Haryana

Sonipat

CC/163/2015

AJAY PAL S/O AJIT SINGH - Complainant(s)

Versus

1. THE MANAGER STAR HEALTH AND ALIIED INSURANCE CO. LTD. - Opp.Party(s)

PARVEEN KAUSHIK

17 Sep 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

SONEPAT.

             

 

                             Complaint No.163 of 2015

                             Instituted on:15.05.2015

                             Date of order:17.09.2015

 

Ajay Pal son of Ajit Singh, r/o H.No.712, Village Khubru, tehsil Ganaur, distt. Sonepat.

…Complainant.       

Versus

 

1.The Manager, Star Health and Allied Ins. Co. Ltd., City Centre, IInd Floor, Above Reliance General Ins. GT road, Panipat.

2.Star Health and Allied Ins. Co. Ltd., 1 New Tak Street, Valluvarkottam High road, Chennai-600034 through its General Manager.

                                                …Respondents.

 

COMPLAINT UNDER SECTION 12 OF

THE CONSUMER PROTECTION ACT,1986

 

Argued by: Sh. Parveen Kaushik, Advocate for Complainant.

           Sh. Surender Malik, Advocate for respondents.

 

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 he took a health insurance cashless policy valid upto 15.4.2015 from the respondents and unfortunately on 19.8.2014, the complainant fall and received twisting injury on his right knee.   The complainant was got admitted in St. Stephen’s Hospital, Delhi where his right knee was operated . The complainant informed the respondents in this regard and lodged the claim, but the respondents did not make the payment of the treatment.  The complainant has made the payment of Rs.82117/- to the said hospital. The complainant again felt pain and swelling on his right knee and MRI was conducted upon him on 13.3.2015 and he again admitted on 1.4.2015 in the said hospital where his right knee was again reoperated.  The complainant again made the payment of Rs.41583/- to the said hospital.  But both the claims have been declined by the respondent insurance company and that amounts to a grave deficiency in service on the part of the respondent. So, he has come to this Forum and has filed the present complaint.

2.        In reply, the respondents have submitted that  the complainant has lodged a false claim with the respondents.  The complainant has not disclosed about the pre-existing disease in the proposal form at the time of inception of the policy.  As per the report of MRI, there is no evidence of joint effusion.  Hence it is not an acute injury.   However, there is evidence of chondral injury and para meniscal cyst which are evident of chronic chances.   Hence, the claim of the complainant was rightly repudiated vide letter dated 20.10.2014. The complainant is not entitled to even a single penny from the respondents since there is no deficiency in service on the part of the respondents and thus, prayed for the dismissal of the present complaint.

3.        Both the parties have been heard.  All the documents have been perused very carefully and minutely.

4.        Learned counsel for the respondents has argued that the complainant has lodged a false claim with the respondents.  The complainant has not disclosed about the pre-existing disease in the proposal form at the time of inception of the policy.  As per the report of MRI, there is no evidence of joint effusion.  Hence it is not an acute injury.   However, there is evidence of chondral injury and para meniscal cyst which are evident of chronic chances.   Hence, the claim of the complainant was rightly repudiated vide letter dated 20.10.2014. The complainant is not entitled to even a single penny from the respondents since there is no deficiency in service on the part of the respondents.

          In the present case, the respondents have not disputed the issuance of policy and medical treatment taken by the complainant during the validity of the insurance policy.  But their stand is that the complainant has not disclosed about the pre-existing disease in the proposal form at the time of inception of the policy.  But in our view, since the complainant has obtained the health insurance policy from the respondents and he has taken the treatment from the hospital during the validity of the insurance policy, so definitely the respondents are liable to make the payment of the amount which he has incurred on his treatment.  As per the complainant, he has incurred Rs.82117/- and Rs.41583/- on his treatment and when he lodged the claims with the respondents, both his claims were declined by the respondents and they repudiated the claims of the complainant wrongly and illegally.  In our view,  the complainant has been able to prove the deficiency in service on the part of the respondents. Thus, we hereby direct the respondents to make the payment of Rs.123700/- (Rs.82117 + 41583=123700/-) to the complainant within a period of one month from the date of passing of this order, failing which, the above said amount shall fetch interest at the rate of 09% per annum from the date of passing of this order till realization.

          With these observations, findings and directions, the present complaint stands allowed.

          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 17.09.2015.