BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 310 of 2018
Date of Institution : 14.12.2018
Date of Decision : 28.05.2019
Parvesh Garg son of Sh. Sudamal Garg, resident of 81-B, Gali Dakotan Wali, Opp. Shani Mandir Sirsa, Tehsil and Distt. Sirsa.
……Complainant.
Versus
- Star Health and Allied Insurance Co. Ltd, Branch Office at Ground Floor, Opp. Shakti Motor, Near IDBI Bank, Dabwali Road, Sirsa, through its Branch Manager.
- Star Health and Allied Insurance Co. Ltd., 1 New Tank Street, Valluvar Kottam High Road Numgambakkam Channai-600034 through its authorized person/ Manager.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH.R.L.AHUJA………………. ……PRESIDENT.
SH.ISSAM SINGH SAGWAL ………MEMBER.
MRS. SUKHDEEP KAUR……………..MEMBER.
Present: Sh. Amit Goyal, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
The case of the complainant, in brief, is that complainant purchased a health insurance policy from opposite party no.1 at Sirsa for himself and for his family members including his wife Smt. Suman Garg vide policy No.P/211121/01/2018/001817 on 10.10.2017 against payment of Rs.12,856/- (previous policy No.P/211121/01/2017/000945) for a period of one year from 10.1.2017 to 9.10.2018 (it should be 9.1.2018) for sum assured of Rs.6,75,000/-. It is further averred that complainant is continue policy holder of ops and taking the health insurance policies from ops since five years i.e. from 10.10.2014 and present policy during the period of which the present claim of complainant lies. That wife of complainant namely Suman Garg was suffering with disease and diagnosed “Bulky uterus with large uterine fibroid” by Dr. Pankaj Garg, M.D. (Radiodiagnosis), Garg Diagnostic Centre, Sirsa vide USG whole abdomen dated 28.3.2017 and she started medication after diagnose of disease. However, the problem was still subsisting and on 21.8.2018 she again undergone USG whole abdomen on the advice of Dr. G.S. Gupta c/o Sigma Hospital, Sirsa and diagnosed “Bulky uterus with fibroid thickened endometrium” vide USG dated 21.8.2018 conducted by Dr. Mohit Mahipal, MD (Radiodiagnosis) c/o Ridhi Sidhi Diagnostic & Research Centre, Sirsa and ultimately on 6.92.2018 she got admitted for her treatment from Dr. G.S. Gupta of Sigma Hospital, Sirsa wherein on the advice of the doctor she again undergone antenatal sonography (TVS) and diagnosed “early intra-uterine pregnancy. Large intra-mural uterine fibroid” by Dr. Vishal Garg of Vishal Ultrasound and Diagnostic Centre, Sirsa. The complainant intimated the ops in this regard on even date and after treatment and operation, she was discharged on 10.9.2018. It is further averred that the complainant incurred total amount of Rs.50,000/- on her treatment including hospital charges, tests, medical bills. The complainant has submitted all the medical records, bills as well as other necessary documents as required by the ops. The complainant on the demands of ops has also submitted the certificate of the treating doctor. It is further averred that thereafter the complainant submitted the claim to the ops alongwith original bills as well as medical summary etc. That later on complainant provided all the relevant documents as demanded by the ops for verification and for settlement of medical claim and the ops started lingering the matter on one pretext or another and finally refused to entertain the claim of complainant on unreasonable ground without passing any speaking order. There is deficiency in service on the part of ops and the ops are intentionally delaying and refusing to entertain the claim of complainant. The complainant has been paying under Health insurance policy for more than last four years i.e. since the year 2014 continuously and the pre-condition or a waiting period if any is not applicable in the case of complainant. That the complainant has also sent legal notice to the ops but to no effect. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement asserting therein that true facts of the case are that insured availed Family Health Optima insurance policy covering Mr. Parvesh Garg- self, Suman Garg spouse, Prince Garg and Prachi Garg dependant children for the sum insured of Rs.5,00,000/- for the period 10.10.2014 to 9.10.2015, 10.10.2015 to 9.10.2016, 10.10.2016 to 9.10.2017 and 10.10.2017 to 9.10.2018 as per terms and conditions of the insurance policy believing that the information provided by the insured is true and correct. The claim was reported in the 4th year of the inception of the policy and claimed an amount of Rs.49,281/-. It is further submitted that insured patient, Mrs. Suman Garg was admitted in Sigma Hospital on 6.9.2018 and discharged on 10.9.2018 and as per discharge summary, the insured was diagnosed as Fibroid Uterus with early pregnancy and submitted claim for Rs.49,281/- towards reimbursement of medical expenses. On scrutiny of the claim documents, it is observed that as per discharge summary, the insured patient was admitted with the complaints of bleeding P/V and pain in abdomen, diagnosed with fibroid uterus with early pregnancy and underwent D&C with TAH with BSO. Thus, the answering ops have called for following documents vide letter dated 299.2018, 14.10.2018 and 29.10.2018:-
i. As per submitted documents mentioned as known case of uterine
fibroid, when it was first diagnosed.
ii. First consultation papers and investigations including the same.
iii. HPE reports.
iv. Complete OT notes.
v. All previous OPD consultation papers prior to this admission.
vi. Original final bill with breakup alongwith seal and sign.
It is further submitted that in reply, the insured submitted a self declaration letter, without the documents. The claim was again reviewed and observed that discharge summary of the above hospital shows that the insured patient has undergone treatment primary for complication related to pregnancy, which is not covered under the policy as per Exclusion No.13. Further as per the discharge summary, the insured has undergone D and E with TASH, thus the ops have raised query to submit HPE report, but the insured has not submitted the same. Hence, the claim was repudiated based on the exclusions and the same was communicated to the insured vide letter dated 17.11.2018. Remaining contents of the complaint are also denied and prayer for dismissal of complaint made.
3. The parties then led their respective evidence.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. Admittedly, the complainant had purchased health insurance policy from opposite party no.1 at Sirsa for himself and his family members including his wife Smt. Suman Garg on payment of Rs.12,856/- for period 10.1.2017 to 9.1.2018 and he is continue policy holder since 10.10.2014. As per averments made in the complaint, wife of complainant was suffering from a disease which was diagnosed as “Bulky uterus with large uterine fibroid” by Garg Diagnostic Centre, Sirsa vide USG whole abdomen dated 28.3.2017 and medication was started, but however, problem continued. She again undergone USG whole abdomen on the advise of Dr. G.S. Gupta of Sigma Hospital, Sirsa and diagnosed “Bulky uterus with fibroid thickened endometrium” vide USG dated 21.8.2018 conducted by Dr. Mohit Mahipal of Ridhi Sidhi Diagnostic & Research Centre, Sirsa and ultimately on 6.9.2018 she got admitted for treatment from Dr. G.S. Gupta in Sigma Hospital, Sirsa where she again undergone antenatal sonography (TVS) and diagnosed “Early intra-uterine pregnancy. Large intra-mural uterine fibroid” by Dr. Vishal Garg of Vishal Ultrasound and Diagnostic Centre, Sirsa. The complainant lodged claim with the opposite parties for an amount of Rs.50,000/- which was spent on the treatment of wife of complainant alongwith relevant documents, however, same was repudiated on 17.11.2018. In order to prove his plea in the complaint, complainant has tendered affidavit Ex.C1 in support of his plea taken in the complaint and also tendered copies of policy documents Ex.C2 to Ex.C6, copy of repudiation letter Ex.C7 and documents of the treatment taken by wife of complainant and bills etc. Ex.C8 to Ex.C35.
6. On the other hand, the opposite parties have furnished affidavit of Sh. Rajiv Jain Ex.RW1 in which he has deposed on the lines of their defence plea. He has categorically stated that the insured has submitted claim records towards reimbursement of medical expenses of Rs.49,281/- but however, on scrutiny of the claim documents it was found that insured patient Smt. Suman Garg was admitted in Sigma Hospital on 6.9.2018 and discharged on 10.9.2018 and as per discharge summary, the insured was diagnosed as Fibroid Uterus with early pregnancy and further as per discharge summary, the insured patient was admitted with complaints of bleeding P/V and pain in abdomen, diagnosed with fibroid uterus with early pregnancy and underwent D&C with TAH with BSO. The ops had called for the above said documents vide letters dated 29.9.2018, 14.10.2018 and 29.10.2018 and in reply, the insured submitted a self declaration letter without the document. He has further deposed that discharge summary of the above hospital shows that the insured patient has undergone treatment primarily for complication related to pregnancy which is not covered under the policy as per exclusion clause.
7. The perusal of the medical record of the Sigma Hospital reveals that wife of complainant had not approached the doctor of Sigma Hospital only with a motive of pregnancy test rather she was suffering from abdomen pain etc., as a result of which during course of investigation, it was found that she is suffering from uterus bulky in size and shows larges fibroid of size – 6.9 x 6.0 cms. which is evident from the report of Garg Diagnostic Centre, Sirsa dated 28.3.2017 Ex.C8 and again on 21.8.2018 Ridhi Sidhi Diagnositc & Research Centre vide report Ex.C9 reported that Urinary bladder is p;artially distended. Uterus is anteverted, bulky in size and shows hypoechoic lesion of size 85x75 mm in right lateral wall. ET is 15 mm. No gestational sac noted. No adnexal cyst or mass noted. So, it is proved fact on record that treatment given by doctor of Sigma Hospital, Sirsa was not only for the test of pregnancy but rather it was for the disease which was diagnosed by them. So, it appears from the evidence of parties that ops have arbitrarily and illegally repudiated the claim of complainant and as such order of repudiation is hereby set aside.
8. In view of above discussion, we allow this complaint and direct the opposite parties to settle and pay the claim of complainant as per terms and conditions of the policy within 45 days from the date of receipt of copy of this order, failing which the complainant will be entitled to interest @7% per annum on the claim amount from the date of order till actual realization. We further direct the ops to pay a sum of Rs.5000/- as composite compensation and litigation expenses to the complainant. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:28.05.2019. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member
DCDRF, Sirsa DCDRF, Sirsa
