BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.

                                                          Consumer Complaint no.185 of 2015                                                              

                                                          Date of Institution         :    19.10.2015

                                                          Date of Decision   :  25.10.2016.

Smt. Rukmani wife of Sh. Bhup Singh, resident of H.No. B/20/1253, Near Hanuman Mandir, Patel Basti, Begu Road, Sirsa, Tehsil and District, Sirsa, Haryana.

            ….Complainant.                     

                   Versus

1. Reliance Life Insurance Company Ltd., H-Block, Ist. Floor Dhirubhai Ambani Knowledge City, Navi Mumbai (Maharastra)- 400710, through its President or Executive Director.

2. The Branch Manager, Reliance Life Insurance, Dabwali Road, Sirsa (Haryana) 125055.

3. The Manager, Medicare TPA Services (I) Pvt. Ltd. 6B, Bishop Lefroy Road, Kolkata 700020

                                                                             ..…Opposite parties.

            Complaint under Section 12 of the Consumer Protection Act,1986.

Before:        SHRI S.B.LOHIA…………………PRESIDENT

                  SHRI RANBIR SINGH PANGHAL ……….……MEMBER.

Present:       Sh. S.S. Kathuria,  Advocate for the complainant.

        Sh. S.S. Mandia, Advocate for opposite parties no.1 & 2.

       Opposite party no.3 exparte.

ORDER

                   Case of complainant, in brief, is that on the advertisement of Medical Insurance policy of op no.1, on 28.12.2011 complainant and her son Kapil Sharma had purchased ‘Reliance Care For You Plan’ policy for the sum assured of Rs.2,00,000/- through agent/ broker Sh. Chetan Sharma for three years and had paid Rs.5328.58/- as first premium. The office of ops had also issued a policy in their favour. The complainant suddenly fell down in the house on 22.9.2014 and she suffered injuries on her back and was taken to doctor Pankaj Gupta, Dept of Neurosurgery, S.M.S. Hospital and Medical College, Jaipur on 23.9.2014 and after check-up doctor advised her for some tests i.e. MRI, X-ray etc. and provided treatment but she was not cured. Thereafter, doctors had advised her different tests from diagnosis centers and then doctor advised her for surgery. On 19.11.2014, she was got admitted in Amar Medical and Research Centre, Kiran Path, Mansarower, Jaipur for surgery and on 20.11.2014 surgery was conducted upon her and she was discharged on 28.11.2014. She had incurred an amount of Rs.1,62,892/- there.  The complainant as per instructions of ops submitted all the relevant original documents including bills to the ops concern alongwith claim form on 28.11.2014 to ops for cash less scheme but same was rejected without assigning any cogent reason and Amar Medical and Research Centre, Kiran Path, Mansarower, Jaipur received its bills in cash from the complainant. Thereafter, complainant submitted many requests to disburse her claim through her husband by sending mails etc. but ops did not pay any heed and they refused to pay the claim of complainant. The complainant also contacted with the ops and requested to pay the claim amount but all in vain and ops concern had also refused to pay the claim on 9.3.2015 without any cogent reason. She also got served a legal notice upon ops on 21.5.2015, but to no effect. Hence, this complaint.

2.                Upon notice, opposite parties No.1 & 2 appeared and filed reply wherein issuance of policy to the complainant has been admitted. It is submitted that claim was received in the office of answering ops, wherein complainant Rukmani alleged to have undergone treatment from Amar Medical and Research Centre, Jaipur and spent an amount of Rs.1,62,892/-. She was admitted with Spondylosis of Lumbosacral Region on 19.11.2014 with date of discharge on 28.11.2014.  On receipt of the claim documents, same were forwarded to an independent TPA (Third party arbitrator) duly licensed and registered from IRDA for adjudication of claim on merits and being an expert, op no.3 after going through the terms and conditions of the policy repudiated the claim of the claimant as claim for alignment in questions falls within three years waiting period, specified in the policy. The policy was issued on 28.12.2011 and there is three years waiting period for Diskectomy treatment undergone by the complainant, hence the claim of the claimant being not admissible was not paid and prayer for dismissal of complaint has been made.

3.                Op no.3 did not appear despite notice sent through registered post and due acknowledgment and was proceeded against exparte.

4.                In evidence, the complainant has tendered her affidavit Ex.C1, copy of policy Ex.C2, repudiation letter Ex.C3,, details of medical expenses Ex.C4, copy of claim form Ex.C5, treatment record Ex.C6 and Ex.C7, bills and receipts Ex.C8 to Ex.C17, MRI report Ex.C18, test reports Ex.C19 to Ex.C24, medical bills Ex.C25 to Ex.C50, copy of card issued by ops Ex.C51, copy of aadhar card Ex.C52, copy of pan card Ex.C53, legal notice Ex.C54 and postal receipts Ex.C55 to Ex.C57. On the other hand, ops tendered in evidence affidavit Ex.RW1/A, affidavit Ex.RW2/A and documents Ex.R2 to Ex.R7.

5.                We have heard learned counsel for the parties and have gone through the case file carefully.

6.                There is no dispute that complainant and her son had obtained medi-claim insurance policy from the opposite parties on 28.12.2011. The claim of the complainant has been repudiated on the ground that claim for alignment in question falls within 3 years waiting period specified in the policy. It is further mentioned in the repudiation letter Ex.C3 that the inception of policy is 28.12.2011, member is admitted with spondylosis of lumbosacral region on 19.11.2014, there is 3 years waiting period for Diskectomy as per policy clause 5.5. Hence, claim is not admissible and not payable. However, there is specific mention in clause 5.6 of the policy that the “waiting period will not apply for hospitalization or medical expenses incurred due to Accident.” In this case also, the complainant fallen down on 22.9.2014 and therefore, received the injuries on her back which is also an accident and therefore, the opposite parties have wrongly and illegally repudiated the claim of the complainant. The repudiation of the claim of the complainant is not justified and is set aside.

7.                The complainant has claimed that she has spent an amount of Rs.1,62,892/- on her treatment of said disease and have placed on file various bills in this regard from which it is proved on record that she has spent the above said amount. Therefore, she is entitled to the above said amount of Rs.1,62,892/- spent by her on her treatment. Hence, we allow the present complaint and direct the opposite parties to pay the said amount of Rs.1,62,892/- alongwith interest @9% per annum from the date of filing of present complaint i.e. 19.10.2015 till actual realization. We also direct the opposite parties to pay a sum of Rs.10,000/- to the complainant as compensation for harassment including litigation expenses. This order should be complied by the opposite parties jointly and severally within a period of 45 days from today. Copy of the order be supplied to the parties free of costs. File be consigned to the record room after due compliance. 

Announced in open Forum.                                     President,

Dated: 25.10.2016.                                     District Consumer Disputes

                                                                   Redressal Forum, Sirsa.

                                      Member.