Haryana

Sonipat

10/2015

NEELAM BAGGA W/O SHARVAN KUMAR BAGGA - Complainant(s)

Versus

1. STAR HEALTH AND ALLIED INS. CO. LTD.,2. STAR HEALTH AND ALLIED INS. CO.,3. MAMTA FINANCIAL SERVIC - Opp.Party(s)

Naveen Ranga

09 Sep 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

SONEPAT.

             

 

                             Complaint No.10 of 2015

                             Instituted on:12.01.2015

                             Date of order:07.10.2015

Neelam Bagga wife of Sharvan Kumar Bagga, r/o H.No.307, Sector 13, Urban Estate, Sonepat.

…Complainant.       

Versus

 

1.Star Health and Allied Ins. Co. Ltd.,  Registered and Corp. office 1, New Tank Street, Valluvar Kottam High road, Nungambakkam, Chennai-600034 through its Managing Director.

2.Star Health and Allied Ins. Co. Ltd., Branch office plot no.4, 3^rd floor, B Block Community Centre, Janakpuri, New Delhi-58, through its Manager/Authorized person.

3.Mamta Financial Services, Green Crescent road, Near Hero  Showroom, Opp. Sector 14, Sonepat through its Prop/Manager.

 

                                                …Respondents.

 

COMPLAINT UNDER SECTION 12 OF

THE CONSUMER PROTECTION ACT,1986

 

Argued by: Sh. Naveen Ranga, Advocate for Complainant.

           Sh. Surender Malik Adv. for respondent no.1 and 2.

           Sh. Vishal Khapra, Adv. for respondent no.3.

           (Defence of respondent no.3 struck off on 26.8.2015)

 

Before-    Nagender Singh-President. 

          Prabha Wati-Member.

          D.V. Rathi-Member.

 

O R D E R

 

          The complainant has filed the present complaint against the respondents alleging therein that family health optima insurance policy no.P/161118/01/2014/002217 was issued in the name of her husband Shri Sharvan Kumar Bagga w.e.f. 30.6.2013 to 29.6.2014.  In the month of Jan, 2014, the complainant consulted the specialists from Fortis Hospital  who suggested surgical procedure.  The complainant was admitted in Fortis Hospital Shalimar Bagh, Delhi on 24.1.2014 and surgery was done on 25.1.2014 and the complainant was discharged on 27.1.2014.  The complainant has spent an amount of Rs.3,51,300/- on her treatment.  The complainant intimated the respondents and completed all the required formalities by submitting all the documents.  But to the surprise of the complainant, the respondents rejected the claim of the complainant . The complainant requested the respondents to consider the essential certificate issued by the Fortis Hospital regarding the surgery and treatment of the complainant, wherein it is specifically mentioned that the Bariatric Surgery is potentially lifesaving surgery and is not a cosmetic surgery.  But the respondents failed to put their reliance upon the said certificate and that amounts to a grave deficiency in service on the part of the respondents. So, she has come to this Forum and has filed the present complaint.

2.        The respondents no.1 and 2 has only filed their written statement, whereas no reply was filed by the respondent no.3 and due to this, respondent’s no.3 defence was struck off vide order dated 26.08.2015.       

          The respondents no.1 and 2 in their written statement has submitted that the treatment and operation of the complainant falls in the category of cosmetic surgery for obesity and weight control and does not fall in the life saving surgery as the complainant got bariatric and metabolic surgery to get reduce her weight and to stop for further increasing of her weight. The said surgery of bariatric and metabolic is not for control of diabetes.  The essential certificate dated 29.1.2014 is a result of collusion between the doctor and the complainant.  The claim of the complainant was rightly rejected since the claim of the complainant does not fall within the policy/scheme of the respondents and does not cover the medi claim policy and thus, prayed for the dismissal of the present complaint since the complainant is not entitled for any relief and there is also no deficiency in service on the part of the respondents no.1 and 2.

3.        We have heard learned counsel for both the parties at length and have also gone through the entire relevant records available on the case file very carefully.

4.        Learned counsel for the complainant has submitted that the respondents wrongly and illegally rejected the claim of the complainant.  The complainant has spent an amount of Rs.3,51,300/- on her treatment. But to the surprise of the complainant, the respondents rejected the claim of the complainant. The complainant requested the respondents to consider the essential certificate issued by the Fortis Hospital regarding the surgery and treatment of the complainant, wherein it is specifically mentioned that the Bariatric Surgery is potentially lifesaving surgery and is not a cosmetic surgery.  But the respondents failed to put their reliance upon the said certificate and that amounts to a grave deficiency in service on the part of the respondents.

          On the other hand, ld. Counsel for the respondents no.1 and 2 has submitted that the treatment and operation of the complainant falls in the category of cosmetic surgery for obesity and weight control and does not fall in the life saving surgery as the complainant got bariatric and metabolic surgery to get reduce her weight and to stop for further increasing of her weight. The said surgery of bariatric and metabolic is not for control of diabetes.  The essential certificate dated 29.1.2014 is a result of collusion between the doctor and the complainant.  The claim of the complainant was rightly rejected since the claim of the complainant does not fall within the policy/scheme of the respondents and does not cover the medi claim policy and thus, prayed for the dismissal of the present complaint since the complainant is not entitled for any relief and there is also no deficiency in service on the part of the respondents no.1 and 2.

          Now the main question arises for consideration before this Forum is that whether the complainant is entitled for any relief against the respondents or not?

          We have perused the document Annexure D i.e. Essential Certificate dated 29.1.2014 issued by Dr Atul N.C. Peters, Fortis Hospital, Shalimar Bagh, Delhi wherein it is mentioned that –

          “ This is to certify that Neelam Bagga, 43 years old lady is a case of hypertension, diabetes mellitus, joint pains, backacke, snoring, acidity, reflux, depression and with morbid obesity (BMI 34.9 kg/m2) and had been admitted in Fortis Hospital for Laparoscopic Gastric Byepass, a surgical procedure for treating morbid obesity.

          Morbid obesity is a serious disease that may be associated with severe complications many of which are life threatening.  It is now accepted worldwide that the best treatment option for morbid obesity is Bariatric Surgery, wherein Laparoscopic Gastric Bypass is a potentiality life saving surgery and not a cosmetic surgery and help in treating the diseases as mentioned above. It is currently accepted as the only permanent available cure for morbid obesity”.

          So, after hearing both the learned counsel for the parties at length and after going through the entire relevant material available on the case file very carefully, we have come to the conclusion that definitely the complainant is entitled to get the claim amount from the respondent no.1 and 2 because we find the repudiation of the claim of the complainant to be wrong and unjustified.  Thus, we hereby direct the respondents no.1 and 2 to make the payment of Rs.3,51,000/-  to the complainant alongwith interest at the rate of 09% per annum from the date of filing of the present complaint till realization.

          With these observations, findings and directions, the present complaint stands allowed qua respondents no.1 and 2.

          Certified copy  of this order be provided to both the parties free of costs.

          File be consigned after due compliance.

 

 

(Prabha Wati)        (DV Rathi)           (Nagender Singh)                    Member, DCDRF,             Member, DCDRF        President, DCDRF,

Sonepat.             Sonepat.             Sonepat.

 

ANNOUNCED- 07.10.2015.