Haryana

Karnal

CC/4/2018

Miss Avneet Kaur - Complainant(s)

Versus

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

Pardeep Gill

15 Nov 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                             Complaint No.4 of 2018

                                                         Date of instt. 04.01.2018

                                                         Date of decision:15.11.2018

 

Miss Avneet Kaur d/o Shri Vikramjit Singh Minor girl age about 14 years resident of house no.745, New Prem Nagar, near Aghi Market, Karnal now residing at House no.59, Friends Colony, Kaithal Road, Karnal through her father Shri Vikramjit Singh.                                                                                                                                                                                                …….Complainant

                                        Versus

 

1. Star Health and Allied Insurance Co. Ltd. no.15, Sri Balaji Complex, 1^st floor, Whites Lane, Roy Apettach Chennai-600014.

2. Star Health and Allied Insurance Co. Ltd. no.930/8, RJ Tower, Second floor, G.T. Road, opposite I.B. College, Panipat (Haryana)

3. Star Health and Allied Insurance Co. Ltd. opposite Mini Secretariat, Sector-12, Karnal through its Branch Manager.

 

…..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act.            

 

Before   Sh. Jaswant Singh……President.       

      Sh.Vineet Kaushik ………..Member

              Dr. Rekha Chaudhary……Member

 

 Present   Shri Pardeep Gill Advocate for complainant.

                Shri Gaurav Gupta Advocate for OPs.

               

                (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that the father of complainant Shri Vikramjit Singh had taken a mediclaim insurance policy namely “Family Health Optima Insurance Plan,” vide policy no.P/211112/01/2017/009010, valid from 24.02.2017 to 23.02.2018 for assured sum of Rs.5 lac. The complainant is also insured in the said policy, vide customer ID no.6625374-3. It is alleged that there was some differences between the father and mother of the complainant. Because of said differences, the mother of complainant namely Smt. Sonia was residing in her parental home at the relevant time of hospitalization of complainant. Due to the absence of her mother the health of the complainant started deteriorating day by day. Resultantly, on 28.07.2017 the health of complainant became serious. The father of complainant taken her to Virk Hospital Randhir Lane, near Dayal Singh college Karnal for medical check-up. The doctor concerned had admitted the complainant into the hospital and she remained under treatment since 28.07.2017 to 02.08.2017. Rs.35,000/- were incurred in her treatment. The intimation regarding the hospitalization of complainant was sent to OPs. The father of complainant lodged the claim with the OPs and submitted all the required documents, medical reports and medical bills etc. and had completed all the formalities for reimbursement of claim for hospitalization expenses but OPs repudiated the genuine claim of the complainant, vide letter dated 29.08.2017 without any justified grounds. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed their written version raising preliminary objections with regard to concealment of true and material facts; limitation; jurisdiction; mis-joinder and non-joinder of necessary parties and complainant is estopped by his own act and conduct from filing the present complaint. On merits, it is pleaded that the insured availed Family Health Optima Insurance Plan, vide policy no.P/211112/01/2017/009010 for the period of 24.02.2017 to 23.02.2018 covered Vikramjit Singh-self, Sonia-spouse, Avneet Kaur, Vanshpreet Kaur & Channdeep-daughters for the sum insured of Rs.5,00,000/-. The claim was reported in the 5^th month of the policy. The insured was admitted at Virk Hospital, Karnal on 28.7.2017 for the treatment of AC Anxiety Disorder/Inflammatory Arthritis and submitted claim records for reimbursement of medical expenses. On scrutiny of the claim records, it is observed that:

        As per Discharge summary, the insured was admitted on 28.07.2017 and discharged on 2.8.2017 and diagnosed as AC Anxiety Disorder/Inflammatory Arthrtitis.

As per exclusion clause no.3 © of the policy, the company is not liable to make any payment in respect of any expenses incurred by the insured person during the first two years of continuous of the policy on all treatments (conservative, interventional, laparoscopic and open) related to all diseases of uterus, fallopian tubes, cervix and ovaries, dysfunctional uterine bleeding, pelvic inflammatory diseases, benign breast diseases. Thus, the claim was not payable during the first two years of the continuous of policy. Hence, the claim of the complainant was repudiated, vide letter dated 29.08.2017. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence her affidavit Ex.CW1/A and documents Ex.C1 to Ex.C26 and closed the evidence on 5.7.2018.

4.             On the other hand, OPs tendered into evidence affidavit of Rajiv Jain Ex.RW1/A and documents Ex.R1 to Ex.R11 and closed the evidence on 15.10.2018.

5.             We have heard the learned counsel for both the parties and perused the case file carefully and have also gone through the evidence led by the parties.

6.             The case of the complainant is that the father of the complainant had taken Family Health Optima Insurance Plan from OPs and complainant was also insured under the said policy. The mother of the complainant left her house due to differences between her father and complainant got hospitalized due to absence of her mother. Resultantly, the health of the complainant stated deteriorating day by day and complainant become serious. Complainant remained under treatment since 28.07.2017 to 02.07.2017 in Virk Hospital, Karnal. Rs.35000/- were incurred in the treatment. The father of the complainant had lodged a claim with OPs alongwith medical bills but the claim was repudiated without any justified ground.

7.             On the other hand, the case of the OPs is that the insured was admitted at Virk Hospital, Karnal on 28.07.2017 for the treatment of AC Anxiety Disorder/Inflammatory Arthritis and submitted claim records for reimbursement of medical expenses. On scrutiny of the claim records, it is observed that:

        As per Discharge summary, the insured was admitted on 28.07.2017 and discharged on 2.8.2017 and diagnosed as AC Anxiety Disorder/Inflammatory Arthrtitis.

The above finding confirms that the insured has undergone treatment for Inflammatory Arthritis, which is during the first year of the policy and as per the terms and conditions of the policy, the company is not liable to make any payment in respect of any expenses incurred by the insured during 1^st two years of continuous operation of insurance cover. The claim was rightly repudiated as per abovesaid terms and conditions of the policy.

8.             Admittedly, the father of the complainant had purchased Family Health Optima Insurance Plan from the OPs and complainant was also insured in the said policy. The treatment taken by the complainant is also admitted. The complainant incurred Rs.35000/- for the treatment at Virk Hospital, Karnal. This fact was not revert by the OPs by way of leading any cogent evidence. There is no record on the file to prove that complainant has pre-existing disease. It is not possible for any layman to read over and understand all the terms and conditions which are in a large number of papers. Thus, the OPs cannot take the shelter of such conditions and there is a deficiency on the part of the OPs.

9.             Thus, as a sequel to above discussions, we allow the present complaint and direct the OPs to pay the medical claim to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization.  We further direct the OPs to pay Rs.5500/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:15.11.2018

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

               

        (Vineet Kaushik)                (Dr. Rekha Chaudhary)

            Member                               Member