District Consumer Disputes RedressalCommission ,Faridabad.
Consumer Complaint No..146/2021.
Date of Institution: 18.3.2021.
Date of Order: 16.09.2022.
Mr. Gurbaksh Lal Bedi, H.No 2CJK 56 NH2, NIT Faridabad,Pin Code 121001
…….Complainant……..
Versus
Star Health And Allied Insurance Co. Ltd. Sri Balaji Complex 15, whites road, Chennai 600014
…Opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: AmitArora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………… Member.
PRESENT: Complainant in person.
Opposite party ex-parte vide order dated 12.07.2022.
ORDER:
The facts in brief of the complaint are thatComplainant complained against Star Health and Allied Insurance Company and advisor Mr. Dinesh Bareja for fraud and misrepresenting the medical facts in the policy issued to the insured person-Senior citizen. The policy was purchased on 07th Feb 2017, and paid a premium of INR 20700/- for first year.Patient medical condition was explained to the advisor Mr. Dinesh Bareja at the time of policypurchase and he misrepresented the medical existence of the pre-existing diseases under majorcomplications and denied to consult the medical reports to mention the correct facts about preexisting diseases. The complaint relates to the false commitments made by company Star Health and Allied insurance company and their advisor in terms of Policy plan Senior Citizens Red Carpet Health Insurance Policy. The complainant had incurred a Loss of premiums amount paid to the company in year 2017, 2018, a claim amount of INR 35000 in 2019 and furthermore forced cancellation of the policy worth Sum insured amount 5 Lacs. Complainant had also attempted to take the matter to the insurance ombudsman and application made to the concern authorities and details of documents attached for further reference. Detailed Complaint mentioned below.
1. On 7th Feb 2017, Proposer Ms. Shaifall Bedi purchased a senior citizen star health red carpet health insurance policy for her father Mr. Gurbaksh Lal Bedi. The main reason to buy the policy was to assure the safety and arrange financial backup at the time of medical emergencies, as in Jan 2017 the insured person got admitted to a clinic in Faridabad in an emergency due to high blood pressure. The doctor explained that the patient blood pressure was too high and by the time the patient reached the clinic, the patient got blood clot in the brain due to bleeding and suffered a mild paralytic attack. Looking at the medical condition, the proposer decided to buy health insurance for her parents both father and mother and contacted Mr. Dinesh Bareja, the insurance agent.
2. The medical condition was discussed and explained to Star health insurance agent Mr. Dinesh Bareja (7840068895) Neither the company nor had the agent asked to present the medical reports of the patient to cover the critical illness in the policy documents,
3. At the time of the policy the company mentioned that pre-existing diseases Hypertension and its major complications. On further questioning, advisor Mr. Dinesh Bareja explained proposer that this policy "Hypertension and its major complications" covers all major critical diseases happened due to high BP. Furthermore the policy for senior citizens covers all major illness and diseases after one year from the date of policy.
4. From 2017 till 2019 the insured patient was getting medical treatment from B.K.Hospital(Civil Hospital) Heart Centre Meditrina.
5. In 2019 on September, insured person got high bp and numbness feeling in his right leg and admitted to Fortis Escorts hospital in Faridabad. Due to numbness in patient right leg, the patient was kept under observation of neurological doctor Mr.Rohit Gupta.
6. Policy proposer filed the request for cashless treatment of the insured patient in the hospital to cover the hospital charges. The company denied the approval for cashless treatment of the insured patient for diagnosed disease.
7. The customer care executive confirmed on the phone that we had not declared the details of old CVA relating to insured person, which were found to be pre-existing at the time of taking the policy for the first time during 07.02.2017 to 06.02.2018. This amounts to non disclosure of the material facts and company was cancelling the policy on the basis of Fraud.
8. Proposer had requested policy advisor to help as during the time of policy, all the facts and medical condition of the patients were clearly told and he had committed that the blood clot and CVA would be covered under major complications of hypertensions.
9. Proposer attempted to call and write directly to Star health grievances cell and explained the matter but no body heard grievances.
10. Proposer had also visited the star health office in Gurgaon and discussed the matter with Mr.Lalit (star health executive) because the insurance agent Mr. Dinesh Bareja was in continuous touch with Mr.Lalit to explain the claim process at the time of admission of the insured patient in hospital. It came a big shock when Mr.Lalit told him that Dinesh Bareja was not direct advisor of the star health so he cannot help him. However Mr. Lalit, executive of the star health asked him to submit the documents to seeking reimbursement of the expenses incurred relating to the treatment of the insured patient. Proposer had submitted the original documents for claim reimbursements and result was rejection mail.
11. Proposer filled a written complaint to Office of the insurance ombudsman on 5th March 2020.Due to covid 19 pandemic the ombudsman office arranged for a video conference on 4.08.2020 with star health person and grievances were explained. He had explained the officer that patient had got blood bleed and clot in brain due to high blood pressure and that's why he purchased the policy and now the company was representing this fraud case. During video conference the ombudsman officer told star health person that in the policy it was clearly mentioned that patient had hypertension and all these history of CVA were implications of high bp.He also asked star health person to share the policy terms and conditions. Proposer was optimistic that at least he understood my concern. Later on 2nd September, proposer got a mail that the case was dismissed and complaint is treated as closed.
12. Proposer strongly opposed the decision and wanted to take this matter of Fraud done from star health company to next appellate authority. The company not only rejected the claim but forcefully cancelled Senior Citizen policy after continuous payment of 3 years premium. During the first claim submitted in 2019 from the time the policy was purchased. The company cancelled the policy and refunded the premium amount of INR 21,240 paid for 2019 only.
13. Why the company had not asked for medical reports of the insured policy holder before policy taking. Why the company had not scrutiny the medical reports and mentioned the complete medical history of the patient/insured policy holder and referred to medical terminology of the old CVA and B.G Bleed when it was clearly told to the insurance agent. The responsibility lies with the company agent and blame company for this fraud and forcefully cancelling the policy. He request respected presiding officer to please take my grievances and help me to get the approval for cashless claim amount rejected by the company star health and reinstate the policy in place effecting from 2017.The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) pay a compensation claimed below for financial loss/interest lost and mental agony suffered due to the negligence and misrepresentations of the facts of the opposite parties.
b) pay a sum of Rupees 1 Lac to the complainant towards the aforementioned liability along with the interest 18% on claim amount.
14. Notice issued to opposite party on 09.06.2022 not received back either served or unnerved.Tracking details filed in which it had been mentioned that “Item Delivery confirmed”. Mandatory period of 30 days expired. Hence, Opposite party was proceeded against e-parte vide order dated 12.07.2022.
15. The complainant led evidence in support of his respective version.
16. We have heard complainant in person and have gone through the record on the file.
17. In this case the complaint was filed by the complainant against opposite party– Star Health and Allied Insurance Co. Ltd. with the prayer to: a) pay a compensation claimed below for financial loss/interest lost and mental agony suffered due to the negligence and misrepresentations of the facts of the opposite parties. b) pay a sum of Rupees 1 Lac to the complainant towards the aforementioned liability along with the interest 18% on claim amount.
To establish his case, the complainant has led in his evidence , affidavit of Shaifali Bedi D/o of Shri Gurbaksh Lal Bedi vide Ex.CW1/A,, Annexure B1 – senior citizens Red Carpet Health Insurance Policy, B2 – Star Health Allied Insurance company Limited, Attached to and party of policy No. P/161200/01/201/008189, B3 – Identity card, B4 & B5– Senior Citizens Red Carpet Health insurance policy terms and conditions, Annexure C1 to C4 – Discharge summary, C5 - Test report, C6 – Electroencephalograhy report, C7 & 8– test report, C9 receipt, C10 to 17 – inpatient detail bill, C18 -21 – The Cardio Medicare Centre , C22 - B.K.Hospital (Civil Hospital) Faridabad, C23 – Discharge summary, C24 – 27 – B.K.Hospital, Civil Hospital Faridabad, C28 – Bill cum receipt, C29 - Prescription from Pulse Hospital, C30 - Prescription form B.K.Hospital Faridabad, D1 – claim form, D2 - Guidance For Filing claim Form – Part A,,D3 – Claim Form – Part-B, E1 – Denial of preauthorization request for cashless treatment, E2 – Rejection of authorization for cashless treatment, E3 – letter dated 25.11.2019 regarding non disclosure of PED cancellation, E4 – Endorsement schedule, G1 – Hospitalization Benefit Policy, G2 to G3 – Advance Premium Receipts, F1 & F2– Ombudsman report dated 05.03.2020 & 11.09.2022,,F3 –F5 – Ombudsman order dated 31.08.2020.
18. There is nothing on record to disbelieve and discredit the aforesaid ex-parte evidence of the complainant. Since opposite party has not come present to contest the claim of the complainant, therefore, the allegations made in complaint by the complainant go unrebutted. From the aforesaid ex-parte evidence it is amply proved that opposite party has rendered deficient services to the complainant.
19. As per F3, order passed by the Insurance Ombudsman on 31.8.2020 in which it has been mentioned that “as per the Fortis Escorts document of 15.07.2017 after the inception of policy, the complainant’s father had intra-cerebral hemorrhage (ICH) in January 2017 and the same has not been disclosed to the insurance company at the time of inception of policy. As such it is clear that complainant’s father had CVA that resulted in development of hematoma before inception of policy. Since there is non-disclosure of material facts in the instant case and the complainant has concealed the past medical problem at the time of inception of policy, the complaint is liable to be dismissed. The case is accordingly dismissed.”
20. Keeping in view of the above order passed by Insurance Ombusman, the Commission is of the opinion that no deficiency in service on the part of the opposite party has been proved. Hence, the complaint is dismissed. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 16.09.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
