, agony and humiliation to the complainant on various occasions. Further for the cost of the litigation
   Rs. 5,000/-
4. Pass any such and/ or other order which deems fit & proper in the present circumstances, in the interest of justice.

The complaint has been contested by the OPs.OP 1 has filed a written statement wherein it has taken a preliminary objection that the complainant has not approached this Forum with clean hands and has suppressed material facts.It has admitted that it had issued a policy of Insurance in respect of the Insured for the period 26/10/2013 to 25/10/2014.It has however, claimed that it had repudiated the claim lodged by the complainant in accordance with terms and conditions of the policy.As regards claim No. 1 for the treatment of Insured at OP 2 hospital, it has stated that it was observed that the Insured was treated for BPAD in mania which is related to psychiatric disorder.

It has stated that this claim was not payable in view of the exclusion clause 3.12 of the policy purchased.As regards the claim for admission in Sir Ganga Ram Hospital from 02/07/2014 to 09/07/2014 OP 1 has again claimed that the claim was rightly repudiated because of non disclosure of the material fact.OP 1 has referred to the discharge summary wherein it was recorded that the Insured was a known case of HT for 6 -7 years which fact was not disclosed at the time of purchase of policy of Insurance.OP 1 has claimed that since its consent was obtained by concealment, it has repudiated the claim lodged by complainant.OP 1 has claimed that the complaint is without any merit and is liable to be dismissed.It has prayed accordingly.

           OP 2 has filed a separate written statement.  It has taken a preliminary objection that the complainant has no cause of action to file a complaint against it.  OP 2 has contested the claim on merits and has prayed for the dismissal of the complaint. 

           On behalf of the complainant an affidavit was filed supporting the contents of the complaint.   On behalf of OP 1 an affidavit was filed by Shri Rajneesh Kohli Asstt. Vice President Claims.   On behalf of OP 2 an affidavit was filed by Dr. Neelesh Tiwari.

We have heard arguments advanced at the bar and have perused the record.The subject matter of the complaint related to two separate claims filed by the complainant in respect of the Insured.In respect of the first claim the Insured was admitted in Hospital of OP 2.The discharge summary dated 30/05/2014 reveals that the Insured was diagnosed by a psychiatrist (specialist) as a case of BPAD in Mania with known case ofHypertension(HTN).OP 1 has repudiated the claim by virtue of exclusion clause 3.12 of the policy which reads as under :

‘’3.  Exclusion:  The company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by any insured person in connection with or in respect of:-

(12) Convalescence, general debility, mental disorder, Run-down condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, Intentional self injury and use of intoxicating drugs/alcohol’’

             A reading of the exclusion clause 3.12 makes it amply clear that claim on account of mental disorder cannot be entertained under the terms and conditions of the policy.  In our considered opinion the claim was rightly repudiated by OP 1.       

In respect of the second claim the OP 1 has rejected the same on the plea that the policy was obtained by making a misstatement of health.Our attention has been drawn to the proposal form wherein the Insured was specifically asked as to whether he has suffered from any disease/illness.The answer was given in the negative.The discharge summary prepared at Sir Ganga Ram Hospital on 09/07/2014 records that the Insured was a known case of HTN for 6/7 years.A contract of Insurance is based on utmost faith.The Insured was bound to disclose any previous ailment at the time of purchase of the policy.The Insured has suppressed the fact that he was suffering from HT for the last 6/7 years and was on regular medication.We are therefore, convinced that the second claim was rightly repudiated by OP 1 and further it was within its right to cancel the policy of Insurance.

We see no merits in this case, the same is hereby dismissed.Copy of the order be supplied to the parties as per rules.

         Announced on this  ___________day of __________2018.