GURBAX SINGH & ANR SON OF LATE KARTAR SINGH Vs. STAR HEALTH AND ALLIED INSURANCE COMPANY LTD & 3 ORS

JUDGEMENT

(1.) Brief facts are that the complainants, Gurbax Singh and his wife, Harvinder Kaur, bought, Senior Citizen Red Carpet Insurance Policy, from the Star Health & Allied Insurance Company Ltd. (OPs1 & 2), having coverage of, Rs.2,00,000/- each on 18-05-2008. The premium of Rs.9,500/- each was paid. The policy was renewed from time to time upto 20-05-2013. The Complainant no.2, Harvinder Kaur, had fallen in the bath room at her residence and suffered hair-line fracture in her wrist, for which she took treatment from a local doctor. Thereafter, in the month of December, 2011, she felt slight pain in her right shoulder. It was diagnosed as Frozen Shoulder. She had consulted five to six doctors and took treatment. The pain did not subside, therefore, MRI of right shoulder was conducted. It was diagnosed as Rotator Cuff Tear/Right Shoulder Impingement Syndrome/ Acromio-Clavicular Joint Arthiritis Right Shoulder. The surgery was advised to her, whereupon, she got admitted in Max Super Speciality Hospital at Mohali on 24-05-2012 and was operated on the next day. She was discharged from the hospital on 29-05-2012. She had incurred Rs.1,82,960.96/- as expenses towards her treatment. The complainant submitted claim form to OPs along with the discharge summary, bills, etc., but, the OPs vide letter dated 21-07-2012 repudiated the claim on the ground that complainant no.2 had been a known case of Parkinsonism since 2006. It was not disclosed by her at the time of filling the proposal form. Thus, it amounted to concealment/non-disclosure of the material fact. Moreover, OP-1 & 2 had cancelled the mediclaim policy of complainant no.2 and refunded the premium amount of Rs.9,500/-. Thus, the complainants alleged that the acts of the OPs amounted to deficiency in service and also an unfair trade practice. Therefore, the complainants filed a complaint before the District Consumer Disputes Redressal Forum, II, Chandigarh (for short "the District Forum").

(2.) The OPs 1 to 3 filed their joint written version and denied any illegality in the repudiation of the claim. The OPs submitted that at the time of inception of the policy, the complainants did not disclose in the proposal form that Harvinder Kaur had been suffering from Parkinsonism since 2006, and she was under treatment for the same. As per medical record of Dr. Bhatia's Clinic, on 31-10-2011, she was taken to the said Clinic, after alleged fall in bathroom. She suffered fracture of lower end of radius and was treated conservatively by applying the POP sling. In the prescriptions, it was also mentioned as "Parkinsonism +". Harvinder Kaur had also taken treatment at Silver Oak Hospital, Mohali on 25-03-2012 for 'Right Shoulder Pain with Limitation'. In the medical record, the treating doctor at Silver Oak Hospital, Dr. Amit Singh had clearly mentioned as "Parkinsonism 2+" i.e. she was suffering from Parkinsonism since 2006. Thus, complainant no.2 had concealed the material fact, while filling the proposal form. The claim of complainant no.2 was rightly rejected under condition no.7 of the terms & conditions of the policy. The Max Hospital (OP-4) filed their written statement and submitted that, OP-4 was nowhere concerned with the repudiation of the claim. OP-4 admitted that the complainant no.2 was charged Rs.1,82,950/- towards medical expenses.

(3.) On the basis of the pleadings and evidence, the District Forum allowed the complaint against OPs 1 to 3 and dismissed the complaint qua OP 4. The OPs 1 to 3 were directed jointly and severally to pay 70% of Rs.1,82,960/-, the amount claimed, alongwith Rs.35,000/- to the complainant as compensation and Rs.10,000/- as cost of litigation.