Chandigarh

DF-II

CC/25/2020

Siraj Uddin Admed - Complainant(s)

Versus

Star Health & Allied Insurance Company Limited - Opp.Party(s)

Adv. Pushpinder Kaushal

18 Dec 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	25 of 2020
Date  of  Institution	:	13.01.2020
Date   of   Decision	:	18.12.2024

 

 

 

 

Siraj Uddin Ahmad, aged about 42 years, r/o House No.639, Ground Floor, Sector 69, Tehsil & District SAS Nagar, Mohali-160062.

             … … … Complainant

 

Versus

 

1.  Star Health & Allied Insurance Company Limited through its Director, Registered & Corporate Office 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034.

2.  Star Health & Allied Insurance Company Limited, through its Branch Manager, Area Office SCO No.5A, 2^nd Floor, Madhya Marg, Sector 7-C Chandigarh.

   … … … Opposite Parties

BEFORE:  MR.AMRINDER SINGH SIDHU,       PRESIDENT

                MR.B.M.SHARMA,                 MEMBER

                               

Argued by:    Sh.Subash Chand, Advocate Proxy for Sh.Pushpinder Kaushal, Counsel for Complainant.

Sh.Satpal Dhamija, Counsel for Opposite Parties(OPs).

 

 

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

 

1]       The complainant has filed the present complaint pleading that he had taken Medi-Claim Policy i.e. Star Comprehensive Insurance Policy from OPs on 27.01.2014, which was renewed from time to time and lastly it was renewed on 22.01.2019 by paying a premium of Rs.27,116/-, for the period 27.01.2019 to 26.01.2020. Copies of the policies are annexed with the complaint as Annexure C-1 to C-3. The policy covered the family members of the complainant i.e. his wife Nishat Parveen, daughter Lubna Siraj, daughter Rida Siraj and son Ayan Ahmed. It is alleged that after taking the policy in the year 2014, the complainant vide letter dated 21.03.2014 (Annexure C-4) duly informed the OPs that his daughters Lubna Siraj and Rida Siraj are suffering from Anemia since 2007 and through this letter made a request to the OPs to update the same in their record.

 

    It is pleaded that the elder daughter of the complainant Lubna Siraj was got admitted in PGIMER on 20.08.2018 for treatment of Acute Febrile Illness with Systemic Sepsis, Acute Gall Stone Pancreatitis with Acute Hemolysis and Respiratory Failure. She underwent Splenecetomy Surgery on 21.08.2018 and discharged on 28.08.2018. Again daughter of the complainant had to get admitted in the PGIMER, Chandigarh from 07.09.2018 to 12.09.2018 for her treatment and in this regard, the complainant brought into the notice of the OPs about her treatment and raised his claim by submitting the bills & other related documents with the OPs, as treatment of the daughter of the complainant was covered under the policy of the OPs. Copy of the discharge summaries are annexed with the complaint as Annexure C-5 & C-6. The documents were acknowledged by the OPs vide e-mail dated 07.12.2018 (Annexure C-7). Vide letter dated 18.12.2018 (Annexure C-8), further documents were demanded from the complainant, which were duly submitted but since the date of submission of documents, no communication was made or received by the complainant.

 

     It is further pleaded that again the daughter of the complainant Lubna Siraj was to get admitted in Max Super Specialty Hospital, Phase 6, Mohali, Punjab, from 11.11.2019 to 18.11.2019 for treatment of AFI with Systemic Sepsis with Gall Stone Pancreatitis and in this regard, the complainant had spent an amount of Rs.2,71,299/- and submitted his claim with the OPs which was duly acknowledged by them vide e-mail dated 28.11.2019 as Claim No.CLI/2020/211100/0637875. Copies of the bill are annexed with the complaint as Annexure C-9(colly) and copy of e-mail dated 28.11.2019 is Annexure C-10. The complainant was shocked upon receiving the e-mail dated 11.12.2019 (Annexure C-11) vide which the complainant was informed by the OPs the repudiation of the claim of the complainant on the pretext that complainant has not disclosed the medical history/health details of the insured-person in the proposal form which amounts to misrepresentation/non-disclosure of material facts and as per Condition No.9 of the Policy, the OP Insurance Company is not liable to make any payment in respect of any claim. Even vide letter dated 19.12.2019 (Annexure C-12), the OPs in a totally arbitrary and unlawful manner deleted the name of Lubna Siraj from the coverage w.e.f. 28.12.2019 due to non disclosure of pre existing disease. Alleging the aforesaid act amounts to deficiency in service on the part of OPs, the complainant has filed the present consumer complaint with a prayer to direct the OPs to reimburse the claim amount of Rs.2,71,299/- along with interest, to include the name of Lubna Siraj (insured) in the coverage, to pay compensation for mental agony & harassment and cost of litigation expenses.   

 

2]       The OPs in their written version have stated that insured had submitted the claim documents for reimbursement of claim expenses for hospitalization for amounting to Rs.2,80,000/-. Thereafter, a Medical Team of the answering OPs scrutinized the claim documents and observed that patient was hospitalized for the treatment of Acute Febrile Illness with Systemic Sepsis, Acute Gall Stone Pancreatitis with Acute Hemolysis and Respiratory Failure. It is observed from the discharge summary of PGIMER, Chandigarh, for the admission on 20.08.2018 submitted during cashless processing that the insured patient is a known case of HbH (Hemoglobin H Disease) Disease from the year 2008 with Anaemia which is prior to inception of the first medical insurance policy. It is stated that at the time of inception of first year policy from 27.01.2014 to 26.01.2015, insured has not disclosed the above mentioned medical history/health details of the insured-patient in the proposal form which amounts to misrepresentation/non-disclosure of material facts. It is stated that as per Condition No.9 of the Policy, if there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the OP company is not liable to make any payment in respect of any claim. Hence, the claim of the complainant was rightly repudiated as per the terms and conditions of the Insurance Policy. Denying any deficiency in service as well as all other allegations, the OPs have prayed for dismissal of the complaint.

 

3]       Replication has also been filed by the complainant controverting the assertions of OPs as made in their written version.

 

4]       Parties led evidence in support of their contention.

 

5]       We have heard the learned counsels for the parties and have gone through entire documents on record.

 

6]       It is an admitted case of the parties that the subject policy was purchased by the complainant first time on 27.01.2014, regarding which reference has also been made in the subject policy (Annexure C-1) valid w.e.f. 27.01.2019 to 26.01.2020 covering the complainant, his wife Nishat Parveen, his daughters Lubna Siraj (insured patient) & Rida Siraj and Son Ayam Ahmed. The insured patient Lubna Siraj was admitted in the treating hospital i.e. Max Super Speciality Hospital, Phase 6, Mohali, on 11.11.2019 for treatment of AFI with Systemic Sepsis with Gall Stone Pancreatitis and was discharged on 18.11.2019 as is also evident from Discharge Summary Annexure R-10 and the treating hospital raised the bill and the complainant had lodged the claim with the OPs for the medical bill raised by the treating hospital to the tune of Rs.2,71,299/- and the said claim of the complainant was repudiated by the OPs vide repudiation letter dated 11.12.2019 (Annexure R-12) on the ground of that insured patient is a known case of HbH (Hemoglobin H Disease) Disease from the year 2008 with Anaemia which is prior to inception of the first medical insurance policy from 27.01.2014 to 26.01.2015 and insured has not disclosed the above mentioned medical history/health details of the insured-patient in the proposal form which amounts to misrepresentation/non-disclosure of material facts and as per Condition No.9 of the Policy, if there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the OP company is not liable to make any payment in respect of any claim. Not only this, vide letter dated 19.12.2019 (Annexure C-12), the OPs arbitrarily and illegally deleted the name of Lubna Siraj (Insured Person covered under the policy) from the coverage w.e.f. 28.12.2019 due to non disclosure of Pre Existing Disease.

 

7]       The main issue involved in the present complaint is, whether ‘Repudiation Letter’ issued by OPs to the complainant is valid & legal or not?

 

         In order to find answer to this question, the following facts and circumstances alongwith relevant law are necessary to be discussed:-

 

8]       In the back drop of the foregoing admitted and disputed facts on record, it is clear that the entire case of the parties is revolving around the terms and conditions of the policy, medical record having been relied upon by the complainant and the repudiation letter Annexure R-12 and the same are required to be studied carefully to determine the real controversy between the parties.

9]       Perusal of the Policy Terms and Conditions at Page 6 (Annexure R-1) clearly indicates that in case of pre-existing disease to the insured patient, expenses related to treatment of such disease be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy. The relevant portion of the same is reproduced as under:-

                    “3. EXCLUSIONS

The Company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of,

Applicable for Sections 1 to 6

1.  Pre Existing Diseases as defined in the policy until 48 consecutive months of continuous coverage has elapsed, since inception of the first policy with any Indian Insurer”

10]     Thus, one thing is clear from the documents, having been relied upon by both the parties in the present case, that the insured patient had admitted in Max Super Specialty Hospital, Phase 6, Mohali from 11.11.2019 to 18.11.2019 for treatment of AFI with Systemic Sepsis with Gall Stone Pancreatitis and since as per the policy schedule the said medical expenses are not covered for four years from the date of inception of the subject policy i.e. 27.01.2014 till 27.01.2018, the claim of the complainant does not fall under the aforesaid exclusion clause of the subject policy as the present treatment was taken by the insured patient in the year 2019, making further clear that the OPs have wrongly misinterpreted the exclusion clause of the policy schedule and thereby repudiated the claim of the complainant.

11]     Also, it is imperative to mention here that the OPs have denied the present claim of the complainant by violating the terms and conditions of their own policy which clearly defines the term "pre-existing disease" which proves the fact that the OPs are only laying trap for the poor and gullible consumers to sell their product and once they are in their net they start wriggling out from their obligations. Thus, the act of OPs firstly by repudiating the genuine claim of the complainant and then deleted the name of insured person Lubna Siraj from the coverage amounts to deficiency in service and indulgence in unfair trade practice.

12]      It is also imperative to mention here that when the complainant, vide his letter dated 21.03.2014 (Annexure C-4), duly informed the OPs about the disease of her minor daughters, it is the duty of the OPs to take step in this regard i.e. either to update their record or to cancel the policy & not to continue with the policy or called any document from the complainant, which the OPs have not done. Rather the OPs have been continuously renewing the policy after receipt of the premium from the complainant and upon arisen of the claim, to raise dispute qua non-disclosure of the pre existing disease certainly amounts to deficiency in service.

13]      Further, it has been held by Hon’ble State Consumer Disputes Redressal Commission, U.T. Chandigarh in complaint titled as SBI General Insurance Company Limited Vs. Balwinder Singh Jolly 2016(4) CLT 372 that if Insurance company failed to conduct thorough (Medical) check up of the policy holder (at the time of issuance of the policy) then Insurance company has no right to decline the insurance claim on non disclosure of the facts of pre existing disease when the policy was taken.

14]      Not only this, it is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sorts of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims.

15]      In similar set of facts the Hon’ble Punjab & Haryana High Court, Chandigarh in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others, 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

16]      In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is partly allowed and the OPs are directed as under:-

i)  OPs are directed to pay claim amount of Rs.2,71,299/- to the complainant along with interest @ 6% per annum from the date of repudiation of the claim as per Annexure R-12 i.e. 11.12.2019 till the date of its actual realization.

ii) OPs are directed to include the name of Lubna Siraj (insured) in the coverage till the validity of the policy.

    The above said order shall be complied with by the OPs within a period of 45 days from the date of receipt of certified copy of this order.

17]      The pending application(s) if any, stands disposed of accordingly.

        The Office is directed to send certified copy of this order to the parties, free of cost, as per Rules under The Consumer Protection Rules, 2020. After compliance file be consigned to record room.

Announced

18.12.2024                                                               

Sd/-

 (AMRINDER SINGH SIDHU)

PRESIDENT

 

Sd/-

 (B.M.SHARMA)

MEMBER

as