Chandigarh

DF-I

CC/564/2015

Mr Naveen Kumar Singla - Complainant(s)

Versus

M/s Star Health and Allied Insurance Co. Ltd. - Opp.Party(s)

Polly Shera

09 Feb 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

============

Consumer Complaint  No	:	CC/564/2015
Date  of  Institution	:	24/08/2015
Date   of   Decision	:	09/02/2016

 

 

 

 

 

 

Naveen Kumar Singla son of Shri Vinod Kumar, resident of House No. 4414/A, Sector 46-D, Chandigarh.

 

…......... Complainant.

Vs

 

M/s Star Health and Allied Insurance Company Limited, SCO 130-131, 4^th Floor, Sector 34-A, Chandigarh.

 

…........ Opposite Party

 

BEFORE:   MRS. SURJEET KAUR            PRESIDING MEMBER

          SH. SURESH KUMAR SARDANA     MEMBER

 

For Complainant	:	Sh. Polly Shera, Advocate.
For Opposite Party	:	Sh. Gaurav Bhardwaj, Advocate.

 

PER SURESH KUMAR SARDANA, MEMBER

 

 

          Succinctly put, the Complainant had purchased one medical insurance policy from Opposite Party vide Policy No.P/700002/01/2015/001140 on 12.04.2014 (C-1) and got the same renewed on 12.04.2015 for a further period of one year i.e. from 15.04.2015 to 14.04.2016 (Annexure C-2). As per terms of the said insurance policy the Complainant was allowed the benefit of medical reimbursement for a sum of Rs.2,00,000/- on hospitalization by the Opposite Party. Unfortunately, on 22.05.2015 the Complainant met with an accident and fell down from his bike injuring himself. Initially, he was taken to Govt. Medical College & Hospital, Sector 32, Chandigarh. However, due to lack of medical staff and facilities there, the parents of the Complainant shifted him to Eden Hospital, Industrial Area, Phase-I, Chandigarh which is an approved hospital of the Opposite Party for cashless treatment. The Doctors at the Eden Hospital advised the Complainant that a MRI of the Lumber Spine was required to be done. The MRI was done and as per the MRI report though there was no fracture in the vertebrae or dislocation detected there was a definite injury to the spine and also swelling due to injury to the spine which needed hospitalization and immediate treatment. The Complainant underwent treatment as per the advice and diagnosis of the doctors at Eden Hospital who have in unequivocal terms stated in the diagnostic report that the injury and swelling sustained by the Complainant was due to the accident and have not attributed the same to be a previously present ailment. The claim of the Complainant was forwarded by the Eden Hospital to the Opposite Party for approval and reimbursement. However, when the Opposite Party chose to ignore the medial diagnosis, opinion of concerned doctors to repudiate the genuine claim of the Complainant, a legal notice dated 20.07.2015 (Annexure C-4) was served upon the Opposite Party, but the same failed to yield the desired results. Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Party, the complainant has filed the instant complaint.

 

2.      Notice of the complaint was sent to Opposite Party seeking its version of the case.

 

3.      Opposite Party, in its reply, while admitting the factual aspects of the case, has asserted that the claim of the Complainant was repudiated by the Opposite Party, after due application of mind, and as per policy terms and conditions as the Complainant has misrepresented and suppressed the material fact about the exact cause of the disease. It has been pleaded that the disease of the Complainant has specifically been excluded as per Exclusion No.3(f) of the Policy. It has been urged that the MRI report is very clear “The impression is ‘Lumbar Myospasm’. Minimal posterior bulge is seen at L4-5 with mild spinal canal stenosis (shorter Pedicle). No obvious nerve root impediment is seen”. It means that the pain is non-traumatic in origin. The same is due to degenerative lumbar disc disease. Denying all other allegations and stating that there is no deficiency in service on its part, Opposite Party have prayed for dismissal of the complaint.

 

4.      The Complainant also filed rejoinder wherein the averments as contained in the complaint have been reiterated and those as alleged in the written statement by the Opposite Party have been controverted.

 

5.      Parties were permitted to place their respective evidence on record in support of their contentions.

 

6.      We have heard the learned Counsel for the parties and have also perused the record, with utmost care and circumspection. 

 

7.      The claim of the Complainant was repudiated by the Opposite Party vide letter dated 09.06.2015 (Annexure R-5) as per the Exclusion No.3(f) of the Policy, which is as under:-

 

“3.  EXCLUSIONS:

The Complainant shall not be liable to make any payments under this Policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of:

1.   xxxxx xxxxx xxxxx xxxxx xxx

2.   xxxxx xxxxx xxxxx xxxxx xxx

3.   During the First two years of continuous operation of insurance cover,

a.   xxxxx xxxxx xxxxx xxxxx xxx

b.   xxxxx xxxxx xxxxx xxxxx xxx

c.   xxxxx xxxxx xxxxx xxxxx xxx

d.   xxxxx xxxxx xxxxx xxxxx xxx

e.   xxxxx xxxxx xxxxx xxxxx xxx

f.   Degenerative disc and vertebral diseases and degenerative diseases of the musculo-skeletal system.”

 

8.      We have also gone through the Certificate dated 26.5.2015 (Annexure C-7) issued by the attending Specialist Doctor of Eden Hospital, which in clear terms state that the Complainant came to emergency with sustaining injuries to left side of back on 22.5.2015 with severe pain and swelling in left flank, tenderness was also present.

 

9.      A conjunctive reading of the aforesaid shows that the treatment given to the Complainant was on account of his sustaining injuries and not due to degenerative lumber disc disease as projected by the Opposite Party while repudiating the claim of the Complainant. In this view of the matter, we are of the considered opinion that the Opposite Party was not justified in denying the well founded claim of the Complainant of the said ground.

 

10.      For the reasons recorded above, the present complaint of the Complainant deserves to succeed against the Opposite Party, and the same is allowed. The Opposite Party is directed:-

 

[a]  To release the claim amount of Rs.35,910/- spent by the Complainant on his treatment;

 

[b]  Pay Rs.25,000/- as compensation on account of deficiency in service and causing mental and physical harassment to the Complainant; 

 

[c] Pay Rs.15,000/- towards costs of litigation;

 

 

11.      The above said order shall be complied within 30 days of its receipt by the Opposite Party; thereafter, Opposite Party shall be liable for an interest @12% per annum on the amount mentioned in sub-paras [a] and [b] above from the date of institution of this complaint, till it is paid, apart from cost of litigation of Rs.15,000/-.  

 

12.      Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

09^th February, 2016                                            

Sd/-

(SURJEET KAUR)

PRESIDING MEMBER

 

Sd/-

(SURESH KUMAR SARDANA)                                                                                                      MEMBER