Haryana

Kurukshetra

CC/510/2019

Jasbir Singh - Complainant(s)

Versus

Rajinder Singh - Opp.Party(s)

Sharwan Malik

01 Apr 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL COMMISSION KURUKSHETRA.

 

Complaint Case No.510 of 2019

Date of instt: 28.11.2019 

                                                Date of Decision: 01.04.2022.

 

Jasbir Singh son of Sh.Inder Singh resident of VPO Kaulapur, Tehsil Thanesar District Kurukshetra.

                                                ……..Complainant.

                        Vs.

1.Rajinder Singh son of Sh.Suchha Singh resident of village Kaulapur Tehsil  Thanesar, District Kurukshetra, agent of Star Health and Allied Insurance Company Limited, SCO No.94, First Floor, Sector 17,Kurukshetra.

 

2.star Health and Allied Insurance Company Limited, SCO no.94 First Floor ,Sector-17, Kurukshetra through its Branch Manager.

 

3.Star Health and Allied Insurance Company Limited, No.15, SRI Balaji Complex 1^st Floor, Whites Lane, Royapettah, Chennai – 600014 through its authorized person.

                 

                                                                             ..………Opposite parties.

 

                 Complaint under section 12 of Consumer Protection Act.  

 

Before       Smt.  Mrs.Neelam Kashyap, President.

                Ms. Neelam, Member.

                Sh. Issam Singh Sagwal, Member.

 

Present:     Shri Sarwan Malik, Adv. for complainant.

                OP NO.1 ex parte.

Sh. Mohit Goyal Advocate for OP No.2 and 3.

           

ORDER     

 

                   This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Jasbir Singh against Star Health and Allied Insurance Company Limited, the opposite parties.

 

2.            Brief facts of the present complaint are that the on the allurement of OP No.1 the complainant had purchased a medi claim  insurance policy namely Family Health Optima Insurance Plan from the Ops vide insurance policy No. P/211123/01/2019/001802  and paid the premium of Rs.10059/- and the said policy was valid for the period from 16.09.2018 to 15.09.2019 and thereafter the policy was renewed for the period from 30.10.2019 to 29.10.2020 vide policy No.P/211123/01/2020/003632.  It is further stated that wife of the complainant namely Maninder Kaur complained problem  of abdomen and the wife of the complainant was admitted on 22.3.2019 in Cygnus  Superspeciality  Hospital Kurukshetra and the  she was discharged from the hospital on 24.3.2019.An amount of Rs.16700/- was spent on her treatment. Thereafter, the complainant approached the Ops and submitted the original bills and other documents with the Ops for releasing the amount of Rs.16,700/-  but the Ops on one pretext or the other avoided the same ultimately vide letter dated 30.4.2019 repudiated the claim of the complainant and kept all the original bills submitted by the complainant with them.  It is submitted that denial of the genuine claim by the Ops amounts to amount to deficiency in services on the part of the Ops. Thus, the complainant has filed the present complaint alleging deficiency in services on the part of the Ops and  prayed that the Ops be directed to pay the claim amount of the complainant alongwith interest and compensation for the mental harassment caused to him and the litigation expenses.

 

3.             Notice of the complaint was given to the Ops. OP no.1 failed to appear and contest the case, therefore, vide order dated 15.01.2020, the OP No.1 was proceeded against ex parte.

 

4.             OP No.2 and 3 appeared and filed written statement disputing the claim of the complainant. It is submitted that the complainant had obtained Family Health Optima Insurance Plan policy for the period 16.9.2018 to 15.09.2019 covering risk of Maninder Kaur. The said policy was further renewed for the period 30.10.2019 to 29.10.2020 and basic floater sum assured was Rs.3.00 lacs. It is submitted that the said policy was subject to terms and conditions. It is submitted that the claim No.CLI/2019/211123/0732938 was received and on receiving the claim on reimbursement basis and query was observed from the consultation dated 22.3.2019 of the Cygnus Hospital Kurukshetra that the insured patient has been treated for  ureteric calculus has arisen within two years from the date of commencement of the first policy. As per waiting period/exclusion no.3 (ii) (b) of the policy, the claim is not admissible for the period from the date of inception of the first policy. On scrutiny of the documents by the insured it is observed:

                i)      As  per YSG report dated 22.3.2019, which reveals left renal mild hydronephrosis. Secondary to? Ureteric calculus. Based on these findings, it is of the opinion that the insured patient has undergone treatment of abdomen pain which is due to ureteric calculi, which is during the  first period of the policy (falls under exclusion No.3 ii(b). and the same is not payable as the said treatment has been taken within two years of the inception of the policy. Thus, it is alleged that there is no deficiency in services on the part of the Ops and prayed for dismissal of the present complaint.

 

4.             The complainant in support of his case has filed his affidavit Ex.CW1A and tendered documents Ex.C-1 to Ex.C-5 and closed his evidence.

 

5.             On the other hand, Ops in support of their case have filed affidavit Ex.RW1/A and tendered documents Ex.R-1 to Ex.R-13 and closed their evidence.

 

6.             We have heard the learned counsel for the parties and have gone through the material available on the case file very carefully.

 

7.             The learned counsel for the complainant while reiterating the averments made in the complaint has argued that  the complainant had purchased a medi claim  insurance policy namely Family Health Optima Insurance Plan from the Ops vide insurance policy No. P/211123/01/2019/001802  and paid the premium of Rs.10059/- and the said policy was valid for the period from 16.09.2018 to 15.09.2019 and thereafter the policy was renewed for the period from 30.10.2019 to 29.10.2020 vide policy No.P/211123/01/2020/003632.  It is argued that  the  wife of the complainant namely Maninder Kaur complained problem  of abdomen and the wife of the complainant was admitted on 22.3.2019 in Cygnus  Superspeciality  Hospital Kurukshetra and the  she was discharged from the hospital on 24.3.2019.An amount of Rs.16700/- was spent on her treatment. Thereafter, the complainant approached the Ops and submitted the original bills and other documents with the Ops for releasing the amount of Rs.16,700/-  but the Ops on one pretext or the other avoided the same ultimately vide letter dated 30.4.2019 repudiated the claim of the complainant on illegal grounds and kept all the original bills submitted by the complainant with them.

 

8.             On the other hand, the learned counsel for the Ops while reiterating the submissions made in the written statement has  argued that  YSG report dated 22.3.2019, which revealed left renal mild hydronephrosis. Secondary to? Ureteric calculus. Based on these findings, it is of the opinion that the insured patient has undergone treatment of abdomen pain which is due to ureteric calculi, which is during the first period of the policy (falls under exclusion No.3 ii(b). and the same is not payable as the said treatment has been taken within two years of the inception of the policy. Thus, it is alleged that there is no deficiency in services on the part of the Ops and prayed for dismissal of the present complaint. However, obtaining of the insurance policy and treatment of the life assured has been admitted by the Ops.

 

9.             After hearing the learned counsel for both the parties, we are of the opinion that the claim of the complainant has been declined on the ground that the said operation  was done for Hydronephrosis, secondary to ureteric calculus. The Ops have based in their opinion on YSG report dated 22.3.2019 but the report Ex.C-2  of Cygnus Super Speciality Hospital reveals that  further investigation did not  reveal calculus  and the disease was found as abdomen functional. As  per report dated 22.3.2019 Rc.C-3 of Cygnus Super Speciality Hospital” No evidence of renal calculus stone was seen”. Further from the report Ex.C-4 “ No evidence of focal lesion seen.  No E/O hydronephrosis in right kidney. No renal calculus.” Therefore, stand of the Ops that  said treatment was done for  ureteric calculi is devoid of any force and the claim of the complainant has been illegally repudiated and the complainant is entitled to Rs.16,700/- spent by him for the treatment of his wife. Therefore, deficiency in services on the part of the Ops is established and the present complaint is liable to be accepted. However, no deficiency in services is made out against OP No.1 and the complaint qua OP No.1 deserves to be dismissed.

 

10.            In view of our above findings and observations, we accept the present complaint and direct the Ops No.2 and 3 to make the payment of Rs.16,700/- to the complainant. The OP No.2 and 3 are further directed to pay Rs.3000/- to the complainant as compensation for the mental harassment caused to him and Rs.5000/- for the litigation expenses. The OP no.2 and 3 are further directed to make the compliance of this order within a period of 30 days from the date of preparation of certified copies of this order, failing which the complainant shall be at liberty to initiate proceedings u/s 25/27 of the Consumer Protection Act.  The complaint  qua OP No.1 stands dismissed. Certified copy of this order be supplied to the parties concerned as per the rules and the file be consigned to the record room after due compliance.

 

Announced in the open Commission.

Dated: 01.04.2022                                               President.

 

 

                                Member                     Member.