Haryana

Sonipat

294/2014

SUMAN W/O RANVINDER KUMAR - Complainant(s)

Versus

1. THE MANAGER STAR HEALTH AND ALLIED,2. DEEPAK KUMAR,3. THE MANAGER STAR HEALTH AND ALLIED INSURANC - Opp.Party(s)

VIKRAM DAHIYA

03 Aug 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

SONEPAT.

             

 

                             Complaint No.294 of 2014

                             Instituted on:07.11.2014

                             Date of order:26.08.2015

 

Suman widow of Ravinder Kumar son of Umed Singh r/o VPO Dipalpur, tehsil and distt. Sonepat.

…Complainant.       

Versus

 

1.The Manager, Star Health and Allied Ins. Co. Ltd., Pawan Plaza, IInd Floor, Subhash Chowk, Sonepat.

2.Deepak Kumar, Manager Mamta Financial Services, Vivekanand Chowk, near Hero Motors, Cudes Agency, Sonepat.

3.The Manager, Star Health and Allied Insurance Co. Ltd., New Delhi office at Civil Lines, New Delhi.

                                                …Respondents.

 

COMPLAINT UNDER SECTION 12 OF

THE CONSUMER PROTECTION ACT,1986

 

Argued by: Sh. Satish Chander, Advocate for Complainant.

           Sh. RK Panchal, Advocate for respondent no.1 and 3.

           Sh. Rajvir Malik, Adv. for respondent no.2.

 

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 her husband Ravinder Kumar had purchased a policy under Family Health Option Insurance Policy as per terms and conditions that in case of any treatment of insured, the respondent shall bear the expenses of such treatment upto Rs.2,30,000/-.   Said Ravinder Kumar was admitted in Saroj Hospital w.e.f. 2.6.2014 to 16.6.2014 and spent mort-than Rs.2,30,000/- on his treatment. But unfortunately the said Ravinder Kumar had expired on 2.8.2014.  During the life time, the said Ravinder has submitted all the documents and original bills to the respondents for claiming Rs.2,30,000/-. But the respondents wrongly and illegally repudiated the claim of the complainant and that amounts to a grave deficiency in service on the part of the respondents.

2.        The respondents no.1,2 and 3 appeared and they filed their separate written statement.

          The respondents no.1 and 3 in their written statement has submitted that the claim of the complainant for an half hour on 2.6.2014 to 16.6.2014 is not covered and other claims were scrutinized and whatever was payable has been paid to the complainant and after scrutinizing the claim records, it was observed that the present ailment of the insured is due to complication of alcohol consumption.  Hence, the respondents no.1 and 3 have denied the cashless authorization.  So, the complainant is not entitled to get the compensation from the respondents.

          The respondent no.2 in his written statement has submitted that the complainant never submitted the bills and documents of the respondent no.2.  The complainant also never approached the respondent no.2 for settlement of the claim. So, there is no deficiency in service on the part of the respondent no.2.

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

4.        Learned counsel for the respondent no.1 and 3 has argued that the claim of the complainant for an half hour on 2.6.2014 to 16.6.2014 is not covered and other claims were scrutinized and whatever was payable has been paid to the complainant and after scrutinizing the claim records, it was observed that the present ailment of the insured is due to complication of alcohol consumption.  Hence, the respondents no.1 and 3 have denied the cashless authorization.  So, the complainant is not entitled to get the compensation from the respondents and thus, prayed for the dismissal of the present complaint.

          But we find no force in the contentions raised by the ld. Counsel for the respondents no.1 and 3 because in the history or past history or in the family history or in the investigation, it was found that the deceased was not alcoholic.  Initially when the deceased Ravinder Kumar was admitted, there was question mark regarding Alcoholic.   There is no specific report of any doctor to prove that the deceased was alcoholic in any manner.

          We have perused the document C5 very carefully.  This is an e-mail sent by Star Health and Allied to Ravinder Kumar (since deceased).  It is mentioned in this e-mail which is reproduced below:-

          “It is observed from the medical records, the insured patient is a case of decompensated liver disease-ethanol related, hepatic encephalopathy, UGI bleed and grade 2 esophageal varices with red sign, endoscopic, variceal ligatioon done. Lab investigations show panchytopenia, hyperbiliri hypoalbuminemia and A/G reversal. All these features show that the insured patient was treated for a complication due to use of alcohol. 

          The perusal of this e-mail shows that there was a presumption that the patient was treated for a complication due to use of alcohol.  But there is no specific report of any lab or any specific report of any doctor to prove that the insured patient was treated for a complication due to use of alcohol.  Accordingly, it is held that the respondents no.1 and 3 have wrongly and illegally repudiated the claim of the complainant.  Thus, we hereby direct the respondents no.1 and 3 to make the payment of Rs.2,30,000/- (Rs.two lacs thirty thousands) 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.  The present complaint with these observations, findings and directions 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 26.8.2015.