Chandigarh

DF-II

CC/587/2015

Sunita Rani - Complainant(s)

Versus

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

Sandeep Bhardwaj,Adv

03 Apr 2017

ORDER

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

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Consumer Complaint  No	:	587 of 2015
Date  of  Institution	:	14.10.2015
Date   of   Decision	:	03.04.2017

 

 

 

 

Sunita Rani w/o Sh.Surinder Kumar Bansal, R/o Flat No.502, Block-D2, GH-79, Sandeep Vihar, Sector 20, Panchkula.     

             …..Complainant

Versus

M/s Star Health and Allied Insurance Co. Ltd., SCO 257, 2^nd Floor, Sector 44-C, Chandigarh, through its Manager/Authorised representative.

….. Opposite Party  

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

                                SH.RAVINDER SINGH              MEMBER 

 

Argued by: Sh.Sandeep Bhardwaj, Counsel for complainant.

            Sh.Gaurav Bhardwaj, Counsel for OP.

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          Briefly stated, the complainant took a health insurance policy namely “Family Health Optima Insurance Plan” from Opposite Party effective from 4.3.2015 to 3.3.2016 for a sum insured of Rs.5.00 lacs. It is averred that all the family members of the complainant were covered under the said policy and the complainant (being duly covered under the policy), at the time of filling the proposal form, disclosed about her being diabetic patient (Ann.C-1).  Unfortunately, the complainant all of a sudden got fever, abdomen pain and backache for which she was admitted to Alchemist Hospital, Panchkula, which was duly intimated to the Opposite Party Insurance Company. It is also averred that the complainant paid an amount of Rs.75,591/- for the said treatment and was discharged on 10.8.2015 (Ann.C-2 & C-3).  Thereafter, a claim was filed with Opposite Party for reimbursement of the expenses incurred for the treatment, which has been repudiated on the ground that the patient had undergone treatment for UTI and pyelonephritis, which are complications of diabetes mellitus (Ann.C-4).  It is submitted that the complainant got admitted in the Hospital due to fever, pain abdomen and backache and on evaluation she was diagnosed with the problem of UTI (Urinary Tract Infection) and Kidney Infection (pyelonephritis) and the same have no nexus with diabetes.  It is also submitted that the claim has been repudiated on false and flimsy grounds. Further submitted that the detailed terms & conditions of the policy were never supplied to the complainant. Alleging the repudiation of claim as illegal and claiming deficiency in service, this complaint has been filed.

 

2]       The Opposite Party has filed reply and while admitting the factual matrix of the case, stated that the complainant had already disclosed about her pre-existing disease in the proposal form and she knew that as per terms & conditions, pre-existing disease is not covered until 48 months period is over since the inception of first policy with the company.  It is stated that the medical literature on the subject clearly states that there is nexus between the UTI and diabetes mellitus (Ann.R-5 colly & R-6).  It is also stated that UTI is a complication arising out of diabetes mellitus type-2.  It is submitted that the urinary tract infection has direct nexus with diabetes mellitus, thus the claim was rightly repudiated after due application of mind and as per terms & conditions of the policy.  It is submitted that without admitting the liability under the policy, the maximum quantum of liability under the policy shall be Rs.68,956/-.  Pleading no deficiency in service and denying rest of the allegations, the complainant has prayed for dismissal of the complaint.

 

3]       Rejoinder has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of the Opposite Party in the reply.  

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the entire record.

 

6]       It is the case where the arbitrariness of the Opposite Party led to the filing of the present complaint due to repudiation of genuine claim raised by the complainant.  It is an admitted fact that the complainant is duly covered under the “Family Health Optima Insurance Plan” issued by Opposite Party, valid for the period from 4.3.2015 to 3.3.2016.  It is also an admitted fact that the complainant duly disclosed about her pre-existing disease at the time of filling the proposal form as she was Diabetic patient at the time of availing the insurance policy from the OP. 

 

7]       Further, it is not disputed that the complainant when suffered from fever, abdomen pain and backache, got admitted at Alchemist Hospital, Panchkula, where she was diagnosed as a case of Acute Right Pyelonephritis and Urinary Tract Infection and got treatment there and was discharged on 10.8.2015.  While repudiating the claim of the complainant raised against the expenditure incurred in the said treatment, Opposite Party claimed that the treatment undergone for UTI (Urinary Tract Infection) and pyelonephritis are the complications of Diabetic Mellitus and as per the exclusion clause NO.1 of the policy, the Opposite Party is not liable to pay expenditure for the treatment for any pre-existing disease/condition until 48 months of continuous cover has elapsed since inception of the policy. This ground of repudiation is altogether absurd and is not corroborated by any authentic expert opinion in this regard.  The Opposite Party though placed on record an extract from internet regarding UTI and pyelonephritis, but in our view, the information, relied upon by the Opposite Party, has not come from any expert in the medical field, hence the same cannot be relied upon.  There is also no direct evidence to prove that the complainant suffered UTI & pyelonephritis due to the fact that the complainant is suffering from Diabetes Mellitus. It is evident from the Discharge Summary (Ann.C-2) that the complainant has not underwent any treatment for Diabetes Mellitus, so the Opposite Party is totally wrong in denying the claim of the complainant, which is not related with any pre-existing disease i.e. Diabetes Mellitus. Hence, the deficiency in service on the part of Opposite Party is proved.

 

8]       Pertinent to mention that the Opposite Party in its reply submitted that maximum quantum of liability, if any, shall be Rs.68,956/- but failed to explain the reason for deduction of rest of the amount.  Hence, its plea in that regard is not acceptable.

 

9]       In view of the above discussion, the present complaint deserves to be allowed and the same is accordingly allowed. The Opposite Party is directed as under ;-

1. To reimburse an amount of Rs.75,591/- to the complainant, incurred by her on the treatment during policy period, along with interest @9% p.a. from the date of repudiation of the claim i.e. 11.9.2015 till actual payment;
2. To pay a sum of Rs.10,000/- as compensation to the complainants on account of mental tension, agony, harassment suffered due to deficient services of the OP.
3. To pay Rs.7,000/- as litigation expenses.

         This order shall be complied with by the Opposite Party within one month from the date of receipt of its certified copy, failing which, it shall also be liable to pay interest @9% p.a. on the amount as at sub-para [b] above from the date of filing this complaint, till its realization, apart from complying with directions as at sub-para [a] & [c] above.

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

Announced

3^rd April, 2017               

                                                                                      Sd/-

                                                                               (RAJAN DEWAN)

                                                                                         PRESIDENT

 

                                                                                                                     

                                                                                                Sd/-                                                                              (PRITI MALHOTRA)

                                                                                      MEMBER

 

Sd/-

 

(RAVINDER SINGH)

MEMBER