| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 22 of 22-01-2020 Decided on : 30-08-2022 Shiv Kumar aged about 42 years S/o Ruldu Ram, R/o H.No.172-A/1, Mandir Wali Gali, Rampura Phul, Tehsil Phul, Bathinda. ...........Complainant Versus Star Health & Allied Insurance Company Limited, No.15, Sri Balaji Complex, 1st floor, Whites Lane, Roy Apettah, Chennai-600014 through its Managing Director/Chairman. Star Health & Allied Insurance Company Limited, Branch Office at SCO-133, 2nd floor, Above TATA Motor Finance, Near Hotel Sweet Milan, Goniana Road, Bathinda through its Branch Manager/Incharge.
..........Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh.Kanwar Sandeep Singh, President Smt. Paramjeet Kaur, Member Present : For the complainant : Sh. Ritesh Singla, Advocate. For opposite parties : Sh.Vinod Garg, Advocate. ORDER Kanwar Sandeep Singh, President : The complainant Shiv Kumar (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against Star Health & Allied Insurance Company Limited and another (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that complainant had purchased family health policy of IFFCO TOKIO General Insurance Co. for the period of 26.08.2016 to 25.08.2017 which was got renewed by the complainant for the period from 26.08.2017 to 25.08.2018 and thereafter from 26.8.2018 to 25.8.2019 on payment of the requisite premium. Under the said Family Health Policy, the complainant, his wife Poonam and unmarried children Geetika-daughter and Yogesh-Son were covered. It is alleged that in the month of August 2019, the insurance advisor of the opposite parties approached the complainant and he allured the complainant to purchase Family Health Policy of the opposite parties and bonafidely believing the tall claims made by the authorized representative/agent of the opposite parties, the complainant agreed to purchase the policy of the opposite parties and the complainant was also assured the earlier policy of the complainant shall be got transferred/ ported with the opposite parties. The complainant bonafidely agreed for the same and purchased Insurance policy No. P/211217/01/2020/001378 for the period from 26.8.2019 to 25.8.2020 with the reference of previous policy NO.52990551 of IFFCO TOKIO Gen. Insurance Co. Ltd. Inception date 26.8.2016. The opposite parties also issued identity cards in the name of the complainant, his wife and children having Customer ID No.11974509-1 to 4 and the waiting period of 30 days was also waived keeping in view the pre-existing policy and date of inception 26.8.2016. It is alleged that Geetika daughter of the complainant fell ill on 28.8.2019 due to severe throat infection and was taken to Dr. Arsh in Neeraj Nursing Home where the attending doctor noticed that pulse rate of Geetika was low. He suggested to consult some Heart Specialist. Thereafter Geetika was taken to the hospital of Dr. Sharad Gupta in Pulse Hospital, Bathinda who did T.P.I. The complainant spent Rs.24,890.00 in Pulse Hospital and the said doctor suggested the complainant to immediately take the patient Geetika to Hero DMC, Ludhiana. The complainant then arranged an Ambulance by spending Rs.6,000/- and took-his daughter to Hero DMC, Ludhiana on 28.8.2019 itself. After clinical tests and T.P.I. on 30.8.2019, the daughter of the complainant was diagnosed to be a case of complete heart block and was advised for PPI. The complainant informed the opposite parties about the same and requested for providing cashless treatment to his daughter but the opposite parties rejected the cashless treatment. The complainant spent the amount of treatment of his daughter from his pocket and PPI was done on 3.9.2019. The daughter of the complainant was discharged from the hospital on 7.9.2019. The complainant spent a sum of Rs.3,44,145/- in Hero DMC, Ludhiana, Rs.24,890.00 in Pulse Hospital, Bathinda and Rs.6,000/- for ambulance i.e. total Rs.3,75,035/- It is further alleged that the complainant then lodged insurance claim of Rs.3,75,035/- with the opposite parties for reimbursement and furnished all the requisite documents, but the opposite parties repudiated the lawful claim of the complainant vide letter dated 30.10.2019 with the observation : "It is observed from the discharge summary of the above hospital that the insured patient is symptomatic of the above disease for the past 3 days; the ECG report dated 28.8.2019 shows chronic, longstanding changes. Based on these findings, our medical team is of the opinion that the insured patient has heart disease prior to our policy". The complainant alleged that the opposite parties have illegally and arbitrarily repudiated the lawful claim of the complainant although the daughter of the complainant was not suffering from any alleged ailment or heart problem prior to the date of the purchase of the policy or on the date of the purchase of policy. She had no previous heart problem or disease and she was also not taking any treatment for any heart problem in the past. Further more, the complainant was regularly taking Family Health Insurance Policy for the last three years and took the policy from IFFCO TOKIO General Insurance Co. Ltd., in year 2016-17, 2017-18, 2018-19 and the reference of the policy for the year 2018-19 also finds mentioned in the policy issued by the opposite parties. The complainant repeatedly approached the opposite parties and requested them to reimburse the aforesaid amount of insurance claim, but to no effect and ultimately, they refused to pay any amount of insurance claim to the complainant. Due to the abovesaid illegal acts of the opposite parties, the family of the complainant suffered from great mental tension, agony, botheration, harassment and humiliation and huge financial losses for which he claims compensation to the tune of Rs.1,00,000/-. On this backdrop of facts, the complainant has prayed for directions to opposite parties to pay insurance claim of Rs.3,75,035/- in addition to Rs. 1,00,000/- as compensation besides Rs. 22,000/- as litigation expenses. Upon notice, the opposite parties put an appearance through counsel and contested the complaint by filing joint written reply. In written reply, the opposite parties raised legal objections that intricate questions or law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under the 'Act' and that complainant has no locus standi to file the complaint as Geeta is major and complaint could only be file by her. It has been pleaded that the complainant has concealed material facts and documents from this Commission as well as from the opposite parties. The complainant has not disclosed material facts and there is major misrepresentation of facts regarding past health history. Complainant has availed FAMILY HEALTH OPTIMA Insurance Plan. Policy No. P/211217/01/2020/001378 for the period 26/08/2019 to 25/08/2020. The terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. 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. It has been further pleaded that the claim is reported in the 2nd day of the policy vide claim no. CLI/2020/211217/0388228. As per Pre Authorization request for cashless treatment, the insured/daughter of the complainant Miss Geetika was diagnosed for the Complete Heart Block and raised pre authorization request for cashless treatment and same was denied vide letter dated 29.08.2019 stating that the insured patient was diagnosed for Complete Heart Block, further evaluation is required to as certain the exact onset of the illness/disease. As per the discharge summary dated 28/08/2019, the insured has symptoms since 3 days. As per report dated 28/08/2019, it shows chronic, longstanding. Based on these findings, it is noted that the insured patient has heart disease prior to our policy and the same was not disclosed. At the time of inception of the said policy, which is from 26.08.2019 to 25.08.2020, the insured has not disclosed the above mentioned medical history/health details of the insured-person in the proposal form which amounts to misrepresentation/ non-disclosure of material facts. Hence the claim of insured is repudiated and the same was communicated to the insured vide letter dated 30/10/2019. It has also been pleaded that in proposal, declaration given by the complainant/proposer/Insured forms the basis of the contract between the Proposer and the Company. The complainant in the proposal form has affirmed that the complainant and his wife was in good health and that he has not consulted or taken treatment. The insured has omitted to disclose the material facts at the time of porting of policy, which amount to non-disclosure of material facts. On merits, the opposite parties have reiterated their version as pleaded in legal objections and detailed above. After controverting all other averments of the complainant, the opposite parties prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his Affidavit dated 22.01.2020 (Ex.C-1) and the documents (Ex. C-2 to Ex. C-24). In order to rebut the evidence of complainant, the opposite parties have tendered into evidence affidavit of Rajiv Jain dated 13-03-2020 (Ex.OP-1/14) and the documents (Ex. OP-1/1 to Ex. OP-1/13) The learned counsel for the parties reiterated their version as pleaded in their respective pleadings. We have heard learned counsel for parties and gone through the record. In nut-shell, the case of the complainant is that he purchased Health Insurance Policy for himself and his family from Iffco Tokio General Insurance Company Limited. since 26-8-2016 and subsequently got it renewed till 25-8-2019 i.e. Policy was continuous for three years. Thereafter in the 4th year, complainant got renewed/ported the said policy with the opposite parties vide Family Health Optima Insurance Plan bearing No. P/211217/01/2020/001378 for the period from 26-8-2019 to 25-8-2020 (Ex. C-4). The daughter of complainant Miss Geetika suffered some problem on 28-8-2019 and she remained admitted in Hero DMC, Ludhiana from 28-8-2019 to 07-09-2019. The opposite parties neither approved/allowed cashless treatment nor reimbursed the expenses incurred by complainant rather repudiated the claim of the complainant vide letter dated 30-10-2019 (Ex. C-24) on the ground that :- “We have processed the claim records relating to the above insured – patient seeking reimbursement of hospitalization expenses for treatment of complete heart break. It is observed from the discharge summary of the above hospital that the insured patient is symptomatic of the above disease for the past 3 days; the ECG report dated 28-8-2019 shows chornic, longstanding changes. Based on these findings, our medical team is of the opinion that the insured patient has heart disease prior to our policy.” The opposite parties in para No. 3 of legal objections have admitted that policy in question is a ported policy. Ex. C-4 is the policy in question. A perusal of this document reveals that Geetika dependant child of complainant is insured and date of inception of insurance is 26-08-2016. This policy further reveals Continuity benefit of First year Exclusion is not applicable and First Two Year Exclusion is waived. Therefore, when the opposite parties themselves have declared/admitted inception of policy/coverage since 26-8-2016, and first two year exclusion stands waived, then logic/reason behind denial of insurance claim to insured Ms Geetika is not understandable. The plea of the opposite parties is that the complainant has not disclosed pre-existing disease of Ms Geetika as according to discharge summary dated 28-8-2019, the insured has symptoms since 3 days, thus, insured has heart disease prior to policy. The opposite parties have not placed on file any evidence to prove that prior to 28-8-2019, Ms Geetika was ever treated for any disease/heart problem. Morever, date of inception of policy in question is 26-8-2016. Therefore, contention of the opposite parties that Ms Geetika was suffering from heart disease prior to issuance of policy, is not tenable. Insurance Regulatory and Development Authority (IRDA) vide circular “ Ref No. IRDA/HLTH/MISC/CIR/216/09/2011 Dated 20-09-2011 directed All life insurers and non-life insurers : “The Insurers' decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policy holders losing confidence in the insurance industry, giving rise to excessive litigation.” Keeping in view the evidence placed on file by the parties, this Commission is of the considered opinion that there is deficiency in service on the part of the opposite parties in rejecting the genuine claim of the complainant without any solid ground. Resultantly, this complaint is partly allowed with Rs.10,000/- as cost and compensation against the opposite parties. The opposite parties are directed to pay insurance claim as per bills submitted by complainant keeping in view limitation under the policy (Ex. C-9). with interest @ 8% p.a. w.e.f. 30-10-2019 (date of repudiation) till realization. The compliance of this order be made by opposite parties jointly and severally within 45 days from the date of receipt of copy of this order. The complaint could not be decided within statutory period due to Covid pandemic and heavy pendency of cases. Copy of order be supplied to parties free of cost as per law. File be consigned to record room.
Announced : 30-08-2022 (Kanwar Sandeep Singh) President (Paramjeet Kaur) Member
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