Haryana

Jind

102/14

Rekha - Complainant(s)

Versus

Star Health And Allied Insurance C. Ltd. - Opp.Party(s)

Sh. Rajnish garg

12 Oct 2015

ORDER

                                   

BEFORE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, JIND.

                                           Complaint No. 102 of 2014

   Date of Institution: 1.9.2014

   Date of final order: 19.10.2015

Rekha w/o Vikas Chahal r/o village Dariyawala, Tehsil and District Jind.  

                                                             ….Complainant.

                                       Versus

1. Star Health and Allied Insurance Co. Ltd. 1 New Tank Street, Valluvar Kottam High Road, Nungambakkam Chennai-600034 through its CEO/MD.
2. Star Health and Allied Insurance Co. Ltd. Nariana Complex, second floor, Civil Road near Chhotu Ram Chowk, Rohtak-124001 through its Branch Head/Sr. Manager.

 

                                                         …..Opposite parties.

                          Complaint under section 12 of

                          Consumer Protection Act, 1986.

 

Before:  Smt. Bimla Sheokand, Presiding,Member.

             Sh. Mahinder Kumar, Khurana, Member.

 

Present: Sh. Rajnish Garg, Adv. for complainant.

             Sh. Dalbir Sharma, Adv. for opposite parties.

            

ORDER:

            The brief facts in the complaint are that complainant was  insured for a sum of Rs.10,00,000/-   Vide Health Insurance Policy  No. P/211118/01/2014/000645 dated 8.11.2013 from the opposie parties. The complainant  paid a sum of Rs.12,360/- as premium to the opposite parties. The complainant, her husband and their child are covered in the health insurance policy. The policy was valid

                                Rekha vs Star Health etc.

                                    ……2………

from 8.11.2013 to 7.11.2014. At the time of insurance, the agent told to the complainant’s husband that the policy is cashless. Unfortunately in the month of April, 2014 the complainant feeling the intolerable pain in her heart and his husband took her in the hospital at Jind for treatment. Thereafter, the complainant went to Fortis Hospital, Mohali  on 22.4.2014 and admitted  the same for treatment and spent a sum of Rs.17,550/- for treatment. The doctor told to the complainant that a small hole is found in her heart and the option is surgery for save her life.  The complainant’s husband giving the health insurance policy for payment demanded by the hospital but the opposite parties rejected the cashless treatment of the complainant. Thereafter, husband of complainant took her at Medicity Hospital, Gurgaon for treatment and surgery and admitted the complainant there on 26.4.2014 and spent a sum of Rs.3,41,149.87P for treatment and surgery. The complainnt contacted the opposite parties telephonically regarding against the payment of treatment and surgery but the opposite parties flately refused to pay the same. Deficiency in service on the part of the opposite parties is alleged. It is prayed that the complaint be accepted and opposite parties be directed to pay  a sum of Rs. 17,550/- +Rs.3,41,149.87P.-/ as spent for treatment and surgery, a sum of Rs.1,00,000/- as compensation on account of mental pain and agony as well as to pay a sum of Rs.22,000/- as litigation expenses to the complainant.

 

                      Rekha vs Star Health etc.

                              ……3………

2.     Upon notice, the opposite parties have appeared and filed the written statement stating in the preliminary objections i.e. the   complainant has no cause of action and  locus standi to file the present complaint; the complainant has not come to this Forum with clean hands and has suppressed the true and material facts and this Forum has got no jurisdiction to try and decide the present complaint.  On merits, it is contended that the complainant had only sought permission for cashless treatment of the complainant and no paper of treatment was submitted with the opposite parties.  It is pertinent to mention here that the patient had ASD was a congenital Heart disease with sever PAH, which is a long standing and not disclosed at the time of inception of the policy of insurance. The complainant has not submit the requisite documents and claim form with the opposite parties. There is no question of repudiation of any claim when the same has not been lodged and in such circumstances question of deficiency of service does not arise at all. The complainant deposited the amount of premium at Rohtak and the policy in question also issued at Rohtak. All the other allegations have been denied by the opposite parties. Therefore, there is no deficiency in service on the part of the opposite parties. Dismissal of complaint with costs  is prayed for.

3.     In evidence, the complainant has produced her own affidavit Ex. C-1,  copy of letter Ex. C-2, copy of schedule Ex. C-3,  copy of premium receipt Ex. C-4, copy of customer information sheet Ex. C-5, copy of claim form Ex. C-6, copy of  Fmily Health Optima

                        Rekha vs Star Health etc.

                            ……4………

 

 Insurance Plan Ex. C-7, copy of bill Ex. C-8, copy of letter dated 22.4.2014 Ex. C-9 and copy of bills Ex. C-10 to C-14 and closed the evidence. On the other hand, the opposite parties have produced the affidavit of  Sh. Rajnish Kohli, Assistant Vice President, Ex. OP-1, copy of OPD slip Ex. OP-2, copies of documents Ex. OP-3 to OP-9 and copy of proposal form Ex. OP-10 and closed the evidence.

4.   We have heard the arguments of Ld. Counsels of both the parties and also pursued the record placed on file. Ld. Counsel of the complainant has argued that the complainant Rekha had got the cashless Health policy from Star Health and Allied Insurance co. ltd. and  on feeling severe pain in heart she contacted Fortis Hospital Mohali for check up on 21.4.2014. On check up of the complainant in the Fortis Hospital it was detected that a hole has been developed in her heart  and they charged Rs. 17,550/- as diagnosis fee. The complainant informed  to the opposite parties for making payment to the hospital as the Health Policy was of cashless in nature. But the opposite parties rejected the pre-authorization for cashless treatment on the ground congenital heart diseases with severe  PAH. There is no proof/ evidence of any pre-disease. The deficiency in service on part of the opposite parties is established. Ultimately the complainant was admitted to Medanta Hospital Gurgaon on 26.4.2014 and the same was informed  to opposite parties telephonically and the complainant remained  admitted upto 4.5.2014 and got surgery of the heart. The authorities of Medanta

                          Rekha vs Star Health etc.

                              ……5………

Hospital  charged a total amount of Rs. 3,41,149.87 as a bill and the same has been paid by the complainant.

5           As the payment of Fortis Hospital bill had already been denied to pay, the complainant filed the present complaint in this forum for payment. The noticies were issued to the opposite parties  and they submitted the written statement accordingly. During the pendency of case there have been no discussion/correspondence among the complainant and the opposite parties. The Ld. Counsel of opposite parties argued that the complainant has not submitted his claim. On the other hand Ld. Counsel of complainant has argued, that as the claim of Fortis Hospital has already been rejected from the same policy that is why the complainant has knocked the door of the present Forum. The  Ld. Counsels of both the parties admitted that let the forum may decide the dispute.

6.           After hearing both  the Ld. Counsels, in our views, that Ld. Counsel of opposite parties was not able to prove that the disease of the complainant is pre-existing in nature. After going through the facts we are of the opinion that deficiency in service is established on part of the opposite parties. As the complainant had under gone a heart surgery from Medanta Hospital Gurgaon  and the same is covered in the policy. The complainant is entitled to get amount of Rs. 3,41,149.87 which has been paid by her to Medanta Hospital Gurgaon. So opposite parties are directed to pay a sum of Rs.341,149.87 to the complainant. As per bill of the Fortis Hospital

 

                        Rekha vs Star Health etc.

                                 ……6………

is concerned the same cannot be paid as that was for checkup purpose of the complainant. The order be complianced within one month after receiving the certified copy of the order. In case of failure the opposite parties will pay a simple interest of 9% p.a. to the complainant w.e.f. filing of complaint i.e. 1.9.2014 till its full realization of amount. Litigation fee amounting to Rs. 3100/- is also to be paid to the complainant. Copies of order be supplied to the parties under the rule. File be consigned to the record room after due compliance.

Announced on: 19.10.2015

                                                                Presiding, Member

 Member                                    District Consumer Disputes                                                          Redressal Forum, Jind

 

 

               

 

 

 

 

 

 

 

 

 

 

                        Rekha v/s Star Health etc.

                               

Present: Sh. Rajnish Garg, Adv. for complainant.

             Sh. Dalbir Sharma, Adv. for opposite parties.

            

                Arguments heard. To come up on  19.10.2015 for orders.

  Member                                                                    Presiding member

                                                                                    DCDRF Jind

                                                                                      15.10.2015

 

Present: Sh. Rajnish Garg, Adv. for complainant.

             Sh. Dalbir Sharma, Adv. for opposite parties.

            

             Order announced, vide our separate order of even date. The complaint is  allowed. File be consigned to record room.

Member                                                                    Presiding member

                                                                                    DCDRF Jind

                                                                                      19.10.2015