Chandigarh

DF-II

CC/492/2019

Rajinderpal Singh Athwal - Complainant(s)

Versus

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

S.S. Panag Adv. & T.P.S. Bawa Adv.

09 Jun 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	492 of 2019
Date  of  Institution	:	28.05.2019
Date   of   Decision	:	09.06.2020

 

 

 

 

 

1]  Rajinderpal Singh Athwal son of Sh.Sukhbir Singh, resident of H.No.2050, Sector 15-C, Chandigarh

 

2]  Simran Athwal wife of Rajinderpal Singh Athwal, resident of H.No.2050, Sector 15-C, Chandigarh

             …..Complainants

 

Versus

 

Star Health and Allied Insurance Co. Ltd., through its Managing Director, having its regional office at SCO No.130-131, Sector 34-A, Chandigarh.

    ….. Opposite Party

 

 

BEFORE:  SH.RAJAN DEWAN              PRESIDENT

         SMT.PRITI MALHOTRA             MEMBER 

                    SH.B.M.SHARMA                      MEMBER

                               

For Complainant      :    Sh.T.P.S.Bawa, Advocate

For OP(s)            :    Sh.Gaurav Bhardwaj, Advocate

 

 

PER PRITI MALHOTRA, MEMBER

          The case of the complainants, in brief, is that they had obtained a Medi-claim Policy i.e. LIC’s ‘Jeevan Arogya’, commenced from 28.3.2013 and continued till March, 2018 (Ann.C-1 to C-5) and thereafter shifted/ported with OP Insurance Company since 07.3.2018.  Accordingly, the OP issued policy Ann.C-6 effective from 7.3.2018 to 7.3.2019 and the same got renewed further for the period from 7.3.2019 to 6.3.2020. It has been averred that unfortunately, the complainant No.2 on 8.3.2019 suffered extreme pain in her abdomen and heavy bleeding.  Thereafter, tests got conducted and the doctor advised her that she had developed Hypertrophied fibroid uterus and advised immediate surgery. Accordingly, the complainant No.2 was admitted in Chuttani Medical Centre Nursing Home, Sector 17, Chandigarh, where she was operated upon on the same day and was discharged on 16.3.2019.  It has further been averred that after surgery, complainant No.2 remained under OPD treatment of Dr.R.S.Sachdeva.  It has been claimed that after her operation, she contacted urinary tract infection (UTI) as a result of which she remained under continuous medical supervision and was administrated antibiotic injections & tablets uptill 15.5.2019. After being recovered, the complainant No.2 filed claim with OP along with all requisite documents for reimbursement of medical expenses incurred on the said treatment.  However, the OP repudiated the said claim vide letter dated 30.4.2019.  Hence, this complaint has been field alleging the said repudiation of claim as illegal and a deficient act on the part of OP.

 

2]       The OP has filed reply and while admitting the factual matrix of the case about the issuance of policy in question, about lodging of claim by the complainants, stated that on scrutiny of the claim record, it revealed that the insured patient had undergone hysterectomy for the disease which is during second year of the policy and hence not payable as per waiting period 3(ii) of the policy in question.  It is also averred that the patient has undergone tubal ligation surgery, which involved cutting and tying off the fallopian tubes and the same is for family planning, which is excluded as per Exclusion clause No.13 of the policy.  It is stated that the policy issued in the year 2018 was a fresh policy and it was not a portability case, only fresh proposal form was filled by the complainants and no portability form has been filled or any request for porting the said policy was given.  It is also stated that since the claim of the complainants falls under 2 years waiting period, thus the claim was rightly repudiated by the company. Denying all other allegations and pleading no deficiency in service, the OP has prayed for dismissal of the complaint.

 

3]       Parties led evidence in support of their contentions.

 

4]       We have heard the ld.Counsel for the OP and have perused the entire record including written arguments of complainants.   

 

5]       All the documents pertaining to the health insurance policies obtained by the complainant from LIC for the period from 28.3.2013 to 28.3.2049 (Ann.C-1), paid perium thereof upto March, 2018 (Ann.C-2 to C-5) and policy documents Ann.C-6 & Ann.C-7 of Star Health Insurance Company (OP), reveals that the complainants remained duly covered under the health insurance policies since 2013 initially through LIC of India and thereafter in March, 2018 shifted with OP-Star Health & Allied Insurance Company, without any gap. It is also not in dispute that the complainant No.2 was treated for Hypertrophied Fibroid Uterus during the currency of health insurance policy coverage period from 7.3.2019 to 6.3.2020 and incurred expenses thereupon. 

 

6]       The claim lodged with the OP was rejected vide letter dated 30.4.2019 (Ann.C-10) on the following grounds as mentioned in the reproduction letter:-

 

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of hypertrophied fibroid uterus.

 

It is observed from the submitted medical records that the insured patient has undergone hysterectomy for the above disease which is during second year of the policy. 

 

As per waiting period 3(ii) of the above policy, the Company is not liable to make any payment in respect of any expense incurred by the insured person for treatment of the above mentioned disease during the first two years of continuous operation of the insurance cover. 

 

Further as per the OT notes, the patient has undergone tubal ligation.

 

As per Exclusion No.13 of the policy, the Company is not liable to make any payment in respect of any expenses incurred by the insured person for family planning. 

 

We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.”

 

7]       After having meticulously gone through the documents placed on record and giving due consideration to the repudiation letter of the OP, it has been observed that the genuine claim of the complainants has been rejected by taking very hyper technical opinion by the officials of the OP Insurance company.

 

8]       The repudiation letter reveals that the claim of the complainant has been rejected on two grounds; one as per waiting period claiming that since the policy in question was in the second year, so as per terms & condition No.3(ii) of the policy, the expenses incurred for the treatment of said disease during the first two years of continuous operation of the insurance cover, are not payable.  Secondly, the patient has undergone tubal ligation and as per Exclusion No.13 of the policy, the Company is not liable to make any payment in respect of any expenses incurred by the insured person for family planning.

 

9]       As regards the first ground of rejection, it is well settled preposition of law that the waiting period shall not however apply in the case of the insured person/s having been covered under any individual health insurance scheme with any of the Indian General/Health Insurer for a continuous period of preceding 24 months without any break. 

 

10]      In our opinion, the complainants shall not be deprived of their right recoursing to the technical view by the OP company.  The OP cannot escape from its liability to pay the genuine claim to the complainants.  It is well proved on record that the complainants remained covered under the LIC Policy since 2013 till they shifted to OP Company and that too without any gap of single day.  Thus, the complainants are duly entitled for the continuation benefit and their case has wrongly been processed by the OP Insurance Company.

 

11]      The second ground taken by the OP that they are not liable to make any payment in respect of any expenses incurred by the insured person for family planning procedure, is also not sustainable and also reveals that the case of the complainant has not thoroughly been examined by the Officials concerned of the OP.  From the medical record, it has clearly been established that the age of the patient is 50 years and it is only by virtue of her medical condition that she was operated for tubal ligation and that too was done only when the treating doctor, the expert person, advised so.  The said operation was not by choice of complainant No.2 exclusively for any family planning, but was done as per the advise of the treating doctor.

 

12]      From the above discussion and findings, we are of the opinion that the OP has wrongly rejected the genuine claim of the complainant No.2/Simran Athwal and thereby rendered deficient services. Therefore, the present complaint is allowed with directions to the Opposite Party to reimburse an amount of Rs.82,006/- (as claimed vide claim form   Ann.C-9) to the complainant No.2, subject to the bills submitted by her.  The OP is also directed to pay compensation amount of Rs.10,000/- to the complainant No.2 for causing mental agony, harassment, along with litigation cost of Rs.7,000/-.

         This order shall be complied with by the OP within a period of 30 days from the date of receipt of copy of this order, failing which they shall also be liable to pay additional cost of Rs.20,000/-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

9^th June, 2020                                                                                                                                                               Sd/-  

(RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

 

Sd/-

(B.M.SHARMA)

MEMBER