Haryana

StateCommission

A/458/2016

RELIGEAR HEALTH INSURANCE CO.LTD. - Complainant(s)

Versus

ARPAN DHAWAN - Opp.Party(s)

P.M.GOYAL

09 Feb 2018

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

 

 

 

 

                                                          First Appeal No  :      458 of 2016

Date of Institution:     23.05.2016

Date of Decision :      09.02.2018

 

 

Religare Health Insurance Company Limited, FF 311 G, First Floor, Sushant Shopping Arcade, Sushant Lok, Gurgaon-122001 through Ms. Ramnique Sachar, Manager (Legal), Religare Health Insurance Company Limited, D-3,District Centre, New Delhi-110017

                                      Appellant-Opposite Party No.1

 

Versus

 

 

1.      Arpan Dhawan son of Sh. Arun Kumar Dhawan, at present working in Indusind Bank, 3^rd Floor, Tower 10-B, DLF Cyber City, Gurgaon.

Respondent-Complainant

 

2.      Medanta, The Medicity Hospital, Rajeev Chowk, Gurgaon through its Authorized Person/Signatory.

                                      Respondent-Opposite Party No.2

 

 

 

 

 

 

 

 

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Shri Balbir Singh, Judicial Member       

                            

 

 

 

Argued by:          Shri Hitender Kansal, Advocate for appellant

                             Shri Nitesh Singhi, Advocate for the respondent No.1-complainant

                             Shri B.S. Dogra, Advocate for the respondent No.2

                            

 

                                                   O R D E R

 

NAWAB SINGH J.(ORAL)

 

          Arpan Dhawan-complainant purchased health insurance policy for himself, his wife and two children on December 07^th, 2013 from Religare Health Insurance Company Limited (Insurance Company).  One of his son Nevaan Dhawan born on August 28^th, 2013 fell sick and was admitted in Max Healthcare Super Specialty Hospital, Delhi on January 08^th, 2014 and was discharged on January 17^th, 2014.  He was diagnosed as a known case of congenital nephrosis with acute febrile illness with excessive cry, Sepsis, Meningitis.  He spent about Rs.5.00 lac on the treatment of the child.  He filed claim before the Insurance Company but the same was repudiated on the ground that child was not insured with the disease, he suffered. 

2.                Complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 before the District Consumer Forum.

3.                District Consumer Forum vide impugned order dated April 11^th, 2016 allowed the complaint and directed the Insurance Company to pay Rs.5.00 lacs alongwith interest at the rate of 9% from the date of filing of the complaint, that is, August 28^th, 2014 till realization; Rs.30,000/- as compensation and Rs.3100/- litigation expenses to the complainant.

4.                Aggrieved of the order, Insurance Company has filed the present appeal.

5.                Learned counsel for the Insurance Company has urged that the complainant was not entitled to the expenses incurred by him on the treatment of his son in view of clause 4.3 xi) of the insurance policy, which reads as under:-

                   “Treatment of any congenital anomaly or illness of defects or anomalies or treatment relating to birth defects would not be admissible.”

6.                This Commission does not concur with the submission raised by learned counsel for the Insurance Company.  The son of complainant was born on August 28^th, 2013.  The insurance policy was purchased on December 03^rd, 2013. The complainant had specifically disclosed at time of purchase of the insurance policy that his son was having kidney problem for the last two months, that is, from the month of October 2013.  So, it cannot be termed as any defects relating to birth defects. There is no evidence on record to prove that the disease for which the complainant was admitted in the hospital was by birth. In this view of the matter, the District Forum has rightly allowed the complaint.  Thus, the impugned order does not call for any interference. The appeal is dismissed.

7.      The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

 

Announced 09.02.2018

(Balbir Singh) Judicial Member

(Nawab Singh) President

UK