Delhi

New Delhi

CC/291/2022

Sapana - Complainant(s)

Versus

M/S. Star Health & Allied Insurance Company Ltd. - Opp.Party(s)

02 Jun 2023

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-VI

(NEW DELHI), ‘M’ BLOCK, 1STFLOOR, VIKAS BHAWAN,

I.P.ESTATE, NEW DELHI-110002.

Case No.291/2022        

IN THE MATTER OF:

 

 

Mrs. Sapana

B-71, Bharat Vihar, Kakrola,

New Delhi-110078                                                             ....Complainant

 

                                      VERSUS

 

      Star Health and Allied Insurance Company Limited

      1^st Floor, Himalaya House

      23, Kasturba Gandhi Marg,

      New Delhi-110001                                                        ....Opposite Party

 

      Quorum:

 

      Ms. Poonam Chaudhry, President

      Sh. Bariq Ahmad, Member

 

                                                                                                                        Date of Institution:-09.11.2022                                                                                                                                                                             Date of Order   : -    02.06.2023       

ORDER

 

POONAM CHAUDHRY, PRESIDENT

 

 

 

1. The present complaint has been filed under Section 35 read with 36 of the Consumer Protection Act, 2019 (in short CP Act) read with Rule 7 of the Consumer Protection (Consumer Commission Procedure) Regulation, 2020 against Opposite Party (in short OP) alleging deficiency of services.
2. Briefly stated the facts of the case are that the complainant had taken a on line health insurance policy bearing no. P/160000/01/2022/010161 on 20.12.2021 from opposite party. The said policy was valid from 20.01.2021 to 19.12.2022 for the sum insured of Rs.5,00,000/- (Rupees Five Lakh).
3. The complainant got admitted in the Mahavir Multispecialty Hospital for treatment on 21.09.2022 and remained hospitalizated till 02.10.2022. The said hospital generated the final bill of Rs.2,07,168/- (Rupees Two Lakh Seven Thousand One Hundred Sixty Eighty) which was paid by complainant. Complainant claimed the aforesaid bill from the opposite party vide Claim No. CIR/2023/160000/0928396 but the opposite party rejected the same vide letter dated 18.10.2022. with reason as under:

We have processed the claim records relating to the above insured –patient seeking reimbursement of hospitalization expenses of treatmentof Entric Fever.

It is observed from the submitted records that the insured patient was admitted and treated in an excluded provider (hospital).

As per Exclusion No. (11) Excluded Providers-Code Excl. 11 of the above policy, the expenses incurred towards treatment in any hospital or by any medical Practitioner or any other provider specifically excluded by the insure and disclosed in its website/notified to the policyholders are not admissible.

 

4. It is alleged that the complainant thereafter sent a letter dated 19.10.2022 to OP but no response was received. Complainant having been left with no option approached this Court, hence the present complaint. It is also alleged that the present case is being filed within the period of limitation. The cause of action arose to file present case when the claim of the complainant was rejected by opposite party on dated 18.10.2022. It is further alleged that complainant resides at “New Delhi.” hence, this Court has jurisdiction to entertain the present complaint.
5. It is prayed that OP be directed to pay a sum of Rs.2,07,168/- (Rupees Two Lakh Seven Thousand One Hundred Sixty Eight) to the complainant with pendentelite and future interest @ 18% p.a. from the date of repudiation of claim till realization. OP be also directed to verify and produce the medical treatment record and bills of treatment of complainant from 21.09.2022 to 02.10.2022. Cost of litigation be also awarded.
6. Notice of the complaint was issued to OP, OP was duly served on 09.12.2022. However as written statement was not filed within the statutory period, the defence of OP was stuck off vide order dated 14.02.2023. 
7. Complainant filed her  evidence by affidavit reiterating therein the averments made in the complaint. Complainant filed copy of policy, the treatment record, the bills issued by Mahavir Multispecialty Hospital, The repudiation letter.
8. We have heard the AR of complainant and counsel for OP and perused the record.
9. In view of the unrebutted testimony of complainant and the documents relied upon by complainant, we are of the view that complainant has succeeded in proving that OP was guilty of deficiency of services in repudiating the claim of complainant. Complainant was hospitalized during the tenure of the coverage of policy. We accordingly hold OP/Star Health and Allied Insurance Company Limited guilty of deficiency of services and direct OP to pay Rs.2,07,168/- (Rupees Two Lakh Seven Thousand One Hundred Sixty Eight) to the complainant with interest @ 9% per annum from date of filing of claim within four weeks of date of receipt of order, failing which OP will be liable to pay interest @ 12% per annum till realization. We also direct OP to pay compensation of Rs.50,000/ (Rupees Fifty Thousand only) for mental agony and harassment and Rs.10,000/- (Rupees Ten Thousand only) as cost of litigation to the complainant.

 

A copy of this order be sent to all the parties free of cost. The order be uploaded on the website of this Commission.

File be consigned to record room along with a copy of the order.

 

 

Poonam Chaudhry

(President)

 

 

Bariq Ahmad

(Member)