Delhi

East Delhi

CC/190/2014

MANI RAM - Complainant(s)

Versus

STAR HEALTH - Opp.Party(s)

07 Feb 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 190/2014

 

	MANI RAM S/O LATE SH.BABU RAM R/O RAJ BUILDING MATERIALS, RAJ MARKET, PARGATI VIHAR, KHODA COLONY, NEAR C.R.P.F.CAMP, MAYUR VIHAR PHASE-III, DELHI-110096	….Complainant
Versus
1	M/S STAR HEALTH AND ALLIED HEALTH INSURANCE COMPANY LTD, 20FF AT: 1 NEW TANK STREET VALLUVAR KOTTAM, HIGH ROAD NUNGAMBAKKAM, CHANNAI-600034 THROUGH ITS DIRECTOR	……OP1
2	M/S STAR HEALTH AND ALLIED HEALTH INSURANCE COMPANY LTD, OFF AT: LAXMI DEEP BUILDING, LAXMI NAGAR DISTRICT CENTRE, DELHI-110092 THROUGH ITS DIRECTOR.	……OP2

 

Date of Institution: 19.02.2014

Judgment Reserved on: 01.02.2023

Judgment Passed on: 07.02.2023

                  

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms. Rashmi Bansal (Member)

 

Order By: Sh. Ravi Kumar (Member)

 

 

JUDGEMENT

1. The Complainant has filed complaint against OPs for deficiency of service in not settling his medical claim upon his hospitalization. 

The Complainant in his complaint has stated that he is having Medical Policy of OP since 2008 and which continued and the Policy no.P/161111/012013/000964 was valid from 29.05.2012 to mid night of 28.05.2013 and at the time of insurance it was assured by the OP that in case of any expenses incurred in the medical treatment the same may be reimbursed.  The Complainant suffered Coronary Artery Disease (CAD) and was admitted in Metro Hospital and Heart Institute, Noida on 29.03.2013 and remained admitted there till 05.04.2013 and he was given Medical treatment there and a bill of Rs.350000/- was raised by the Hospital which he paid after borrowing from his relatives and thereafter he raised claim along with supporting original documents before the OP on 24.04.2013 but the same was not approved.  He served legal notice also on the OP which was vaguely replied by OP1 but OP2 did not reply to the said notice.  He has made following prayer in his complaint:

• To direct the opposite parties to make the payment for a sum of Rs.3,50,000/- as hospital expenses and monitory loss and huge expenses of medical bills to complainant with interest @ 12% up to the realization of the payment.
• To direct the opposite parties to make payment for a sum of Rs.15,00,000/- in favour of complainant and against the OPs as damages, compensation for harassment and mental agony.
• To direct the opposite parties to make the payment of a sum of Rs.20,000/-as cost of the Litigation in favour of the complainant against the OPs and
• Pass any other order/orders as deemed fit and proper under the circumstances of the case in favour of the complainant and against the Ops in the interest of justice.

2. OP1 and OP2 have filed joint reply thereby denying the contentions raised by the complainant in his complaint and have stated that complaint has taken Family Health Optima Insurance Policy vide Policy No. P/161111/01/2013/000964 for the period 29.05.2012 to 28.05.2013 covering the complainant and his wife for sum assured of Rs.200000/-.  The Complainant was admitted in the Metro Hospital and Heart Institute, Noida on 29.03.2013 and submitted pre-authorization request from the treating hospital however the OP denied the cashless authorization in the first instance on the ground of non-disclosure of the past medical history of MI (Myocardial Infraction) from 2002 when he had PTCA with stenting of LAD done on 22.11.2002 which was prior to the inception of policy.  It is vital information of past medical history of the Complainant and it was obligatory on the part of complainant to disclose and was a condition precedent for the adequate risk assessment by the insurance company before finalizing his insurance policy.  The non-disclosure or the mis-representation of material facts in the policy form would not only misguide the insurer but also render the insurance contract (Policy) between the insurer and insured ‘void ab-initio’.  In view of the same the cashless authorization was denied on 04.04.2013.
3. The OP had also relied upon the judgment of Hon’ble Supreme Court in the case PC Chacko and Anr. Vs. Chairman Life Insurance Corporation of India and Ors. (2008) 1 SCC 321 wherein Hon’ble Supreme Court upheld repudiation of the contract of insurance on the ground of non-disclosure and mis-statement in the proposal form to the various questions to which the answer was given by the insured.  As per condition No.7 of the Insurance Policy ‘if there is any mis-representation/ non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim’

The Complainant has not come with clean hands and suppressed the material facts from this Forum therefore he is not entitled for any relief.  The OP has relied upon several other judgments of Hon’ble NCDRC inter alia Satish Kumar Vs. Branch Manager LIC (Revision Petition No.4678 of 2009) and also AIR 1962 Supreme Court 814 and 2006 ACJ 34. 

The OP have filed the following documents along with their Written Statement as follows:

• A copy of the proposal from is annexed herewith and marked as ANEXURE-OP2.
• A copy of the policy is annexed herewith and marked as ANNEXURE-OP3. 

4. The Complainant has not filed Rejoinder to the Written Statement and has filed his evidence by way of affidavit wherein he has marked the documents as follows:

- Bills and Claim Form - Exhibit PW-1/A. 

- Hospital expenses of Rs.3,50,000/- bill dated 05.04.2013 – Exhibit A.    

- Legal Notice dated 05.12.2013 - Exhibit PW-1/B.

5. OP has also filed their evidence by way of affidavit wherein they have marked following documents as exhibit:

-Copy of the letter dated 02.04.2013 - Exhibit OP-1/A. 

OPs have also filed additional documents vide their application dated 03.08.2018 as follows:

• Discharge Summary year 2013
• Proposal Form
• Discharge Summary 2002

6. This Commission has heard the arguments of both sides and has perused the documents on record. 

The controversy in the case pertains to non settling of the Medical claim of the complainant despite of his having medical insurance since 2008 which continued during the relevant period upto 2013, when the complainant was admitted in the Metro Hospital and Heart Institute on 29.03.2013 where he underwent treatment for retrosternal chest pain.  The ECG showed fully evolved anteroseptal MI and his coronary angiography was done on 30.03.2013 which revealed double vessel disease and on 03.04.2013 angioplasty was done.  The complainant request for cashless authorization was rejected by the OP on 04.04.2013 (Annexure OP1) on the ground that in the ‘Proposal Form’ - heart disease has not been disclosed and when the complainant raised the final claim before the OP then the same was repudiated on 30.10.2013 on the following ground: 

‘We have perused the claim records relating to the above insured-patient sent to us seeking reimbursement of hospitalization expenses for treatment of CAD.

 

Our medical team has observed from the discharge summary of the above hospital, the Insured patient is an old case of Mi from 2002 and had PTCA done prior to Inception of medical insurance policy.

 

At the time of inception of your first policy which is from 22/MAY/2008 to 21/MAY/2009, you have not disclosed the above mentioned medical history/health details of the insured-person which amounts to misrepresentation/non-disclosure of material facts.

 

As per Condition No.7 of the policy issued to you. If there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim.

 

We, therefore, regret our inability to admit your claim under the above policy and we hereby repudiate your claim.

 

As per Condition 11, the policy is also liable to be cancelled.’

 

In the Proposal Form submitted by the complainant he has replied in negative to the query - ‘medical history- has the proposed person suffered from any disease/ illness irrespective of whether hospitalized or not or sustained any accident? if yes, give details. 

In another query in the proposal form as to whether the proposed person in the last three years had other information relating or outpatient for surgery and any other information relating to health status of the person proposed/ family history of any diseases/ conditions. 

To all these questions the reply was in negative from the complainant’s side. 

Further, from the document marked as Annexure to the Written Statement which is Discharge Summary of the previous treatment taken by the complainant in the year 2002 which reveals that complainant suffered from coronary artery (single vessel) disease (CAD) with anterior wall MI and he underwent Angioplasty on 22.11.2002.  This was a material information which complainant withheld from OP while submitting his proposal form and he did not say anything about his previous medical history of Angioplasty he had undergone in 2002. 

The complainant has relied upon two judgments of Hon’ble NCDRC – Trilok Chand Khanna Vs. United India Insurance Co. (Revision Petition No. 686 of 2007) and LIC Vs. Smt. Priya Sharma (Revision Petition No. 2615 of 2011).  Both these judgments are not para materia to the facts in the present case. 

Availing of insurance benefit is subject to the basic requirement of good faith from both sides.  The complainant was supposed to reveal his medical condition particularly in relation with the heart treatment he had undergone in 2002 by way of Angioplasty.  The OP in their Written Statement had raised this objection very prominently that the complainant has not come to this Forum with clean hands and he with held material information from the OP.  To this objection no Rejoinder/ denial has been made by the complainant and his stand is that once he had taken the Policy for continuous five years then he was entitled for reimbursement of medical expenses.  This stand of the complainant is untenable and while applying for the insurance he should have given all material information including the Angioplasty done in 2002 however he did not do so and hence there is breach of good faith from his side and he cannot take benefit of his own wrong.  The OP has relied upon condition No.7 of the Policy which states that in case the relevant information is not given then the company is not liable to make any payment in respect of any claim. 

In view of the above, this Commission is of the opinion that the complainant has failed to establish deficiency on the part of OPs and therefore the complaint is dismissed. 

Copy of the order be supplied / sent to the parties free of cost as per rules.     

File be consigned to Record Room.

Announced on 07.02.2023