Chandigarh

DF-II

CC/269/2021

Manju Wadhawan - Complainant(s)

Versus

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

Adv. S.M.Wadhera

30 Nov 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	269 of 2021
Date  of  Institution	:	23.04.2021
Date   of   Decision	:	30.11.2022

 

 

 

 

 

 

1]  Manju Wadhawan, aged 55 years, widow of deceased Sh.Ravinder Kumar Wadhawan,

 

2]  Ishan Wadhawan s/o deceased Sh.Ravinder Kumar Wadhawan,

 

Both Resident of H.No.2, Shresth Complex-1, Balaji-11, Lohgarh Road, Zirakpur, District SAS Nagar, 140603 (Punjab)

 

             …..Complainants

 

Versus

 

1]  Star Health and Allied Insurance Company Ltd., through its Chairman cum Managing Director Sh.V Jagannathan, 1, New Tank Street, Valluvar Kottan High Road, Nungambakka, 15 Balaji Complex Chennai 600034.

 

2]  The Branch Manager, Star Health and Allied Insurance Company Ltd., 1^st Floor, SCO-4, Sector 14 Market, Near Payal Cinema, Gurgaon 122001.

 

3]  The Branch Manager, Star Health and Allied Insurance Company Ltd., SCO No.5-A, 2^nd Floor, Madhya Marg, Sector 7, Chandigarh.

 

    ….. Opposite Parties

 

BEFORE:  SMT.PRITI MALHOTRA    PRESIDING MEMBER 

                    SH.S.K.SARDANA            MEMBER

                               

Argued by  : Sh.S.M.Wadhera, Adv. for complainant.

   Sh.Gaurav Bhardwaj, Adv. for OPs.

 

PER PRITI MALHOTRA, PRESIDING MEMBER

         The complaint of the complainants in brief is that husband of complainant NO.1 namely Sh.Ravinder Kumar Wadhawan (since deceased) had taken Family Health Optima Insurance Plan from OP Insurance Company effective from 16.3.2015 to 15.3.2016 and got it renewed regularly from time to time and lastly from 16.3.2019 to 15.3.2020. The insured Ravinder Kumar Wadhawan fell ill and took treatment from PGI, Chandigarh during the currency of insurance policy from 5.9.2019 to 7.9.2019 during which it was found that he is suffering from Liver Disorder.  The insured again admitted in PGI, Chandigarh for treatment from 11.10.2019 to 5.11.2019 and ultimately died on 5.11.2019. The complainants being legal heirs of insured, lodged medical claims with OP Insurance Company to the tune of Rs.4,54,322/- towards the expenses incurred on the treatment of insured during the currency of insurance policy.  However, the OP Insurance Company repudiated the claims on the ground that the insured patient was chronic alcoholic and the disease suffered by the insured as well as the treatment taken was due to use of alcohol (Ann.C-11 & C-12). Hence this complaint has been preferred alleging the said repudiation as illegal and a deficient act on the part of OPs.

 

2]       The OPs have filed joint reply and while admitting the factual matrix of the case, stated that the complainants preferred two claims in respect of treatment taken by insured Ravinder Kumar Wadhawan at PGI, Chandigarh and on scrutiny of both the claim documents, it is observed by the medical team of answering OP that the insured patient is chronic alcoholic, the admission of the insured is for treatment of disease due to use of alcohol and as per Exclusion No.8 of the Policy, the complainant is not liable to make any payment in respect of expenses incurred at hospital for treatment of disease due to use of alcohol.  The OPs were therefore unable to settle the claims under the policy and hence repudiated the same.  It is submitted that it is admitted that the insured had disclosed the alcoholic consumption in the proposal form but the ailment due to consumption of alcohol is not payable as per terms & conditions of the policy.  It is also submitted that without conceding the liability of company to pay the claim, it is stated that maximum quantum of liability under both claims shall be Rs.39,309/- & Rs.3,61,360/- only.  Denying other allegations and pleading no deficiency in service, the OPs have prayed for dismissal of the complaint.

 

3]       Rejoinder has also been filed by the complainants thereby controverting the assertions of the OPs made in their reply.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have perused the entire record including written arguments.

 

6]       In order to avoid burdening the record, we are straightway coming to the moot question involved in the present complaint, which pertains to the rejection of medical claims raised by the legal heirs of policy holder late Sh.Ravinder Kumar Wadhawan.  The record reveals that only reason for the repudiation of the claims is that the complainant has concealed the factum regarding his alcohol consumption and for that non-disclosure of the facts, the claims were repudiated.  The stands of the OPs is belied by the sole document i.e. proposal form placed on record by the complainant vide Ann.C-1 wherein the insured very fairly has disclosed all the factum regarding his health status i.e. regarding being suffering from Hypertension, Diabetes Mellitus and also has Gall Bladder removed due to stone and also duly mentioned the medication being undertaken for B.P and Diabetes.  Further on Page 33 of Ann.C-1 (proposal form), the insured fairly disclosed in detail about consumption of Alcohol and also the duration i.e. 4-5 years and not regularly.  So apparently, the repudiation on ground of non-disclosure qua consumption of alcohol by the policy holder/insured is totally unjustified.

 

7]       It has also been considered that the policy in question was running in the fourth year, which firstly was taken in the year 2015 and being regularly renewed by paying handsome premium by the policyholder.  We are of the considered opinion that after the genuine disclosure made by the policyholder/insured in his proposal form, still meet such fate, show the tendency of the OP Insurance Company to repudiate the claim in stereotype manner without even going through the details of the claim in question as well the disclosure made in the proposal form, which only projects that Insurance Companies are only interested in getting the premium with deep thought in their mind not to pay the claim as & when raised, which clearly shows malafide intentions of the Insurance Companies, which needs to be curtailed in view of the benevolent act i.e. The Consumer Protection Act and has been passed in order to safeguard the consumers from the unscrupulous service providers. 

    

8]       The OPs in their reply in Para No.8 have admitted the factum about the disclosure qua alcohol consumption and also tentatively mentioned amount to be released in the two claims raised after making deductions, which is also not justified and has not legal basis. 

 

9]       Taking into consideration the above discussion and findings, we are of the opinion that the OPs have wrongly repudiated the genuine claims of the complainants and hence remained deficient in their service.  Therefore, the present complaint is allowed against OPs No.1 to 3 with direction to reimburse an amount of Rs.4,54,322/- to the complainants along with interest @9% p.a. from the date of final repudiation i.e. 30.11.2020 till the date of payment.  The OPs No.1 to 3 are also directed to pay compensation amount of Rs.50,000/- to the complainants for causing harassment& agony due to their deficient service, along with litigation cost of Rs.20,000/-.

         This order shall be complied with by the OP No.1 to 3 within a period of 45 days from the date of receipt of copy of this order, failing which they shall be liable to pay additional cost of Rs.15000/- apart from above relief.

         Certified copy of this order be sent to the parties, free of charge. After compliance, file be consigned to record room.

Announced

30^th November, 2022                                                     sd/-

(PRITI MALHOTRA)

PRESIDING MEMBER

 

Sd/-

 (S.K.SARDANA)

MEMBER