Amandeep Singh son of Shri Daya Singh, resident of village Ayalki, Tehsil and District Fatehabad.
…Complainant.
Versus
1.Star Health and Allied Insurance Limited, S.C.O.No.149, 2nd Floor, Red Square Market, Hisar District Hisar through its Manager.
2.Star Health and Allied Insurance Company Limited, Regd. and Corporate Office at 1, New Tank Street Valluvar Kottam High Road Nungambakkam, Chennai-600 034, through its Manager/Director.
3.Anshu Sethi, Authorized Agent or Respondent Company R/o H.No.63/2, Model Town , Fatehabad.
…Opposite Parties.
Complaint U/s 12 of the Consumer Protection Act, 1986
Before: Sh.Raghbir Singh, President.
Sh. M.K. Khurana, Member.
Present: Sh.R.K.Meena, counsel for the complainant.
Sh.Sachdev Bishnoi, counsel for the OPs no. 1 and 2.
OP no. 3 already ex-parte.
ORDER:
The present complaint under Section 12 of Consumer Protection Act, 1986 has been filed by the complainant against the Opposite Parties (hereinafter to be referred as OPs) with the averments that on 17.02.2016 OP No.3 who is Authorized Agent of Ops no.1 and 2 contacted to the complainant at Fatehabad and told about the benefits of the insurance policy of the OPs and convinced the complainant to purchase insurance policy without telling the terms and conditions of the insurance policy. Thereafter the complainant paid a premium of Rs.9504/- to OP no.3 at Fatehabad for getting insured the life of his wife Gurinder Kaur and his son Tej Partap Singh having validity for the period 17.2.2016 to midnight 16.02.2017.
2. It is further submitted that in the month of April, 2016 the complainant met with an accident and as a result of the same, tooth of the complainant was operated and as such expenditure of Rs.10,400/- was incurred by the complainant on his treatment. However, the OPs declined for making payment of the above said expenditure on the ground that treatment of tooth is not covered under the said insurance policy.
3. It is further submitted that in the month of May 2016, the complainant was in need of continuous psychiatric treatment and in this regard when he contacted to the OPs then the OPs refused to provide expenditure of the same on the ground that psychiatric treatment is not covered under the above said policy.
4. It is further submitted that in the month of July 2016, Tej Partrap Singh son of the complainant all of sudden felt severe pain in his left side of lower abdomen and as such Tej Partap Singh was taken in Amar Hospital, Patiala wherein after medical checkup and necessary tests Tej Partap Singh was advised to get operated for varicocele vein 3rd stage and as such Sh.Taj Partap Singh was operated in the month of September 2016. At that time also the complainant contacted the OPs for making payment of the expenditure incurred by him on the treatment of Tej Partap Singh, then also the OPs declined to make payment on the ground that the disease of varicocele vein is not covered under this policy and no insurance claim was given by the Ops. The complainant had incurred approximately expenditure of Rs.50,000/- on the treatment of his son Tej Partap Singh as he was operated on 13.09.2016. It is further submitted that at the time of issuance of the insurance policy the complainant was told by the OPs that all types of disease are covered under the insurance policy in question, but as and when the complainant was in need of help, then it was told to the complainant that the disease are not covered under the aforesaid policy. Thereafter a legal notice was also duly got served to the OPs, but no reply was given to the complainant of the above said legal notice.
5. Thereafter, the complainant filed a consumer complaint before this Forum against the Ops. On being served Ops appeared in the Court and filed an application that the complaint filed by the complainant was pre-mature and asked the complainant to submit the documents for settling the claim. Therefore, the complainant withdraw the above said complaint from this Forum on 27.3.2017 and the complainant again submitted the documents as per instructions of the Ops. However the Ops delayed the matter on one pretext or the other and did not give satisfactory reply to the complainant. However, finally the OPs flatly refused to make payment of the expenditure incurred by the complainant on treatment. The above said act on the part of Ops amounts to deficiency in rendering service to the complainant. The complainant has further prayed that the Ops may be directed for making payment of total amount of Rs.90,800/- incurred by him for treatment under the above said policy. The complainant has further prayed that the Ops may be directed the Ops for making a payment of Rs.50,000/- as compensation and Rs.11,000/- as litigation charges. Hence, the present complaint.
6. On being served, Ops No.1 and 2 appeared and resisted the complaint by filing a written statement wherein various preliminary objections with regard to maintainability, suppression of material facts, mis-joinder and non-joinder of necessary parties, cause of action and jurisdiction etc. have been raised.
7. In reply on merits, it is denied that Mrs. Anshu, is authorized agent of the answering Ops and is residing at Fatehabad. She has been arrayed as a party just to make jurisdiction of this Forum. It is further submitted that the complainant has cooked up fabricated and false story to grab the money from the answering Ops. It is admitted by the Ops that the above said policy valid from 17-2-2016 to 16-2-2017 was obtained by the complainant from the answering Ops. It is further submitted that the Family Health Optima Insurance policy which was obtained by the complainant does not cover accidental benefits. As per Exclusion Clause No.5, the dental treatment is also not covered under the above said policy. It is also further submitted that as per Exclusion Clause No.3 of the above said insurance plan, the company is not liable for making payment in respect of expenses incurred by the insured person for treatment of the ailments i.e. VERICOCELE WITH REDUCE TESTICULAR SIZE during the first two years of continuous operation of the insurance cover. It was the first year of the policy as the policy was issued to the complainant valid from the period 17.2.2016 to 16.2.2017 and the insured was admitted in the hospital and surgically operated in the first year of the policy. It is also further submitted that the complainant had filed a complaint for the same claim and the same was dismissed as withdrawn vide order dated 27.03.2017 by this Forum.
8. It is further submitted that there is no deficiency on the part of OPs in repudiating the claim of the complainant. The repudiation of the claim is perfectly in accordance with the terms and conditions of the policy and as such same is sustainable in the eyes of law. The Op no.1 has further prayed for dismissal of the present complaint being devoid of any merits.
9. Despite proper service OP no. 3 did not appear before this Forum and as such he was proceeded against ex-parte vide order dated 9.10.2017.
10. The learned counsel for the complainant tendered affidavit of the complainant in evidence as Annexure CW1/A along-with documents as Annexure C-1 and C-25. On the other hand, Sh. N.Gopalan, Chief Manager tendered in evidence his affidavit as Ex.R1 on behalf of OPs No.1 and 2. The OPs No.1 and 2 also tendered in evidence the documents as Annexure R2 to Annexure R9 and closed the evidence.
11. We have duly considered the arguments advanced by learned counsel for the parties and have also perused the entire material placed on record. Vide the present complaint the complainant has inter-alia claimed an amount of Rs.10,400/- from OPs for expenditure incurred by him for treatment of his tooth and Rs.30,000/- for expenditure incurred by him for treatment of psychiatric problem. A perusal of the terms and conditions of the policy in question reveals that treatment of tooth and treatment of psychiatric problem is not covered under the policy in question. Therefore, the claim of the complainant for getting a payment of Rs.10,400/- for treatment of his tooth and claim of Rs.30,000/- for psychiatric treatment is not made out.
12. Regarding the claim for treatment of the son of complainant for an amount of Rs. 45,000/-. It is not disputed that life of Tej Partap Singh was insured by the OPs No.1 and 2 and the validity period of insurance was 17.02.2016 to mid-night 16.02.2017. It is also not disputed that an amount of Rs.9504/- paid by the complainant for insurance of the life of Tej Partap Singh and Sh.Gurinder Kaur. It is also not disputed that Tej Partap Singh life insured had taken treatment of the ailments during the subsistence of the policy in question. From Annexure 18, it is evident that an expenditure of Rs.45,000/- was incurred for treatment of Tej Partap Singh. Therefore we are of the considered opinion that the repudiation of the insurance claim qua the expenditure incurred by the complainant on treatment of Tej Partap Singh is not in accordance with the law. Therefore the repudiation of the insurance claim qua the treatment of Tej Partap Singh by the OPs is hereby set aside.
13. In view of the aforesaid discussion, the present complaint is partly allowed and the OPs No.1 and 2 are directed for making a payment of Rs.45,000/- (Rs. Forty five thousand only) to the complainant as expenditure incurred for treatment of his son alongwith an interest @ 8% per annum from the date of filing of the present complaint till realization. No deficiency is proved against OP no. 3. The Ops No.1 and 2 are further directed to make compliance of the present order within a period of 45 days, failing which the above said amount will carry an interest @ 12% per annum for the default period. Copy of this order be supplied to the parties free of costs. File be consigned to record room after due compliance.
Announced in open Forum. Dated:20.06.2018
(Raghbir Singh)
President (M.K.Khurana)
Distt. Consumer Disputes Member
Redressal Forum, Fatehabad.
