Haryana

Karnal

CC/689/2023

Smt. Shewwta Dhiman - Complainant(s)

Versus

SBI General Insurance Company Limited - Opp.Party(s)

Kuldeep Sharma

14 Dec 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                                    Complaint No.689 of 2023

                                                                     Date of instt.07.12.2023

                                                                     Date of Decision:14.12.2023

 

Shweta Dhiman wife of Shri Ravi Kumar, resident of house no.249, village Anjanthali, Tehsil Nilokheri, Karnal.

                                                                                      …….Complainant.

                                                Versus

1. SBI General Insurance Company Limited, registered & Corporate office: “Natraj” 301, Junction of Western Express Highway & Andheri Kurla road, Andheri (East) Mumbai-400069, through its Manager.
2. SBI General Insurance Company Limited, Branch office at SCO No.388-389, Karan Commercial complex, first floor, BD International near Guru Harkishan School, Sector-13, Karnal, through its Branch Manager.
3. Paramount Health Services TPA Pvt., Ltd., plot no.A-442, road no.28, MIDC Industrial Area, Wagale Estate, Ram Nagar, Vithal Rukmani Mandir, Thane (West), Maharashtra-400604, through its Manager.

                                                                                      …..Opposite Parties.

Complaint under Section 35 of Consumer Protection Act, 2019.

Before       Sh. Jaswant Singh………President.   

                   Sh. Vineet Kaushik……… Member.

                   Dr. Suman Singh……..Member.

 

Present: Sh. Kuldeep Sharma, counsel for the complainant.

 

 

(Dr. Suman Singh Member)

                 

Complaint presented today. It be checked and registered.

The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as OPs) on the averments that the complainant had purchased a health policy (Arogya Premier Policy) from the opposite parties vide policy No.000000000713424904, customer ID No.0000000010502458, Member ID No.SBIG10502458 and the said policy commenced from 10.09.2021 and the tenure of said policy is 10.09.2021 to 09.09.2022. For issuing above said policy in favour of the complainant the opposite parties had received Rs.11,074/- as premium amount from the complainant. The opposite parties issued identity cards in favour of the complainant. It is pertinent to mention here that prior to avail the above said health policy the complainant disclosed the fact of the pregnancy to the agent of the opposite parties and agent of the opposite parties also assured that from the date of birth till the age of three months, the newly born infant is also covered in the said policy. 

     That on 30.05.2022 the complainant suffering from labour pain got admitted in Amritdhara Hospital, ITI Chowk, Karnal vide IP No.36234, UHID No.151903 and on 30.05.2022 the complainant had given birth to a male child in the above said hospital, but the delivery of the complainant is pre term delivery and hence the newly born infant is not fit and hence the same has been admitted in NICU in Amritdhara Hospital, ITI chowk, Karnal. It is pertinent to mention here that the complainant prior to admission in the hospital submit the details of above said policy for getting the cashless benefit. As per the above said policy the opposite parties paid the treatment charges of the complainant, but refused to pay the treatment charges of newly born child infant by saying that the infant is not covered under the above said policy. Due to the above said act of the opposite parties, the complainant faced difficulty during her rest period. To pay the hospital bill qua the treatment of infant (newly born child) of the complainant, the complainant arranged Rs.56,850/- i.e. (Rs.54,800/- as hospital bill and Rs.2050/- as medicine bill) and paid the same to the concerned authorities (Amridhara my Hospital) for the treatment of infant (newly born child) of the complainant. Hence, this complaint.

       Argument on point of admissibility heard.

                The complainant has alleged that insurance policy was issued on 10.09.2021 and she has disclosed her pregnancy to the agent. The child was born on 30.05.2022. It is obvious that at the time of issuing the policy the pregnancy cannot be detected. As the same can be confirmed only after five to six weeks. Moreover, there is no mention that the new born baby is covered under the policy. When the policy covers only the complainant the Ops have already compensated the medical expenses of the complainant and have rejected the claim for the new born baby. Thus, in view of the above, the complaint is devoid of any merits and deserves to be dismissed and same is hereby dismissed inlimine. Parties concerned be communicated of the order accordingly and file be consigned to the record room.

Announced
Dated:14.12.2023                 

                        President,

District Consumer Disputes

Redressal Commission, Karnal.

(Vineet Kaushik)   (Dr. Suman Singh) 

    Member                    Member