| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C.No. 319 of 23-11-2020 Decided on : 31-10-2023 Shiv Kumar aged about 59 years son of Sh. Kalu Ram, resident of Ward No.7, Bathinda Road, Balmiki Colony, Jaitu, Distt. Faridkot. ........Complainant Versus Star Health and Allied Insurance Company Ltd., Regd. And Corporate Office, 1 New Tank Street, Valluvar Kottam High Road, Nangambakkam, Chennai 600034, through its The M.D./D.M./Incharge. Star Health and Allied Insurance Company Ltd., SCF No.133, 2 Floor G.T. Road, Goniana Raod, Bathinda 151001, through its the Divisional/Branch Manager,
.......Opposite parties Complaint under Section 35 of the Consumer Protection Act, 2019 QUORUM Sh. R.L Mittal, President Sh. Shivdev Singh, Member Present : For the complainant : Sh.M.S Chauhan, Advocate. For opposite parties : Sh.Vinod Garg, Advocate. ORDER R.L Mittal, President The complainant Shiv Kumar (here-in-after referred to as complainant) has filed this complaint U/s 35 of Consumer Protection Act, 2019 (here-in after referred to as 'Act') before this Commission against Star Health and Allied Insurance Company Ltd., and another (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that complainant purchased the insurance policy from the opposite parties and insured with the opposite parties vide insurance policy No. P/211217/01/2020 /001824, customer code AA0009641868, proposer code No.12285140 which was issued on 25.9.2019 and valid upto 24.9.2020 and in that scheme complainant and his wife Bimla Devi has also been insured for total sum of Rs.10,00,000/-. Opposite parties never issued complete terms and condition of the policy to complainant, rather the opposite parties have issued Insurance policy only. As complainant per this insurance/ the and his wife Bimla Devi are fully covered under medical insurance under cashless scheme of Rs.10 lacs. It is alleged that as per term and condition of the policy the opposite parties shall pay for hospitalization expenses for medical /surgical treatment at their network Hospital. On 8.11.2019, Bimla Devi wife of complainant was suddenly fallen ill and she was suffering from heart disease and she was admitted to DMC Ludhiana on 8.11.2019 and complainant given intimation regarding admission of wife of the complainant due to above said diseased. The wife of complainant was remained admitted there till 13.11.2019 from 8.11.2019 and complainant spent Rs.38,000/- approximately, but the opposite parties did not pay any amount to the said hospital and complainant paid whole the amount of Rs.38,000/- approximately from his own pocket under compelling circumstances. It is further alleged that after the treatment complainant sent the claim with opposite parties and fulfilled all formalities as required by the opposite parties and also sent Bill of amount of Rs.38,000/-, and all documents, but the opposite parties did not pay any payment under insurance scheme till today intentionally and purposely, whereas they are duty bound to make the payment to the hospital before discharge of the complainant. The opposite parties intentionally and purposely harassed the complainant without any cause to swallow the amount of Rs. 38,000/-. The same and vide letter dated 10.4.2020 the opposite parties knowingly and intentionally repudiated the claim of complainant on the basis of false facts that the wife of complainant was pre-existing diseased since the inception of first policy i.e. from 25.9.2019. It is also alleged that before issuing the polic the agent of opposite parties was continued visiting the house of the complainant for issuing the policy and at that time the opposite parties was committing the promise to make the payment immediately if any mishap will occured and now the complainant is running behind the opposite parties to get his rightful claim. The faith of the complainant has been shattered by the opposite parties as lame excuses are on the part of opposite parties. The complainant purchased this policy under the influence and promise made by the opposite parties. Thereafter the complainant approched the officials of the opposite parties in the matter and requested them to reimburse the amount incurred by him on her wife's medical treatment at the said hospital but they refused to do anything in the matter rather they rejected the claim without disclosing any reason. It is alleged that complainant also issued the notice through his counsel Sh.Maninder Singh Chauhan, Advocate on 20.8.2020 and the opposite parties given reply on the basis of false facts that the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease to the notice. It is mentioned that the wife of my client was not suffering from any diseased at the time of issuing the policy and the policy was issued by the opposite parties after fully checking and inquiry by the opposite parties. On this backdrop of facts, the complainant has prayed for directions to the opposite parties to make the payment of Rs.38,000/- with 18% interest from the date of admission of his wife till realization to the complainant and Rs.1,00,000/- as compensation for mental sufferings and Rs.10,000/- as litigation expenses. Upon notice, opposite parties appeared through counsel and contested the complaint by filing written reply raising legal objections that the complainant has concealed material facts and documents from this Hon'ble Forum as well as from the opposite parties, therefore, the complainant is not entitled to any relief. The complainant has availed Family Health Optima Insurance Plan Policy No. P/211217/ 01/2020/001824 for the period 25.09.2019 to 24.9.2020. The terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same were served to the complainant along with the Policy Schedule. Moreover it is clearly stated in the policy schedule that "The Insurance under this policy is subject to conditions, clauses, warranties, exclusions Etc. Attached" It is submitted that the Policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The Complainant has accepted the Policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form. The claim is reported in the 1st year of the policy vide claim No. CLI/2020/ 211217/0763985. As per documents, the insured Mrs. Bimla Devi submitted claim for reimbursement of medical expenses towards the treatment of Acute coronary syndrome (ACS), NTEMI, LV dysfunction, acute left ventricular failure (LVF), severe AS, lower respiratory tract infection (LRTI) on 08/11/2019 and same was repudiated vide letter dated 10/04/2020. It is observed that the findings of ECHO report dated 08.11.2019 confirms primary severe aortic valve stenosis with mild aortic regurgitation and severe LV systolic dysfunction with EF-28%. Based on these findings, the medical team of opposite parties is of the opinion that the insured patient has chronic, longstanding heart disease, which takes more than 2 month to develop, which is prior to the inception of the first medical insurance policy. Hence heart disease is a pre-existing disease. The present admission and treatment of the insured patient is for the pre-existing heart disease. As per Waiting period 3 (iii) of the policy issued to the complainant, the Company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/condition, until 48 months of continuous coverage has elapsed, since inception of the policy with the Company on 25/09/2019. So, the claim was repudiated vide letter dated 10.4.2020. On merits, opposite parties have reiterated their version as taken in the legal objection as detailed above and controverted all other averments of the complainant and prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his affidavit dated 24.11.2020 (Ex. C-18) and the documents (Ex.C-1 to Ex.C-17). In order to rebut the evidence of complainant, the opposite parties have tendered into evidence affidavit of Rajiv Jain dated 12.2.2021 (Ex.OP-1/10) and documents (Ex.OP-1/1 to Ex.OP-1/9 & Ex.OP-1/11). We have heard learned counsel for the parties and gone through the file carefully. Learned counsel for parties have reiterated their stand as taken in their respective pleadings as detailed above. We have given careful consideration to these submissions. It is admitted fact that complainant had purchased medical health policy from opposite parties. The claim of complainant has been recommended for rejection due to pre-existing disease within 1st year of the first policy as the complainant was suffering from Chronic longstanding heart disease. The only question before this Commission is whether decision of opposite parties was right while repudiating the claim of the complainant for reimbursement. First of all, it is nowhere alleged by opposite parties that complainant had refused to get medically examined when he purchased the policy of insurance from opposite parties meaning, thereby, that when the opposite parties did not avail option to get the complainant medically examined, in that case, this Commission has no hesitation in holding that the said condition is deemed to have been waived off by opposite parties. Since the opposite parties have failed to get the complainant medically examined before issuance of policy of insurance, opposite parties, at this stage, cannot take this plea that the complainant was suffering from Chronic longstanding heart disease. Hence, in our considered view, the opposite parties (insurance company) was not right in repudiating the policy in question. Therefore, from the above discussions and evidence on record, it is fully proved that the claim lodged by the complainant was wrongly rejected/repudiated by the opposite parties, which amounts to deficiency in service on the part of opposite parties. Accordingly, present complaint is partly allowed and opposite parties are directed to settle and pay Rs.20,067/- (as per billing sheet attached by opposite party i.e. Ex.OP1/11) in respect of expenditure made by complainant alongwith interest @9% p.a. from the date of filing of complaint till realization. The opposite parties are also directed to pay Rs.5,000/- as compensation on account of mental tension, harassment and litigation expenses. The compliance of this order be made within 45 days from the date of receipt of copy of this order. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room. Announced 31-10-2023 - (R.L Mittal)
President (Shivdev Singh) Member
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