BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 234 of 2018
Date of Institution : 24.09.2018
Date of Decision : 09.04.2019
Sahil Arora aged about 33 years son of of Shri Rajender Kumar Arora, Advocate r/o House No.143, Multani Colony, Sirsa.
……Complainant.
Versus.
- Branch Manager, Star Health and Allied Insurance company Limited, Ground Floor, Rathor Towers, Near IDBI Bank, Dabwali Road, Sirsa.
- Star Health and Allied Insurance Company Limited, No.15, SRI Balaji Complex, First Floor, whites Lane, Royapettah, Chennai-600014.
...…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. R.K.Arora, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
The case of the complainant, in brief, is that the complainant purchased a Health policy bearing No.P/211121/01/2018/000548 in the name of his father Shri Rajender Kumar Arora in the year 2015 now w.e.f. 07.06.2017 to 06.06.2018. That the father of the complainant was suffering from stomach problem and was admitted to R.Gagan Gastro Care, Bhatinda on 20.09.2017 and was discharged on 21.09.2017. Due intimation was given to the Ops for the claim under intimation No.CLI-2018-211121/0320681 dated 20.9.2017. The complainant has spent Rs.19500/- on the treatment of his father and also submitted the bills and other documents to the Ops but in the month of December, 2017, the Op No.1 rejected the medical claim with remarks that the policy holder is having anxiety problem, which is not covered under this policy, so due to that the policy holder is not entitled to get any medical claim. The complainant requested to Ops for reimbursement of the expense insured on the medical treatment of his father and also got served legal notice but to no avail. The act and conduct of the Ops clearly amounts to deficiency in service on their part.
2. On notice, opposite parties appeared and filed written statement taking certain preliminary objections. It is submitted that true facts of the case are that complainant/insured had availed Family Health Optima Insurance Policy vide policy No.P/211121/01/2017/001952, covering Rajender Kumar Arora, for the period 13.05.2015 to 12.05.2016, P/211121/01/2017/000102 for the period 13.05.2016 to 12.05.2017 and policy No.P/211121/01/2018/000548 for the period 07.06.2017 to 06.06.2018 for a sum assured of Rs.3 lacs. The insured had submitted 4 claims in the third year of the policy vide claim Nos. CLI/2018/211121/0336224, CLI/2018/211121/0314750, CLI/2018/ 211121/0566630 and out of which the claim No. CLI/2018/211121/ 0566630 was registered towards the treatment of Fracture Tibia (left leg) which was settled as per terms and conditions of the policy. The insured was admitted in R.Gagan Gastro Care, Bhatinda on 20.9.2017 and got discharged on 21.09.2017 and the patient was diagnosed with Anxity Neurolsis. As per discharge summary the insured was diagnosed with chief complaint of constipation, loss of appetite and vomiting with Anxity Neurolsis but as per exclusion clause No.6 the company is not liable to make any payment in respect of expenses incurred at hospital for treatment of psychiatric, mental and behavioral disorder. The claim was rightly repudiated vide letter dated 20.11.2017. It has been submitted that the complainant has not come to this Forum with clean hands; that he has no cause of action to file the present compliant; that this Forum has no jurisdiction to entertain and decide the present complaint; that the present complaint is time barred and even the complainant has not submitted any proof regarding payment of any consideration. Other contentions have been contorverted and prayer for dismissal of the complaint has been made.
3. Thereafter, both the parties have led their respective evidence.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. The complainant in order to prove his case has placed on record copies of documents such as certificate issued by R.Gagneja Gastro Care Ex.CW1/, Receipts Ex.CW2 to Ex.CW4, Bills Ex.CW5, Ex.CW6, Colonscopy report Ex.CW7, Ultrasound report Ex.CW8, prescription slip Ex.CW9, discharge summary Ex.CW10, report of tests Ex.CW11 to Ex.CW16, prescription slip Ex.CW17, certificate of doctor Ex.CW18 and policy certificate Ex.CW19. On the other hand, the opposite parties have furnished affidavit of Sh.Rajiv Jain, Chief Manager as Ex.RW1, in which, he has reiterated the averments of the written statement. The OPs have also furnished copies of documents such as claim form Ex.R1, proposal form Ex.R2, copy of policy plan and schedule Ex.R3 and Ex.R4.
6. Admittedly, the complainant has purchased a health policy for his father from the OP in the year 2015 under policy No. P/211121/01/2018/000548 now w.e.f 07.06.2017 to 06.06.2018. During the validity of the policy, the father of the complainant was suffering from stomach problem and was admitted to R.Gagan Gastro Care Hospital, Bhatinda on 20.09.2017 and got treatment for the stomach problem till 21.09.2017. He has spent Rs.19500/- on his treatment which includes the medicine bills, doctor expenses and test expenses.
7. The complainant has lodged claim with the OP for the reimbursement of the expenses, but however, the claim of the complainant was repudiated in December, 2017 on the ground that the insured was having anxiety problem, which is not covered under this policy and, as such, he is not entitled to any medical claim.
8. The perusal of the repudiation letter dated 20.12.2017 reveals that the insured was the patient of Anxiety Neurosis. So, it appears from this letter of repudiation that the official of the Ops formed their opinion only on the basis of the documents submitted by the complainant. They have not sought the opinion of their expert/TPA, who are the competent persons to examine and evaluate the reports of investigations as well as the treatment given to the patient. But, in the present case, the Ops have never approached any TPA to get the investigation report examined and to examine the treatment chart as per the discharge summary given by the concerned doctor. The Ops have also not placed on record any affidavit of any expert person or any other competent official of the Ops, who is expert in this field and they have only filed affidavit of Sh.Rajiv Jain, who is Chief Manager of the Ops/insurance company.
9. The perusal of the complaint reveals that the insured Rajender Kumar Arora, is an Advocate by profession and he is a regular legal practitioner and advises to the litigants for their legal problems whereas the present claim has been declined by the Ops, on the ground that the insured was suffering from anxiety. So, it appears that the Ops have repudiated the claim of the claimant in a very ordinary and casual manner without getting the opinion of the expert of this field. So, the repudiation letter is liable to be rejected. It is the legal obligation of the Ops to provide necessary services to the insured who has got the policy for his medical reimbursement and non-providing of services clearly amounts to deficiency in service on the part of the Ops.
10. In view of the above discussion, we hereby allow the present complaint with a direction to the Ops to settle and pay the claim, in accordance with law, within a period of 30 days from the date of receipt of the copy of this order. The Ops are further directed to pay interest @ 7 % per annum from the date of lodging the claim till its realization. The Ops are further directed to pay Rs.2,000/- to the complainant as composite compensation for harassment and litigation expenses. A copy of this order be sent to both the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated: 09.04.2019 District Consumer Disputes
Redressal Forum, Sirsa.
Member Member
DCDRF, Sirsa DCDRF, Sirsa
