BEFORE THE DIST. CONSUMERS DISPUTES REDRESSAL FORUM; DHARWAD.
DATE: 27th June 2014
PRESENT:
1) Shri B.H.Shreeharsha : President
2) Smt.M.Vijayalaxmi : Member
Complaint No.: 19/2014
Complainant/s:
Smt.Devakka W/o.Paris urf Parishwanath Jain, Age: 40 years, Occ: Household work, R/o.Kali, Kabbenur, Tq. & Dist. Dharwad.
(By Sri. S.B.Lakkannavar, Adv.)
v/s
Respondent/s:
- The Manager, Religare Health Insurance Co. Ltd., 303-305, 3rd floor, Bhavani Arcade, New Cotton Market, Hubli-580029. Dist. Dharwad.
-
- Religare Health Insurance Co. Ltd., G.Y.S. Global Plot, No.3, A4-A5 Sector, Noida, Uttar Pradesh 201301.
(By Sri.P.S.Bhat, Adv.)
O R D E R
By: Shri. B.H.Shreeharsha : President.
1. The complainant has filed this complaint claiming for a direction to the respondents to pay hospital charges amounting to Rs.1.50 lakhs under the medical policy with interest and to grant compensation and such other reliefs.
Brief facts of the case are as under:
2. The case of the complainant in brief is that, the complainant had obtained individual health insurance policy from the respondent.1 of the policy belongs to respondent.2. Since the complainant had health problem she got admitted to Sushruta Hospital and Sadana Diagnostic Hospital Hubli & underwent operation and spent more than Rs.1 lakh. In all including other antecedental charges she claims Rs.1.15 lakh. When the complainant submits claim, the respondents made her to wander by giving, false assurances. Hence the complainant filed the instant complaint praying for the relief as sought.
3. In response to the notice issued from this Forum the respondents appeared and filed the written version in detail denying and disputing the complaint averments. Further the respondents taken contention that, the operation, the complainant underwent for Hysterectomy for Fibromyoma which is excluded as per Clause. 4.1 (b) (i) (IX) of the policy terms and conditions for a period of 2 years from the date of issuance of policy & prays for dismissal of the complaint saying that there is no deficiency in service as alleged. The respondent repudiated the claim on valid grounds and thereby they are justified in repudiating the policy claim. Apart from admissions and denials the respondent explained in detail with regard to waiting period, coverage of the policy and lastly prays for dismissal of the complaint.
4. On the said pleadings the following points have arisen for consideration:
- Whether complainant has proved that there was deficiency in service on the part of respondents ?
- Whether complainant is entitled to the relief as claimed ?
- To what relief the complainant is entitled ?
Both have admits sworn to evidence affidavit & relied on documents. The respondent apart from arguments relied on citations. Heard. Perused the records.
Finding on points is as under.
- Negative
- Negative
- As per order
Reasons
Points 1 and 2
5. On going through the pleadings & evidence coupled with documents of both the parties it is evident that there is no dispute with regard to the fact, that the complainant had obtained the medical policy from respondent.1 belongs to the respondent.2. Further there is no dispute with regard to fact, the policy was in force during the relevant period, for which the complainant claimed the claims.
6. Now the question to be determined is, whether the operation underwent by the complainant comes with the coverage of risk, and non settlement of the claim amounts to deficiency in service, if so, for what relief the complainant is entitled.
7. As already discussed supra the crux of the case to be decided here is whether the operation carried to the complainant will comes within the purview of the scheduled benefits. The learned counsel for respondent drew the attention of this fora to the certificate issued by the Sushruta Multispecialty hospital. On perusal of the said certificate, the doctor has mentioned, she (complainant) underwent non descent veginal hysterectomy. With reference to this the learned counsel took the attention of this fora to exclusion clause of the policy schedule at Page.5 Item No.4.1 waiting period and also item 4.1 (b) IX item histeroctomy for menorrhagia or fibromyoma or prolapse of uterus unless necessitated by malignancy and submits, the operation carried out on complainant is the same as item No.9 of exclusion clause. Hence, the complainant is not entitled for the claim. Under those circumstances only the respondent repudiated the claim and urges that there is no deficiency in service and repudiation is done on valid grounds as such respondent justified in repudiating the same.
8. Apart from this non exclusion clause the learned counsel also taken to terms and conditions of the policy schedule and if any dispute it should be referred to arbitration. Hence, claim before this forum is not maintainable. In this regard the learned counsel for respondent take reference to judgment AIR 1976 Supreme Court 287. Since there be a provision u/s.3 of the CP Act, this contention of the respondent cannot be accepted. By looking to the evidence and also the nature of the operation carried out and exclusion clause of the policy schedule the claim of the complainant do not comes under the purview of the coverage of the risk under the policy. The complainant failed to establish her case of deficiency in service. Interalia the respondent with appulsive and cogent evidence justified the repudiation of the claim. Hence, complainant is not entitled for the relief much less the relief as sought.
9. In view of the above discussions we have arrived and proceed to held issue.1 and 2 in Negative.
10. Point.3: In view of the finding on points 1 and 2 proceeded to pass the following
Order
The complaint is dismissed. No order as to costs
(Dictated to steno, transcribed by him and edited by us and pronounced in the open Forum on this day on 27th day of June 2014)
(Smt.M.Vijayalaxmi) (Shri.B.H.Shreeharsha)
Member President
Dist.Consumer Forum Dist.Consumer Forum
MSR
