Haryana

Karnal

CC/410/2017

Manoj Kumar - Complainant(s)

Versus

Religare Health Insurance Company Limited - Opp.Party(s)

Gourav Sharma

08 Apr 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 410 of 2017

                                                          Date of instt. 11.12.2017

                                                          Date of Decision 08.04.2019

 

Manoj Kumar son of Shri Gyan Chand resident of House no.126, Holi Chowk, Assandh, Tehsil Assandh, District Karnal.

 

                                                                         …….Complainant

                                        Versus

 

1. Religare Health Insurance Company Limited, Reg. office 5^th floor, 19 Chawla House, Nehru Place, New Delhi-110019 through its authorized signatory.

2. Indusind Bank, Sector 12, Karnal through its Branch Manager.

 

                                                                        …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

                Dr. Rekha Chaudhary…….Member

 

 Present:  Shri Gaurav Sharma Advocate for complainant.

                  Shri Rohit Gupta Advocate for opposite party no.1.

                   Shri Suraj Kumar Advocate for opposite party no.2.

 

                    (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant purchased a Health Policy no.10938504, valid from 1.1.2017 to 31.12.2017 from OP no.1 through OP no.2 for a sum assured of Rs.5,00,000/- and the complainant paid the premium of the said policy amounting to Rs.5911/- and it was disclosed to the complainant that if during the period of policy, the complainant will fell ill or met with an accident and remained admitted in hospital for minimum 24 hours, the entire expenses of his treatment in the hospital shall be paid by OPs. At the time of policy, the complainant had furnished all the relevant informations to OPs and after satisfying themselves, OPs issued the policy. On 4.8.2017 the complainant fell down from the staircase of his house and received injuries and was got admitted in Shree Hari Hospital, Karnal where he remained admitted  upto 8.8.2017 and he was operated upon by the doctors and more than Rs.26780/- were spent on his treatment besides other expenses. The complainant sent the intimation to the OPs regarding his treatment and requested the OPs to release the payment spent on his treatment but OPs did not make any payment and postponed the matter on one pretext or the other. Finally, vide non-Registration of Claim letter dated 21.08.2017, OPs refused to make the payment and wrongly repudiated the claim of the complainant on the flimsily ground that waiting period for PIVD with Radiculopathy is 2 years. OP no.1 wrongly and intentionally repudiated the claim of the complainant and the complainant was not suffering from any previous injury as alleged by OP no.1 and the injury received by the complainant is covered under the policy and there was no waiting period for the same and the same is not chronic disease and every facts were disclosed to OPs at the time of availing/purchasing of policy and after satisfying themselves from every facts, the policy was issued by OP no.1 in favour of the complainant and once the policy is issued and premium is paid by the complainant, OPs are duty and legally bound to make the payment spent by the complainant on his treatment referred above. Complainant has requested the OPs several times and also issued a legal notice dated 2.11.2017 requesting the OP to make the payment but OPs did not make any payment. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs. OP no.1 appeared and filed written version raising preliminary objections with regard to maintainability; locus standi; cause of action; jurisdiction and concealment of true and material facts. On merits, it is pleaded that the complainant was issued policy of Insurance bearing no.10938504 for a period from 1.1.2017 to 31.12.2018 for a sum insured of Rs.5,00,000/- for insuring the complainant subject to the policy terms and conditions. It is further pleaded that the complainant remained admitted in Shree Hari Hospital, Karnal upto 8.8.2017 and was operated upon by the doctors and more than Rs.26,780/- was spent on his treatment besides other expenses and still now his treatment is going on as outdoor patient and anything contrary to the record is denied. It is denied that the complainant fell down from the staircase of his house on 4.8.2017 and received injuries. It is further pleaded that the complainant approached the OP no.1 and filed Reimbursement Claim for the Hospitalization at Shri Hari Hospital, Karnal for treatment of PVD with Radiculopathy from 5.8.2017 to 8.8.2017. The OP no.1 upon receipt of the documents observed that the claim of the complainant fall under the 2 years waiting period for PIVD with Radiculopathy.

 Radiculopathy is a condition due to a compressed nerve in the spine that can cause pain, numbness, tingling, or weakness alongwith the course of the nerve. Radiculopathy can occur in any part of the spine, but it is most common in the lower back and in the neck.

PIVD Prolapsed disc is actually slipped discs.

The claim of the complainant does not fall under the purview of the policy terms and conditions and the claim stands rejected under clause 4.1(ii)(1) of the Policy Terms and Conditions of the policy terms and conditions by OP no.1 on 21.08.2017 as there is a waiting period of 2 years from the date of inception of policy for admitting any claim relating to spinal disorders. Hence there is no deficiency in service on the part of the OP no.1. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             OP no.3 filed its separate written version raising preliminary objections with regard to jurisdiction; cause of action and concealment of true and material facts. On merits, it is pleaded that the role of the OP no.2 is limited as to a corporate agent/facilitator and whereas the actual insurance is issued by the OP no.1. It is further pleaded that the OP no.2 has wrongly joined as a party to the complaint as the contract of insurance is between OP no.1 and the complainant. Hence there is no deficiency in service on the part of the OP no.2 and prayed for dismissal of the complaint.

4.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C18 and closed the evidence on 20.11.2018.

5.             On the other hand OP no.1 tendered into evidence affidavit of Arvind Singh Ex.RW1/A and documents Ex.OP1 to Ex.OP6 and closed the evidence on 27.03.2019. OP no.2 led no evidence

6.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

7.             The case of the complainant is that he purchased a Health Policy no.10938504, valid from 1.1.2017 to 31.12.2017 from OP no.1, for a sum assured of Rs.5,00,000/-. On 4.8.2017 complainant fell down from the staircase and received injuries and got admitted in Shree Hari Hospital Karnal and more than Rs.26780/- were spent on his treatment. Complainant submitted the documents for releasing the payment spent on the treatment but on 21.8.2017 OP no.1 refused to make the payment on the flimsy ground that waiting period for PIVD with Radiculopathy is 2 years.

8.             On the other hand, case of the OP no.1 is that upon receipt of the documents OP observed that the claim of the complainant fall under the 2 years waiting period for PIVD with Radiculopathy. The claim fo the complainant does not fall under the purview of the policy Terms and Conditions and the Claim stands rejected under clause 4.1(ii)(i) of the policy.

9.             The case of the OP no.2 is that he is only facilitator whereas the actual insurance is issued by the OP no.1.

10.            Admittedly, the complainant was issued policy of insurance for a period from 1.1.2017 to 31.12.2018 for sum insured as Rs.5,00,000/-. As per complainant on 4.8.2017 he fell down from the staircase in his house and received injuries. He was got admitted and operated by the doctor of Shree Hari Hospital, Karnal and spent Rs.26,780/- on his treatment. The claim of the complainant was repudiated by the OP no.1 on the ground that the claim relates to spinal disorders and same does not fall under the purview of the policy terms and conditions. The claim was rejected due to two years waiting period for PIVD Radiculopathy. The version of the complainant is that he fell down the staircase in his house rebutted by the OP no.1, vide certificate Ex.OP5, in which Dr. Apurva Patel specifically mentioned that after reviewing the MRI, the finding are chronic in nature and not accidental before on the MRI reports. Thus, we are of the view that the claim case of the complainant is not fall under the purview of the policy terms and conditions.

11.            Thus, as a sequel to abovesaid discussion, we do not find any merits in the complaint and the same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:08.04.2019

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

               

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                               Member