Chandigarh

DF-II

CC/26/2020

Siraj Uddin Ahmed - 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	:	26 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, which were duly acknowledged by the OPs vide e-mail dated 07.12.2018 as Claim No.CLI/2019/211100/0326317. Copy of the discharge summaries are annexed with the complaint as Annexure C-5 & C-6 and copy of e-mail dated 07.12.2018 is 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. Withholding of the claim of the complainant without any reasonable cause and without sending any intimation to the complainant by the OPs amounts to deficiency in service. Hence, this complaint has been filed by the complainant with a prayer to direct the OPs to settle the claim of the complainant and reimburse an amount of Rs.80,000/- to him incurred on the treatment of his daughter during policy period along with interest and 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 at PGI for amounting to Rs.53,791/-. Thereafter, a Medical Team scrutinized the claim documents and observed that some addition documents, i.e. a letter from treating doctor stating the duration of presenting illness; original affidavit/age proof; history of similar illness in the past for which consulted, complete set of indoor case papers with OT notes and USG report, are required to further process the claim and same were raised from the complainant vide letter dated 18.12.2018. The OPs also sent reminder letters dated 02.01.2019 and 17.01.2019 to the insured requesting him to submit the aforesaid documents but insured failed to submit any reply of the letters. Copies of letters dated 18.12.2018, 02.01.2019 and 17.01.2019 are annexed with the written version as Annexure R-8 (colly). Hence, the claim of the complainant was rejected and communicated vide letter dated 01.02.2019 (Annexure R-9). 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-2) valid w.e.f. 27.01.2018 to 26.01.2019 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. PGIMER, Chandigarh 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 and again she was admitted in the PGIMER, Chandigarh from 07.09.2018 to 12.09.2018 for her treatment as is also evident from Discharge Summary Annexure C-5 & C-6(colly) and the complainant had lodged the claim with the OPs by submitting the medical bills and other related documents. The reimbursement claim of the complainant was rejected by the OPs vide rejection letter dated 01.02.2019 (Annexure R-9) on the ground of non-submission of additional documents by the complainant.

7]       The main issue involved in the present complaint is, whether ‘Rejection 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]       The complainant has specifically stated that though the relevant documents, i.e. Receipts; Medicines Bills and Dr. Prescriptions; Investigation Reports-Lab Reports; Hospital Final Bill and Hospital Discharge Summary, were supplied to the OPs on 07.12.2018, which were duly acknowledged by the OPs vide e-mail dated 07.12.2018 (Annexure C-7), 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 requested to update the same in their record and as such the OPs cannot be allowed to harass the complainant by compelling him to produce the documents same of which were already delivered to OPs and which are not in possession. Despite having the said documents, rejecting the reimbursement claim of the complainant by OPs cannot held to be justified.

 

9]       It is the duty of the OP Insurance Company/their investigating officers to collect the documents required to determine the authenticity of the claim, in case, they are not satisfied with the documents so furnished by the complainant but they failed to do so. The complainant should not be harassed by the OPs by demanding unnecessary documents which are not in his possession. No doubt, the OPs have rejected the claim of the complainant due to non-submission of documents i.e. a letter from treating doctor stating the duration of presenting illness; original affidavit/age proof; history of similar illness in the past for which consulted; complete set of indoor case papers with OT notes and USG report but OPs have neither summoned the concerned record nor examined the concerned doctor before this Commission to prove the same. In nutshell, OPs failed to discharge its burden of proof.

10]      Reliance has been placed on the judgement of Hon’ble Apex Court in ‘Mahakali Sujatha vs. Branch Manager, Future Generali India Life Insurance Co. Ltd.’ II (2024) CPJ 66 (SC) and the relevant portion of the same reads as under:-

“50. …… The cardinal principle of burden of proof in the law of evidence is that “he who asserts must prove”, which means that if the respondents herein had asserted that the insured had already taken fifteen more policies, then it was incumbent on them to prove this fact by leading necessary evidence. The onus cannot be shifted on the appellant to deal with issues that have merely been alleged by the respondents, without producing any evidence to support that allegation………. A fact has to be duly proved as per the Evidence Act, 1872 and the burden to prove a fact rests upon the person asserting such a fact………”

 

11]      Though the OPs have rejected the claim of the complainant on the ground of non-submission of documents but they have also taken plea in the written version that insured patient has been suffering from HbH Disease since 2008 with Anemia which is prior to inception of the first insurance policy but the insured has failed to disclose this pre existing disease in the proposal form which amounts to misrepresentation/non-disclosure of material facts and accordingly OPs rightly repudiated the claim of the complainant as per the terms & conditions of the Insurance Policy. So far as the said ground of OPs i.e. insured patient was suffering from pre existing disease, 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”

12]      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 PGIMER, Chandigarh from 20.08.2018 to 28.08.2018 for treatment of Acute Febrile Illness with Systemic Sepsis, Acute Gall Stone Pancreatitis with Acute Hemolysis and Respiratory Failure and she underwent Splenecetomy Surgery on 21.08.2018 and again she had admitted in the PGIMER from 07.09.2018 to 12.09.2018 for her treatment 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 month of August-September 2018, making further clear that the OPs have wrongly misinterpreted the exclusion clause of the policy schedule. 

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]      In the present complaint, OPs failed to prove on file that the documents supplied by the complainant were insufficient to settle the reimbursement claim of the complainant. Hence, OPs are wrong for asking the additional documents which are not in possession with the complainant and wrongly rejected his claim.

15]      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.

16]      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”

 

17]      In view of the above discussion, it can be safely concluded that the act of OPs/Insurer in rejecting the genuine claim of the complainant is not only wrong and arbitrary but also certainly amounts to deficiency in service on their part. The complaint of the complainant is partly allowed. OPs are directed to pay the claim amount of Rs.53,791/- (i.e. the amount claimed by complainant in Claim Form Annexure R-5) to the complainant along with interest @ 6% per annum from the date of rejecting the claim of the complainant i.e. 01.02.2019 till the date of its actual realization.

 

    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.

 

18]      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