Delhi

New Delhi

CC/591/2015

Preeti gupta - Complainant(s)

Versus

Star Health Allied Insurance Company Limited - Opp.Party(s)

03 Mar 2020

ORDER

 

 

                     CONSUMER DISPUTES REDRESSAL FORUM-VI

                       (DISTT. NEW DELHI),

                              ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

                                                           NEW DELHI-110001

 

 Case No. CC/591/2015                                                Dated:

 In the matter of:     

Smt. Preeti Gupta

C/o M/s Pokhar Mal, Pradeep Kumar

2078 Narela Mandi, Narela ,

Delhi - 110040                                                            …… Complainant

 

        Versus

           

           

            The Manager

            Star Health and Allied Ins Co. Ltd.

            First Floor, Himalaya House, 23 K.G. Marg

            New Delhi- 110031                                                   …….Opposite Party

 

H.M. VYAS – MEMBER

                                                       ORDER

            The gist of the complaint is that the complainant took Family Health Optima Insurance Policy which sum assured Rs. 5,00,000/- valid for the period from 28/07/2014 to 27/07/2015 from OP after having the renewal of previous policy from the preceding policies since 28/7/2010 for which portability was granted by OP and these four policies became  part and parcel of the policy of OP. The policy bonds issued were not having endorsement of any conditional clause, warranty as stated in the bonds. The complainant fell sick and admitted in Medanta-The Medicity Hospital on 18/02/2015 and discharged on 21/02/2015. He was diagnosed as suffering from Eosinophilic Enteritis which is an organic disease and requires regular treatment and follow-up. The OP rejected the cashless facility on 20/02/2015 at the payment of mediclaim on 24/04/2015 on the ground that the claim was not payable as per exclusion clause 10 of the policy. The copy of terms and conditions and exclusion clause no. 10 was collected from the office of OP on 21/07/2015. It is stated that  the disease of the complainant did not fall within the scope of exclusion clause  and therefore the repudiation was erroneous. Prayer for directions to the OP to pay Rs. 78,710/- with the interest @18% per annum has been made beside compensation of Rs. 25,000/- and litigation cost of Rs. 11,000/-.

            After notice the OP filed written statement / version denying all allegations. It is stated that  the claim was not payable on account of non disclosure of pre-existing disease. It is stated that the complainant had undergone treatment for same cause with Fortis Hospital on 14/11/2011 to 18/11/2011 and Metro Hospital  for the period from 07/12/2012 to 11/02/2012. The complainant did not declare the same in the Proposal Form and suppressed the material fact. It is also stated that due to insufficient documents the cashless authorization  was denied and the same was communicated to the complainant vide letter dated 20/02/2015. It is also stated that the discharge summary of the

 

            Medanta –The Medicity confirm that the disease  is non-organic in nature.  Thus, the present admission is for functional pain treated by tablet Duloxetine which is antidepressive. As per exclusion clause no. 10, the complainant is not liable to make the payment of the expenses incurred in the hospital for treatment of psychosomatic disorder.

            Both the parties filed their evidence by way of affidavit. Oral arguments were also addressed.

            The OP has filed the terms and conditions containing the exclusion clause no. 10 where under the repudiation of the claim was made and communicated. The said terms and conditions relate to the period 2013-2014 whereas the policy where under the claim has been made relates to the period of July 2014-2015. Copy whereof filed by the complainant. The policy for the relevant  period2014-15 does not  contain any such alleged  clause 10 as relied  by the OP for repudiation of the claim. The argument of the OP that the claim was not payable under the said clause does not hold and is therefore rejected .

            Further, it is evident and admitted by the OP that the policy was issued  by the OP after allowing the portability of the erstwhile existing policy and so, reliance on any pre-existing disease in existing clause 10 is without substance. We therefore, hold the OP to be deficient in service and direct as under :-

 

                 1)  OP to pay to the complainant for a sum of Rs. 78710/- along with 9% simple interest from the date of filing of the complaint i.e. 04/09/2015.

                  2) OP to pay to the complainant Litigation cost of Rs. 10,000/-.

The Orders shall be complied within 30 days from the date of receipt of this order.

Copy of the order may be forwarded to the parties to the case free of cost as statutorily required. 

Announced in open Forum on:  03/03/2020

The orders be uploaded on www.confonet.nic.in

File be consigned to record room.

 

 

 

                                                           (ARUN KUMAR ARYA)

                                                                                PRESIDENT

 

            (NIPUR CHANDNA)                                                                       (H.M. VYAS)

             MEMBER                                                                                  MEMBER