Punjab

Sangrur

CC/193/2023

Vinod Kumar - Complainant(s)

Versus

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

Sh. Ashish Kumar

11 Jun 2024

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

          

                                                                         Complaint No. 193

 Instituted on:   29.05.2023 

                                                                          Decided on:     11.06.2024

Vinod Kumar aged  about 65 years son of Dharam Vir resident of H.No.102, J.P.Colony, Sangrur District Sangrur ( Mobile No.97810-33933).

                                                          …. Complainant.     

                                                 Versus

1.         Star Health and Allied Insurance Company Limited No.15, Sri Bala Ji Complex, Ist Floor, Whites Lane, Royapettah, Chennai 600014 through its Authorized Signatory.

2.         Star Health and Allied  Insurance Company Limited Branch Office Ist Floor, Sunami Gate, Sangrur above IDBI Bank.Sangrur District Sangrur 148001 through its Branch Manager/ Authorized Signatory.

….Opposite parties. 

QUORUM                                       

JOT NARANJAN SINGH GILL: PRESIDENT

SARITA GARG                           : MEMEBR

KANWALJEET SINGH             : MEMBER

 

For the complainant  : Shri  Ashish Kumar, Advocate              

For the Ops             : Shri Rohit Jain, Advocate.

 

ORDER

 

KANWALJEET SINGH, MEMBER

 

1.             The brief facts of the case are that the complainant obtained the medi classic Insurance policy from Ops vide policy no.P/211223/01/2022/002303 for three years from 22.11.2021 to 21.11.2024. The sum assured was five lacs. Earlier the complainant obtained medical policy since 09.11.2014  without any break. Later on, the same was ported to Star Health i.e. OPs. The policy in question is cashless. No separate terms and conditions were supplied to the complainant by OPs. On 14.12.2022 and 16.12.2022 the complainant suddenly feel uneasiness and he immediately approached Sadbhavna Medical and Heart Institute Patiala and paid a sum of Rs.700/- as check up charges and doctor provided medicine to the complainant and paid  Rs.1350/- for medicine. On 17.12.2022 the complainant admitted in Fortis Hospital, Mohali with complaints of angina on exertion. The past history was recorded as type 2 DM X 8 years and UGIE: mild Gastritis (18.10.2022). The said hospital sent a request for cashless treatment for Rs.10800/- to the OPs  and the same was accepted. An angiography of the complainant was conducted. No response was received by the hospital  from the OPs. The hospital discharged the complainant  after receiving Rs.12500/- and the complainant lodged the claim  but OP no.1 repudiated the claim on 23.03.2023 on the ground that report dated 16.12.2022, the patient has complaints of dysponea on exertion since 1-2 years. As per letter dated 07.03.2023 the patient has complaints of  angina on  exertion for the past three months and thus there is discrepancy in the records which amounts to misrepresentation of facts. On 06.10.2022 OP no.2 organized a medical check up camp in their office the ECG of the complainant  was declared as normal. The complainant never admitted in  any hospital before 17.12.2022  for heart problem. The  OPs committed unfair trade practice and deficiency in service qua the complainant. The complainant  has lastly prayed that the Ops may kindly directed to pay  Rs.50000/- alongwith interest  from the date of demand  of payment till realization and Rs.One Lac on account of mental tension and Rs.10000/- as litigation expenses.  

2.             Upon notice of this complaint, the opposite parties appeared and filed written version, taking preliminary objections that the complainant has not come to the Commission with clean hands. On merits,  the complaint is admitted to be correct to the extent  that the complainant  obtained health policy in question from the OPs. Under the policy the company is also giving added benefits of medical expenses 30 days prior to hospitalization and 60 days after the hospitalization. It is a matter of record  that the complainant obtained  medi claim insurance policy since 09.11.2014. The documents submitted by the complainant on 17.12.2022 that the complainant admitted in Fortis Hospital, Mohali with complaints of angina on exertion. The past history was recorded as type 2 DM X 8 years and UGIE: mild Gastritis (18.10.2022). The said hospital sent a request for cashless treatment for Rs.10800/- to the OPs  and the same was accepted. It was told to the complainant to submit the requisite documents but the insured  has not utilized the cashless facility. The complaint is admitted to be correct to the extent that the complainant lodged the claim  with OPs for reimbursement of the claim amount of Rs.15858/- only.  The OP no.1 repudiated the claim 23.03.2023 on the ground that report dated 16.12.2022, the patient has complaints of dysponea on exertion since 1-2 years. As per letter dated 07.03.2023 the patient has complaints of  angina on  exertion for the past three months and thus there is discrepancy in the records which amounts to misrepresentation of facts. As per condition no.1  of the policy  issued to the complainant if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to pay the claim. Hence the claim was rejected. The remaining allegations are denied by the OPs and lastly prayed the complaint may kindly be dismissed with special costs.

3.             In support of his case the complainant tendered into evidence self attested affidavit Ex.C-31 and some documents which are Ex.C-1 to Ex.C-30 and Ex.C-32 to Ex.C-37 and closed evidence.

4.             On the other hand, to rebut the case of the complainant, the opposite parties have produced  documents i.e  Ex.Ops/1 affidavit and Ex.Ops/2 to   Ex.Ops/16  and closed evidence.  

5.             We have heard the learned counsel for OPs and gone through the record file carefully with the valuable assistance of the learned counsel for the opposite parties. Arguments of both the parties are similar to their respective pleadings, so  there is no need to reiterate the same to avoid repetition.

6.             Now, come to major controversy,  whether the complainant is liable for relief  as claimed by him in his prayer or  not?

7.             During the arguments learned counsel for OPs more focused on D CONDITIONS (standard of conditions) on page no.12 of Ex.OPs/4 which is reproduced as under:-

“Disclosure of information:- The policy shall be void and all premium paid thereon shall be forfeited to the company in the event  of misrepresentation, mis description or non-disclosure of any material fact by the policyholder.”

From the pleadings of OPs, it is not disputed that the medi classic Insurance policy  in question obtained by complainant from  OPs and paid the total premium of Rs.83621/- as per Ex.C-1 on page 2. The term of the health policy in question is valid from 22.11.2021 to 21.11.2024 for three years and the sum insured was Rs.5,00,000/-. This Commission has the considered opinion after perusal of Ex.C-11 to Ex.C-30 bills of medical treatment  and medicine receipts paid  by complainant on different dates  of Rs.34226/- .

8.             It is writ large on the file from the perusal of Ex.OP-2 has shown the policy no.002642 issued in the name of Sunita Rani  wife of one Pardeep Kumar resident of  Barnala. Under the policy supra mentioned the premium of Rs.37046/-. The period of insurance  mentioned as 27.12.2022 to 26.12.2023. It transpires from the perusal of Ex.OPs/3 shown  the name of insured as Sunita Rani and basic  sum insured of Rs.10,00000/-.

Per contra,  in the present case in hand the sum insured  was five lacs  and  the policy term was for three years. As per Ex.C-2 (six pages). The complainant name has shown as Vinod Kumar resident of Sangrur. During arguments, the complainant described to this Commission that he has no relation in any manner with Sunita Rani resident of Barnala.

This Commission has no hesitation  to hold that documents Ex.OPs/2 and Ex.OPs/3 has no concern with the present case in hand. We feel Ex.OPs/2 and Ex.OPs/3 are the dictum of the case. We further feel Ex.OPs/2 and Ex.OPs/3 have not helpful  to the Ops no.1 and 2 to prove their innocence with regard to reimbursement of the claim of the complainant.  From the perusal of Ex.OPs/5 is  a request for cashless hospitalization for medical insurance policy in question which was duly recommended by Dr. Ankur Ahuja Cardiology, Fortis Hospital Mohali to the OPs. It transpires from the perusal of Ex.OPs/6  is a cashless authorization letter duly issued by the OPs. The round stamp of Zonal Office, Delhi Embosses on the same. The pre authorization dated 1`7.12.2022  approved an amount of Rs.10800/- by the Ops. The total estimated amount of Rs.20,000/-   has shown in the authorization summary.

9.             Moreover, on the second page of Ex.OPs/6  it is specifically mentioned that this is only the provisional amount, final amount will be worked out once the hospital submits the final bill with a discharge summary  and other related documents. As per Ex.OPs/7 dated 20.02.2023 letter issued by  OP no.1 regarding the rejection and withdrawal of approval given earlier. In this letter ( supra) it has mentioned the decision of OP no.1  to reject the claim and  the authorization has already given from cashless treatment of the above diagnosed disease  stands withdrawn. As per Ex.OPs/12 Dr. Ankur Ahuja certified that the complainant was admitted under their care at Fortis Hospital, Mohali. Doctor mentioned that the patient presented with complaints of angina  complaints of angina on exertion which increased to retrosternal chest discomfort at rest from three months. He was admitted on 17.12.2022 for Coronary Angiography which revealed CAD LM+ TVD.  Ex.OPs/15 is claim repudiation letter dated 23.03.2023. It has shown in the letter that it is observed that the OP no.1 repudiated the claim 23.03.2023 on the ground that report dated 16.12.2022, the patient has complaints of dysponea on exertion since 1-2 years. As per letter dated 07.03.2023 the patient has complaints of  angina on  exertion for the past three months and thus there is discrepancy in the records which amounts to misrepresentation of facts.  Ex.OPs/16  is the bill assessment sheet of final admissible amount of Rs.15858/- . However, as per Ex.C-32, OP no.2 organized  a medical camp in its office  on 06.10.2022. The ECG  of the complainant was declared as normal. This Commission has the considered opinion of Ex.OPs/16 the admissible amount has shown as Rs.15858/- .  While from the perusal of Ex.C-11 to Ex.C-13 the total amount of Rs.34226/-  for medical treatment and medicine has spent by the complainant. From the perusal of Ex.OPs/4 on page no.6 of terms and conditions of the policy  it is specifically mentioned in clause 8 and 9 which are reproduced as under:-

Clause 8: Pre-hospitalization expenses: Medical expenses incurred upto 60 days immediately  before the insured person is hospitalized.

Clause 9: Post-Hospitalization expenses: Medical expenses insured upto 180 days immediately  after the insured person discharged from the hospital. On the other hand, reply on merits in para no.3 (a) it is specifically mentioned that  under the policy the company also giving the added benefits of medical expenses 30 days prior to  hospitalization and 60 days after the hospitalization. In this context the stand of Ops is in itself contradictory with regard to pre and post hospitalization benefits to the insurer. “The person who seeks equity must do equity”

We hold the terms and conditions are binding  upon the parties . No party can go beyond the terms and conditions of the policy in question. From this angle Ex.C-11 to Ex.C-30 the bills of medical treatment and medicine incurred to the complainant which are in total of Rs.34226/- . On the other hand, in the light of Ex.OPs/16  the OPs admitted admissible amount of Rs.15858/- . We hold that the complainant  is entitled  for an amount of Rs.34226/- plus Rs.15858/- total Rs.50084/- as reimbursement of medical bills against the health insurance policy in question which  was insured  by the OPs of Rs.5,00,000/- qua the  complainant. At this juncture, from the pleadings of OPs and evidence produced by way of affidavit alongwith other documents produced on the file are not proved by way of cogent, reliable and trustworthy evidence to prove their innocence. 

10. This Commission observed that the middle class family members are availed the medical health service/insurance policy after deposited the hard earned money as premium of the policy. In case of serious health problem occurred to the consumer and when the condition of the person is deteriorating, who having not a enough money for treatment in emergency cases. In this critical situation the health policy plays an utmost important role to save the life of an ordinary person. We feel that ops are duty bound to examine and not to issue medi-claim policy when the consumer is suffering from pre-existing disease, Ops firstly assess the fitness of the person and after complete satisfaction, then they should issue the health policy. In the light of celebrity  judgment in Civil Appeal No.7437 of 2011 titled as "P.Vankat Naidu Vs LIC of India". The Hon'ble Supreme Court of India held that Since the respondents had come out with the case that the deceased did not disclose correct facts relating to his illness, it was for them to produce cogent evidence to prove the allegation. The appeal is allowed. In LPA No. 1537 of 2011 titled as “Iffco Tokio General Insurance Company Ltd. Vs Permanent Lok Adalat Gurgaon and others” 2012(1)R.C.R.(Civil) 901:2012(2)PLR 547 decided on 26.08.2011. The Hon'ble Punjab and Haryana High Court held that the law is well settled with regard to the standard form of contracts. When the bargaining powers of the parties is unequal and consumer has no real freedom to contract the Courts would strike down such unfair and unreasonable clause in a contract, where parties are not equal in bargaining power. It was also held that claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the Policy. It was for insurance company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. Claim cannot be denied.
11.       It is duty of the Consumer Commission to redress the grievances of the aggrieved Consumer in the light of Consumer Protection Act, 2019. On the above discussion, this Commission has the considered opinion that Ops are liable for unfair trade practice and deficiency in service qua the complainant. Furthermore, Insurance Companies meant money from their innocent consumers by way of receiving the premium in crores throughout the country. On the other hand, phenomenon is toward the insurance companies are avoiding by one pretext another to pay the liability of insurance claim to the aggrieved consumers, we feel that an insurance contract is known as a contract of  “ uberrima fides” based on “ utmost good faith ” which is fully applicable in the present complaint. This isafit case to redress the grievance of the complaint. Further, this Commission directed the Ops   to discontinue the unfair trade practice qua  their respective innocent consumers.

       12.             Resultantly,  keeping  in view of the peculiar  facts and the circumstances of the case   in hand  and with  careful  analysis  of the evidence available on record and in the light of judgments pronounced by Hon’ble Supreme Court of India (supra) and Hon’ble Punjab & Haryana High Court, we partly allow the complaint and direct the Ops  to pay to the complainant  an amount of  Rs.50000/- as prayed  alongwith interest @7% p.a. from the date of  filing the complaint till realization.  Further, the OPs are directed to pay a consolidated sum of Rs.5000/- as compensation and litigation expenses.

13.            This order of ours shall be complied within 45 days from the receipt of copy of the order.

 

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

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

                                Announced.                                              

                                June 11,2024.

 

( Kanwaljeet Singh)    (Sarita Garg)  (Jot Naranjan Singh Gill)

    Member                        Member                  President

  

BBS/-