Haryana

Gurgaon

CC/185/2014

Kunwar Pal Singh - Complainant(s)

Versus

M/s Star Health - Opp.Party(s)

29 Jun 2016

ORDER

                                          DISTRICT   CONSUMER   DISPUTES   REDRESSAL FORUM, GURGAON-122001

                                                                                        Consumer Complaint No: 185 of 2014                                                                                                                               Date of Institution: 09.06.2014                                                                                                                                                          Date of Decision:  29.06.2016

Kunwar Pal Singh s/o Sh. Omkar Singh, R/o A-203, Saraswati Enclave, near Bharat Gas Godown, Pataudi Road, Gurgaon.

                                                                                                                                                                                                                         ……Complainant.

                                                Versus

M/s Star Health and Allied Insurance Company Ltd (service to be effected through ) Branch Office at 12, 13 and 14, Ground Floor, Ganpati Complex, Opposite Payal Cinema, Old Delhi Road, Gurgaon.

 

Sethi Hospital, 301/302/4, Model Town, Basai Road, Gurgaon through its authorized person/signatory.

 

 

Paras Hospital, C-1, Sushant Lok, Phase-I, Sector 43, Gurgaon through its authorized person/signatory.  

 

..Opposite parties

                                                                                               

Complaint under Sections 12 & 14 of Consumer Protection Act,1986                                                                  

 

BEFORE:     SHRI SUBHASH GOYAL, PRESIDENT

SMT JYOTI SIWACH, MEMBER

                   SH.SURENDER SINGH BALYAN, MEMBER.

 

Present:        Complainant in person

                    Shri Deepak Gupta, Adv for OP-1

                    OP-2 exparte

                    Shri Kapil Chaudhary, Sr. Executive for OP-3.

 

ORDER       SUBHASH GOYAL, PRESIDENT.

The case of the complainant, in brief, is that he was working with SRS Diecasting Pvt. Ltd, Gurgaon as a HOD Maintenance and the said company had taken group policy under the name and style of Group Mediclaim Tailormade Policy bearing No.P/16/1117/01/2013/004491 valid w.e.f. 21.01.2013 to 20.01.2014 and policy No.P/16/1117/01/2014/005383 valid w.e.f. 21.01.2014 to 20.01.2015 from the OP-1. At the time of taking the policy it was assured by the insurance company that all the expenses incurred by the insured on hospitalization etc shall be fully paid by the insurance company if the person is hospitalized in some particular hospitals which includes in the policy. The complainant was suffering from POTT’S SPINE CHOLELITHIASIS, ENTERIC FEVER and contacted OP-2 who advised for some necessary tests. After conducting the necessary tests he was admitted in OP-2 hospital on 19.11.2013 and was discharged on 22.11.2013 and the OP-2 has charged a sum  of Rs.21,522. The complainant was further admitted in OP-3 hosptial on 22.11.2013 and was discharged on 24.11.2013 and the OP-3 hospital has charged a sum of Rs.34,432/-. The complainant was again admitted in the hospital of OP-3 on 03.02.2014 and was discharged on 06.02.2014 where he spent Rs.75,127/- and thus, the complainant has incurred a total sum of Rs.1,31,081/- on account of treatment taken by him from OP-2 & OP-3 hospitals. Thereafter the complainant submitted the claim with OP-1 but the opposite party No.1 flatly refused to reimburse his claim which tantamounts to deficiency in service on its part. The complainant prayed that the opposite party No.1 be directed to reimburse the claim of the complainant with interest besides awarding compensation of Rs.50,000/- for harassment and mental agony.

2                 OP-1 in its written reply has alleged that complainant was admitted in Paras Hospital, Gurgaon on 03.02.2014 for the treatment of psoas abscess. It was observed from the medical records submitted for the admission on 22.11.2013 vide claim No.166399 that the present ailment for which the insured patient has undergone treatment is a complication of Pott’s Spine which is existing 11 months prior to the date of the said admission i.e. prior to the inception of the medical insurance policy. Hence the present  ailment of the above insured persons is  pre-existing disease. As per Exclusion Clause No.1 of the policy, the Company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease, until 48 months of continuous coverage has elapsed since inception of the first policy with the company. Hence the claim of the complainant was rightly repudiated by the insurance company and the same was communicated to the insured vide letter dated 03.05.2014. Thus, there was no deficiency in service on the part of opposite party no.1.

3                 However, OP-2 did not turn up before this Forum despite service and thus, was proceeded exparte vide order dated 19.09.2014.

4                 OP-3 in its written reply has alleged that the approval of claim was a matter between the insurance company and the complainant and the OP-3 has no role to get approved the claim of the complainant. However, the complainant has availed the services of the OP-3 and the OP-3 has charged for the same. Thus, there was no deficiency in service on the part of OP-3.

5                 We have heard the parties and have perused the record available on file carefully.

6                 Therefore, from the facts and circumstances of the case, evidence on the file and the arguments advanced by the parties, it emerges that the complainant has filed the present complaint against the OPs alleging deficiency in service on their part on the ground that he was insured with the OP-1 under mediclaim insurance policy obtained through his employer company  and during the subsistence of the insurance policy he fell ill and remained admitted in Sethi Hospital during the period from 19.11.2013 to 22.11.2013 and thereafter he remained admitted in Paras Hospital, Gurgaon during the period from 22.11.2013 to 24.11.2013 and from 03.02.2014 to 06.02.2014 and thus, he has incurred a total sum of Rs.1,31,081/- on his treatment during the above said periods. Accordingly, he submitted the claim with the OP-1 which was repudiated by the OP-1 on the ground that as per Exclusion Clause No.1 of the policy the insurance company was not liable to make any payment in respect of expenses for treatment of pre-existing disease until 48 months of continuous coverage has elapsed, since inception of the first with the company. The repudiation of the claim of the complainant was totally wrong and illegal.

8                 However, the contention of the OP is that the claim of the complainant was rightly repudiated by the opposite party as according to the discharge summary of Sethi Hospital, the insured patient was admitted with the complaints of pain in abdomen with distension of abdomen, recurrent vomiting, fever and breathlessness and the insured was earlier admitted in Komal Hospital with the complaints that the patient is bedridden, cannot stand walk since last 11 months due to old history of spine injury. The past treatment records were not submitted by the insured. MRI dated 21.11.2013 reveals features suggesting POTT’s spine with pre paravertebral fluid collection, compression over nerve roots. As such the complainant was having pre existing disease and as per Exclusion Clause 1 of the policy, the company was not liable to make any payment in respect of expenses for treatment of the pre-existing disease, until 48 months of continuous coverage has elapsed, since inception of the first policy with the company. Hence, the claim was repudiated rightly by the insurance company.

9                 Therefore, after going through the facts and circumstances of the case and the evidence placed on file it is evident that the complainant was insured with the OP-1 vide policy P/161211/01/2011/001874 which was valid from 24.01.2011 to 23.01.2012 showing the name of insured Kunwar Pal Singh and Guddi Devi  with IDV of Rs. 2 Lacs. The complainant has also produced on file the certificate of his employer in which the period of insurance was mentioned as under:

                   Period                                       Policy Number

          24.01.2011 to 23.01.2012          P/161211/01/2011/001874

          24.01.2012 to 23.01.2013          P/161211/01/2012/003208

          21.01.2013 to 20.01.2014          P/161117/01/2013/004491

          20.01.2014 to 20.01.2015          P/161117/01/2014/005383

          20.01.2015 to 19.01.2016          P/161117/01/2015/006761

 

It seems that the complainant was having insurance policy since 24.01.2011. However, the claim of the complainant was repudiated vide letter dated 30.12.2013 which reads as under :-

“Our medical team has observed from the investigation reports and hospital records including the discharge summary, the insured patient is symptomatic of back pain due to Pott’s spine for the past 11 months which is prior to inception of medical insurance policy. Hence the present ailment of the insured patient is a pre existing disease.”

“The team has pointed out that the insured patient is covered under the first medical policy from 21.01.2013 to 20.01.2014 and has undergone treatment for cholelithiasis during the first year of the policy”

From the above repudiation letter it is transpired that the complainant was having pre-existing disease 11 months prior to the inception of medical insurance policy i.e. from 21.01.2013 as shown by the opposite party despite the fact that the  complainant was insured with the OP-1 since 24.01.2011. If it is presumed that the complainant was having pre existing disease 11 months prior to 21.01.2013 then also the case of the complainant does not fall within the exclusion clause of the insurance policy as the complainant was insured with the OP-1 since 24.01.2011. Thus, at the time of taking of the insurance policy the complainant was having no pre-existing disease and denial of the claim on the ground of pre-existing disease tantamoutns to deficiency in service on the part of the OP-1 insurance company.

10.               Therefore, we direct the  opposite party no.1 to reimburse the claim of the complainant as per the terms and conditions of the policy with interest @ 9 % p.a. from the date of filing of the present complaint i.e. 09.06.2014 till realization. The complainant is also entitled to compensation as well as  litigation expenses to the tune of Rs.5000/-. The OP- 1 shall make the compliance of the order within 30 days from the date of receipt of the copy of this order. The parties be communicated of the order accordingly and the file be consigned to the records after due compliance.

 

Announced                                                                                                 (Subhash Goyal)

29.06.2016                                                                                                           President,

                                                                                                            District Consumer Disputes

                                                                                                              Redressal Forum, Gurgaon

 

(Jyoti Siwach)        (Surender Singh Balyan)

Member                 Member