Haryana

Ambala

CC/69/2018

Ankush Aggarwal - Complainant(s)

Versus

Cigna TTK Health Insurance Co Ltd - Opp.Party(s)

23 Jul 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                          Complaint case no.        : 69 of 2018.

                                                          Date of Institution         : 27.02.2018.

                                                          Date of decision   : 23.07.2018.

 

Ankush Aggarwal s/o Sh.Anil Aggarwal r/o 3703/3, Aggarwal Bhawan, Cross Road No.1 Bengali Mohalla, Ambala Cantt.

……. Complainant.

 

1.Cigna TTK Health Insurance Company Limited, # 1^st Floor, SCO 149/150, Sector 9-C, next to Yes Bank, Madhya Marg, Chandigarh-160009.

2.Cigna TTK Health Insurance Company Ltd. 401/402, Raheja Titanium, Western Express Highway, Goregaon (east), Mumbai-400063.

 

….…. OPs.

 

 

BEFORE:   SH. D.N. ARORA, PRESIDENT

                   SH. PUSHPENDER KUMAR, MEMBER                   

                  

Present:       Sh.Rohit Mittal, counsel for complainant.

                   OPs exaprte.

                  

ORDER:

                   In nutshell, brief facts of the present complaint is that the complainant had obtained a medi-claim policy No.PROHLR050001869 from OP No.1 being a portable case having validity upto 28.07.2012 and was continuously in the 5^th year as the complainant had actually purchased cashless benefit claim policy in the year 2012 with Bajaj Allianz General Insurance Company and after that the complainant ported the above said policy to Religare Health Insurance  in the year 2013-14 valid from 26.07.2013 subsequently renewed on 31.07.2014, 29.08.2015 and thereafter the complainant ported the above said policy with OP No.1 having validity from 16.09.2016. The complainant suffered acute pain in urethra and was diagnosed with stone problem in left renal calculus & left Ureteric Calculus with Grade 1 Hydronephrosis Left Kidney on 14.02.2017 at Rajeev Ultrasound Centre.  The complainant visited the doctor at M.M. Hospital on 15.02.2017 and the doctor referred him to Mayo Healthcare Super Specialty Hospital on 16.02.2017 and got the treatment of stone problem. The complainant intimated the OP about the claim No.BLR-0517-CL-0010046 and had submitted the original bill of Mayo Hospital raised till 17.02.2017 to the tune of Rs.81,826/-  but the OPs rejected the claim of the complainant without any reason on 23.09.2017 with the ground that the ailment/procedure for which the claim is made as per USG report Left Renal Cortical Cyst and its complication UTI, Prostatitis and this disease / procedure excluded for two of year from the date of commencement of the policy. Hospitalization is within this waiting period and hence not admissible.  
The act and conduct of the OPs clearly amounts to deficiency in service on their part. In evidence the complainant has tendered affidavit Annexure CA and documents Annexure C1 to Annexure C29.  

2.                          Notices were sent to the OPs through registered post but none has turned up on their behalf, therefore, they were proceeded against exparte vide order dated 25.04.2018.

3.                          We have heard counsel for the complainant and carefully gone through the case file.

4.                          As per complainant the policy in question was ported with the OPs and the same was continue for the last 5 years and during the subsistence of the policy he felt ill and took treatment by spending Rs.90936/- Annexure C15 paid through Annexure C18, Annexure C19, Annexure C22, Annexure C14, Annexure C17, Annexure C20, Annexure C21, Annexure C10, Annexure C11 and  but the OPs have rejected the claim on the ground that ailment/procedure for which the claim is made as per USG report Left Renal Cortical Cyst and its complication UTI, Prostatitis and this disease / procedure excluded for two of year from the date of commencement of the policy. Hospitalization is within this waiting period and hence not admissible (Annexure C25). Perusal of Annexure C6 reveals that for Roll over/Portability cases continuous coverage will be considered from the first policy inception  date with use or other insurer (as applicable) .  This very document has been issued by the OPs but it is strange when the policy was agreed to be treated as continue from the first policy then how the repudiation letter Annexure C25 can be sustained rather this shows that how the OPs are bent upon the reject the genuine claim of the complainant. Even otherwise, the pleadings and contentions put forth by the complainant remained unrebutted as the opposite parties are exparte. So, we have no other option but to believe the version of the complainant. From the contents of the complaint, it is proved that complainant has been harassed by the opposite parties as they had failed to reimburse the amount for which the complainant had purchased the above said policy by paying the premium thereof.

5.                          In view of the above said factual position, this Forum concluded that the OPs have wrongly and illegally repudiated the claim of the complainant. Accordingly, this Forum has no hesitation to accept the present complaint with costs and direct the Ops to release the amount spent by the complainant amounting to Rs.90936/- alongwith interest 9 % per annum from the date of filing of complaint till its realization alongwith the costs which is assessed Rs.5,000/-. The compliance of the order be made within a period of 30 days. Copies of the order be sent to the parties concerned, free of costs, as per rules. File after due compliance be consigned to record room.

 

Announced on: 23.07.2018                         (D.N. ARORA)

                                                                         President

 

    

     (PUSHPENDER KUMAR)

                                                                          Member