Chandigarh

DF-II

CC/768/2017

Pritpal Singh - Complainant(s)

Versus

Star Health and Allied Insurance Co. Ltd., - Opp.Party(s)

Devinder Kumar Adv.

27 Apr 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	768 of 2017
Date  of  Institution	:	04.10.2017
Date   of   Decision	:	27.04.2018

 

 

 

 

Pritpal Singh, H.No.614, Sector 18-B, Chandigarh.   

             …..Complainant

Versus

Star Health and Allied Insurance Co. Ltd., earlier at SCO 257, 2^nd Floor, Sector 44-C, Chandigarh, Now at SCO No.130-131-Top Floor, Sector 34-A, Chandigarh through its Manager.

    ….. Opposite Party 

 

BEFORE:  SH.RAJAN DEWAN             PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER 

                               

 

 

Argued by :- Sh.Devinder Kumar, Adv. for complainant.

             Sh.Puneet Jain, Adv. & Sh.Amit Gupta, Adv. for             Opposite Party

 

 

PER PRITI MALHOTRA, MEMBER

 

         Briefly stated, the complainant took a Mediclaim policy i.e. Senior Citizen Red Carpet Insurance Policy from Opposite Party for himself and his wife Jasbeer Kaur by paying premium of Rs.19,000/-, which was valid from 20.1.2015 to 19.1.2016 (Ann.C-1 & c-2 colly.). It is averred that the wife of the complainant suddenly fell ill and had severe chest pain on 29.9.2015 and she was taken to PGI, where she was advised angioplasty (Ann.C-3).  Accordingly, the wife of the complainant was admitted in PGI, Chandigarh on 7.10.2015 and stents were implanted by the doctors and a total amount of Rs.1,80,000/- was spent by the complainant on the said treatment (Ann.C-4 colly.).  Thereafter, the complainant lodged a claim with the Opposite Party and submitted all requisite documents.  However, the Opposite Party neither settled the said claim of the complainant nor repudiated it despite making several requests. Hence, this complaint has been filed alleging deficiency in service on the part of Opposite Party.  

 

2]       The Opposite Party has filed reply and while admitting the factual matrix of the case, stated that the wife of the complainant, prior to taking the medical policy from Opposite Party, was suffering from long-standing hypertensive ischemic coronary artery disease due to which she fell ill and had severe chest pain and was treated at PGI, Chandigarh. It is stated that present admission is due to complication of hypertension, which is included in the policy as pre-existing disease and for that the Opposite Party is not liable to make any payment during 1^st year of the policy.  It is also stated that the Opposite Party has rightly repudiated the claim of the complainant on the ground of pre-existing disease and the same was also communicated to the complainant vide letter dated 29.12.2015. Pleading no deficiency in service and denying rest of the allegations, the Opposite Party has prayed for dismissal of the complaint.

 

3]       Replication has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of the Opposite Party in reply. 

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the entire record.

 

6]       It is observed that the insurance companies often incline towards the rejection of the claim rather than honouring their commitment to indemnify the insured.

 

7]       In the present complaint, the repudiation of the claim raised by the complainant is taken as surprise that how the insurance companies are avoiding the genuine claims at the cost of their own enrichment. It is very well explained under the terms & conditions of the policy that in case treatment is availed for any pre-existing disease during the coverage period then fifty percent of the claim shall be payable. Acting contrary to its own terms & conditions, the Opposite Party wrongly repudiated the whole claim as raised by the complainant stating that the insured had taken the treatment for the complication of pre-existing disease and thus not covered for the reimbursement.  This outright rejection of the claim draws an adverse inference. Before finalizing the liability of the Opposite Party in the present complaint, we go a step further to mention that the complainant is not entitled for the amount so mentioned in the referred terms & conditions, but is entitled for the whole claim since the insured has not taken any treatment or incurred the expenses on the treatment of any pre-existing disease.

 

8]       Nowhere it has been opined by any expert of the Opposite Party nor proved that the ailment suffered by the insured was pre-existing or the ailment suffered by the insured was the complication of the pre-existing disease suffered by the insured.  Even if it is presumed that the present ailment suffered by the insured is complication of her pre-existing disease, even then there is no term & condition of the policy whereby the expenses incurred for the treatment of complication arising out of the pre-existing disease are not covered. There is no such whisper about the same in the terms & conditions as placed on record. Therefore, in view of the matter, we are of the opinion that the repudiation of the claim of the complainant done by the Opposite Party is totally unjustified, untenable and amounts to deficiency in service.    

 

9]       From the above discussion & findings, the deficiency in service on the part of Opposite Party has been proved, which certainly has caused harassment and humiliation to the complainant. Therefore, the complaint stands allowed against the OP. Accordingly, the Opposite Party is directed to reimburse the amount of Rs.1,80,000/- to the complainant along with interest @9% p.a. from the date of repudiation i.e. 29.12.2015 till payment and also to pay compensation amount of Rs.10,000/- to the complainant for rendering deficient services with litigation cost of Rs.7000/-.

 

         This order shall be complied with by the Opposite Party within a period of 30 days from the date of receipt of its certified copy, failing which the Opposite Party shall be liable to pay additional compensation cost of Rs.10,000/- apart from above relief.

 

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

27^th April, 2018                                                                                                                                                                      

(RAJAN DEWAN)

PRESIDENT

 

 

 

 (PRITI MALHOTRA)

MEMBER