Punjab

Sangrur

CC/208/2023

Sanjeev Kumar Garg - Complainant(s)

Versus

Star Health and Allied Insurance Company Company Ltd. - Opp.Party(s)

Sh. Sanjeev Goyal

05 Dec 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR 

                                                                        Complaint No. 208

 Instituted on:   12.06.2023

                                                                         Decided on:     05.12.2024

Sanjeev Kumar Garg aged about 44 years son of Shri Ram Chand Garg, resident of H.No.90, Street No.2, Partap Nagar, Sangrur.

                                                         …. Complainant.     

                                                 Versus

1.             Star Health and Allied Insurance Company Limited, Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai, through its Managing Director. 2.           Star Health and Allied Insurance Company Limited, SCO 17, 1^st Floor, Kandhari Complex, Stadium Road, Patiala through its Branch Manager.

                                                        ..Opposite parties.

For the complainant         :       Shri Ashish Kumar Garg, Adv.

For Opp.parties                :       Shri Rohit Jain, Adv.

Quorum                                          

Jot Naranjan Singh Gill                  : President

Sarita Garg                                      : Member

Kanwaljeet Singh                             : Member

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT

1.             Complainant has preferred the present complaint against the opposite parties  on the ground that in the month of November, 2020 the agent of the OPs approached the complainant for getting the health insurance policy of their company, as such the complainant proposed for the insurance policy of OPs for an amount of Rs.10,00,000/- under Family Health Optima Insurance Plan and paid the requisite premium and thereafter the OPs issued policy bearing number P/211115/01/2021/005660 for the period from 30.11.2020 to 29.11.2021 under which the complainant, his wife and two minor children were insured. The policy was received by the complainant by registered post, but no terms and conditions were supplied to the complainant. The said policy was got renewed by the complainant for the period from 30.11.2021 to 29.11.2022 and further from 30.11.2022 to 29.11.2023 vide policy number P/211115/01/ 2023/006817. Further it is averred that since there was no claim under the previous policies, therefore, the bonus of Rs.3,50,000/- was added and total coverage comes to Rs.13,50,000/- besides the recharge benefits of Rs.1,50,000/- thus the total sum assured under the policy for the said period i.e. 30.11.2022 to 29.11.2023 was Rs.15,00,000/-. Further case of complainant is that in the month of September, 2022, the complainant suffered from cough and took OPD treatment from Umeed Multi Speciality Hospital, Sangrur and the doctor prescribed medicines and the complainant cured after follow up treatment for about three months.  Further case of the complainant is that on 25.01.2023, when the complainant was in his flat at Panchkula, then he suddenly felt uneasiness and pain in chest, as such he was taken to The Bliss Hospital, Sector 20, Panchkula and the doctors of that hospital diagnosed the complainant as a case of heart attack and as such he was taken to Paras Hospital, Panchkula, where ECHO and the medical tests were conducted and found the blockage of all the major arteries. Further case of the complainant is that the doctor of Paras Hospital advised the complainant for bypass surgery and gave an estimate for the tentative expenditure to the tune of Rs.5,50,000/-. Accordingly, a pre-authorization request was sent to the OPs for cashless treatment, but no revert was received from the OPs for the same and as such the complainant chose to get the treatment at his own. The complainant remained admitted in Paras Hospital, Panchkula from 25.01.2023 to 06.02.2023 and thereafter the complainant took follow up treatment and complete bed rest as advised by the doctors and the complainant spent an amount of Rs.8,00,000/- on his treatment.  Further case of complainant is that after recovering from the surgery, the complainant immediately lodged the claim with the OPs for the reimbursement and submitted all the documents and bills with the OPs. Further case of complainant is that the OPs from the medical record observed that the complainant was using Obstructive Sleep Apnoea (snoring controlling instrument) and accordingly asked the complainant vide letter dated 25.03.2023 to give the details of the use of snoring controlling instrument, which was duly replied that he was having snoring problem as his wife was disturbing a lot, therefore, his family friend recommended this instrument to avoid snoring  and also told the OPs that he has no past history of heart disease. The grievance of complainant is that the OPs wrongly, illegally and arbitrarily repudiated the genuine claim of the complainant vide letter dated 05.04.2023 on the ground that the complainant has not submitted the duration of Obstructive Sleep Apnoea and its prior treatment record. After the repudiation of the claim, the complainant was shocked to receive an endorsement schedule dated 08.03.2023, whereby the OPs wrongly and illegally deleted the coverage of complainant from the policy in question w.e.f. 11.03.2023 on the ground of non-disclosure of pre-existing disease. Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to release the claim amount of Rs.8,00,000/- alongwith interest @ 18% per annum from the date of surgery till realisation, the OPs be directed to withdraw the endorsement schedule dated 8.3.2023 and to restore the coverage of the complainant with immediate effect and further claimed compensation and litigation expenses.

2.             In reply filed by OPs, preliminary objections are taken up on the grounds that the complainant has no locus standi to file the present complaint, that the complaint is not maintainable in the present form, that the complainant has dragged the OPs in false litigation and that the complainant has not come to this Commission with clean hands. On merits,  it is admitted that the complainant obtained the insurance policy in question for Rs.10,00,000/- under Family Health Optima Insurance Plan and paid the requisite premium under the policy for the period from 30.11.2020 to 29.11.2021 and renewal of the said policy for the period from 30.11.2021 to 29.11.2022 and from 30.11.2022 to 29.11.2023 is also admitted. It has been denied that the terms and conditions of the policy were not supplied to the complainant. Further it has been denied that the complainant ever suffered from cough and took OPD treatment from Umeed Multi Speciality Hospital, Sangrur. It is stated further that as per the documents the complainant was taken to Paras Hospital, Panchkula and the doctor of the said hospital conducted ECHO and the medical test and found the blockage of all the major arteries and the doctor to save the life advised Bypass Surgery to the complainant as such the complainant remained admitted in Paras Hospital, Panchkula from 25.1.2023 to 6.2.2023, however, it is denied that the complainant spent an amount of Rs.8,00,000/- on his treatment. It is submitted further that the complainant submitted the bills worth Rs.5,23,359/- only. It is admitted that the complainant lodged the claim with the Ops for reimbursement of claim amount and the OPs from the medical record observed that the complainant was using Obstructive Sleep Apnoea (snoring controlling instrument) and accordingly asked the complainant vide letter dated 25.3.2023 to give the details of the use of snoring controlling instrument. The complainant has not submitted all the documents and bills to the OPs. It has been stated further that the claim of the complainant has rightly been repudiated vide letter dated 5.4.2023 on the ground that the complainant has not submitted the duration of obstructive sleep apnoea and its prior treatment record. It has been stated further that the said problem has concern with the heart disease of complainant and the coverage of complainant has rightly been deleted w.e.f. 11.3.2023. Lastly the OPs have mentioned in the reply that the maximum quantum of liability under the terms and conditions of the policy shall be Rs.4,30,823/- only. The other allegations levelled in the complaint have been denied and prayed for dismissal of the complaint with costs.

3.             The learned counsel for the complainant has produced Ex.C-1 affidavit, Ex.C-2 to Ex.C-14 copies of documents and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OPs/1 affidavit, Ex.OPs/2 to Ex.OPs/20 copies of documents and closed evidence.

4.             We have gone through the pleadings put in by the parties along with their supporting documents with their valuable assistance. 

5.             It is an admitted fact between the parties that complainant with his wife and two minor children were insured with the OPs under the medical insurance policy in question, a copy of which on record is Ex.C-4. The contention of the complainant is that during the subsistence of the insurance policy in question the complainant took treatment from Paras Hospital, Panchkula for bypass surgery and remained admitted there from 25.01.2023 to 06.02.2023 and spent the amount of Rs.8,00,000/-. In the present case, the grievance of the complainant is that though he was insured under the insurance policy, but the OPs wrongly and illegally repudiated the rightful claim of the complainant vide letter dated 5.4.2023 Ex.C-12 on the ground that the complainant has not submitted the record about Obstructive Sleep Apnoea and its prior treatment record, whereas this disease has no nexus with the heart surgery, more so when the complainant never took treatment of Obstructive Sleep Apnoea.  Another grievance of complainant is that the OPs have wrongly deleted the coverage of the complainant vide endorsement schedule Ex.C-13 w.e.f. 11.03.2023 due to non disclosure of pre-existing disease, which should be restored from that date also.  On the other hand,  the learned counsel for the OPs  has admitted that the complainant obtained the insurance policy in question. It is further contended that the claim was denied on the ground that the complainant has not submitted the documents regarding the duration of obstructive sleep apnoea and its prior treatment record and accordingly asked the complainant vide letter dated 25.03.2023 Ex.C-10 to give the details of the use of snoring controlling instrument but he did not submit any satisfactory reply to the OPs nor submitted  the documents. It has been stated further that the claim of the complainant has rightly been repudiated vide letter dated 5.4.2023 on the ground that the complainant has not submitted the duration of obstructive sleep apnoea and its prior treatment record. It has been contended further that the said problem has concern with the heart disease of complainant and the coverage of complainant has rightly been deleted w.e.f. 11.3.2023 and lastly prayed for dismissal of the complaint. We have perused the reply of the complainant Ex.C-11 wherein the complainant had categorically submitted that there was no treatment record of OSA and there was no past history or hospitalization record of heart disease.  We are unable to go with this contention of the learned counsel for the OPs and further are of the view that the claim can not be rejected on the ground of disease i.e. OSA (Obstructive Sleep Apnoea) which has no nexus with the bypass surgery of the complainant. Moreover OPs have failed to produce on record that obstructive sleep apnoea can cause heart disease. To support his case, the learned counsel for the complainant has cited the law laid down by the Hon’ble Apex Court of India in Sulbha Prakash Motegaonkar versus Life Insurance Corporation of India 2021(3) SCC 561, wherein in para number 7 it has been mentioned that  it is not the case of the Insurance Company that the ailment the deceased was suffering from was a life threatening disease which could or did cause the death of the insured. In fact the clear case is that the deceased died due to ischaemic heart disease and also because of myocardial infarction. The concealment of lumbar spondilitis with PID with sciatica persuaded the respondent not to grant the insurance claim. Further in para number 8 it has been held that the National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischaemic heart disease and myocardial infarction had nothing to do with his lumbar spondilitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified. As such, we find that the Ops have wrongly repudiated the claim of the complainant.

 

6.             Now, coming to the quantum of compensation payable to the complainant. Admittedly, the insurance policy is for the sum insured of Rs.10,00,000/-.  The complainant has  claimed an amount of Rs.8,00,000/-, but we are unable to accept such a contention of the complainant as the complainant has produced various bills on record, when totalled the same were found to be of Rs.4,84,333/-, as such, we find that the OPs are liable to pay to the complainant an amount of Rs.4,84,333/- which were illegally and wrongly withheld by the Ops. As such, the repudiation letter dated 05.04.2023 Ex.C-12 and Endorsement Schedule Ex.C-13 are set aside. 

7.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

8.             Accordingly, in view of our above discussion, we allow the complaint and direct OPs to pay to the complainant the claim amount of Rs.4,84,333/- alongwith interest @ 7% per annum from the date of filing of the present complaint i.e. 12.06.2023 till realisation. We also direct the OPs to restore the insurance policy in question i.e. coverage of the complainant w.e.f. 11.03.2023 after getting deposited the requisite premium amount without charging any late fee or interest from the complainant. Further OPs are directed to pay to the complainant an amount of Rs.10,000/- as compensation for mental tension, agony and harassment and further an amount of Rs.10,000/- on account of litigation expenses. This order be complied with within a period of sixty days of receipt of copy of this order.

9.             The complaint could not be decided within the statutory time period due to heavy pendency of cases.

10.           Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance.      

                        Pronounced.

                       December 5, 2024.