Haryana

Kurukshetra

CC/319/2019

Bhavik - Complainant(s)

Versus

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

Gaurav Bansal

16 Mar 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION  KURUKSHETRA.

 

Consumer Complaint No.317 of 2019

Date of Instt.:  8.08.2019

Date of Decision:  16.03.2021.

 

Bhavik (minor) son of Sh.Puneet Sharma son of Sh.Vinod Sharma, resident of house No.107, Ward No.5-A, Bhagwan Nagar Colony, Pipli, Kurukshetra, minor through his father Sh.Puneet Sharma, being natural guardian and next friend.

                                                              …….Complainant.       

                                                   Versus

1.Star Health and Allied Company Limited, 15, Balaji Comp[lex, 1^st Floor, Whites Lane Royapettah, Chennai – 600014.

2. Star Health and Allied Company Limited SCO No.94, First Floor, Sector 17, B ack side of Hotel Silver Sand, Kurukshetra.

3. Star Health and Allied Company Limited Grievance Department no.1. New Street, Valluvar Kottam High Road, Nungambakkam, Chennai – 600034.

4. Star Health and Allied Company Limited Office of Insurance Ombudsman, SCO No.101, 102 and 103, 2^nd Floor, Batra Building Sector 17-D, Chandigarh 160017.                                                                                                                                                                                                   

                                                                ….…Opposite parties.

 

               Complaint under Section 12 of Consumer Protection Act.

 

Before        Smt. Neelam Kashyap, President.    

                   Ms. Neelam, Member. 

                   Shri Issam Singh Sagwal, Member.                           

 

Present:      Sh.  Gaurav Bansal counsel for the complainant.

                   Sh.Gaurav Gupta Advocate for OPs.

                  

 ORDER

                   This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by the complainant Bhavik    against Star Health and Allied Company Limited etc. - the opposite parties.

 

2.                In brief, the case of the complainant had purchased a medi claim insurance policy No. P/700002/01/2019/026833 and the premium was paid to the OPs. The said policy commenced from 28.11.2018 and was valid till 28.11.2019. It is submitted that OPs got conducted medical checkup of the complainant before issuance of the said policy and issued the said policy after satisfying themselves from the medical checkup of the complainant. It is further averred that the complainant met with an accident and was admitted in K.C.Sachdeva Hospital Karnal from 29.11.2018 to 2.12.2018 and spent an amount of Rs.1,00,000/- on his treatment.  It is submitted that the complainant approached the OPs and submitted the requisite documents for the claim but the OPs postponed the matter on one pretext or the other which amounts to deficiency in services on the part of the OPs. Thus, the complainant has filed the present complaint alleging deficiency in services on the part of the OPs and prayed that the OPs be directed to pay the claim of Rs.1.00 lacs alongwith interest, compensation for the mental harassment and agony caused to him and the litigation expenses.

 

3.                Upon notice, OPs appeared and filed written statement disputing the claim of the complainant.  It is submitted that the insured claim an amount of Rs.41,917/- in the first day of the policy. The patient was diagnosis as  DISPLACED FRACTURE SUB THROCHENTRIC RIGHT FEMER.  The insured Mr. Bhavik got hospitalized on Sachdeva Hospital- Karnal on 29.11.2018. The insured submitted pre-authorization request towards the treatment for ACS, on scrutiny of the pre auth document, the onset could not be ascertained, hence, the pre auth was denied and the same was informed to the insured to approach for reimbursement vide letter dated 29.11.2018. The insured sub seqeuent submitted the claim for reimbursement of medical expenses for Rs.41,917/- towards the above mentioned treatment. On scrutiny of the claim it was obse4rved that the insured availed online policy on 28.11.2018 at 09.54PM and he allegedly fallen down from scooty on 29.11.2018 at 10.00AM, whereas the findings of x-ray dated 29.11.2018 shows longstanding injury. It is submitted that based on the findings of x-ray their medical team was of the opinion that the insured patient had the above injury prior to inception of the first medical insurance policy.  The above findings show that the said injury is outstanding one and being pre existing is not covered under the said policy. Thus, it is submitted that there is no deficiency in services on the part of the OPs and prayed that the present complaint be kindly dismissed.

 

4.                The complainant in support of his complaint has filed affidavit Ex.CW1/A and tendered documents Ex.C-1 to Ex.C-19 and closed his evidence.

 

5.                On the other hand, OPs in support of their case have filed affidavit Ex.RW1/A and tendered documents Ex.R-1 to Ex.R-14 and closed their evidence.

 

6.                We have heard the learned counsel for the parties and gone through the material available on the case file very carefully.

 

7.                The learned counsel for the complainant while reiterating the averments made in the complaint has argued that complainant had purchased a medi claim insurance policy No. P/700002/01/2019/026833 and the premium was paid to the OPs. The said policy commenced from 28.11.2018 and was valid till 28.11.2019. It is further argued that OPs got conducted medical checkup of the complainant before issuance of the said policy and issued the said policy after satisfying themselves from the medical checkup of the complainant. It is further argued that the complainant met with an accident and was admitted in K.C.Sachdeva Hospital Karnal from 29.11.2018 to 2.12.2018 and spent an amount of Rs.1,00,000/- on his treatment.  It is argued that the complainant approached the OPs and submitted the requisite documents for the claim but the OPs postponed the matter on one pretext or the other which amounts to deficiency in services on the part of the OPs.

 

8.                On the other hand, learned counsel for the OPs while reiterating the contentions made in the written statement has argued that the proposal for the said policy was made on online on 28.11.2018 and the policy in question was issued on 29.11.2018.   It is argued that the complainant sustained injuries on 29.11.2018 at 10:00 AMPM  and was   admitted in the hospital only at 4.00PM. No FIR or DDR has been got registered regarding the said accident. Therefore, it is argued that the alleged injury is longstanding one and is not covered under the said policy and prayed that the present complaint be dismissed. It is also argued that the policy in question was issued from the office of OPs at Andheri (E)Mumbai and he got treatment at Karnal, therefore, this  Commission has got no jurisdiction to entertain and decide the present complaint. It is also argued that as per repudiation letter Ex.R-14, the injury in question was prior to inception of the first medical insurance policy and is pre existing one and as per waiting g period 3(iii) of the policy, the company is not liable to make any payment in respect of expenses for the treatment of the pre existing disease/condition, until 48 months of the continuous coverage has elapsed, since the date of commencement of the first year policy on 29.11.2018. Thus, it is argued that the present complaint may kindly be dismissed as the claim of the complainant has been rightly repudiated by the OPs.

 

9.                After hearing the learned counsel for the parties and going through the case file we are of the view that the claim of the complainant has been rightly repudiated by the OPs.  In this case, as per the complainant has sustained injuries on 29.11.2012 at 10.00AM and was got admitted in the hospital at 4.00PM only  but the OPs declined pre-authorization and complainant was asked for reimbursement. Thereafter vide Ex.C-7 the complainant applied for reimbursement of the claim. In this case, the complainant sent the proposal for  obtaining the said policy on line at 9.54pm and he allegedly got injury at 10.00AM but as per Ex.C-9 he was admitted in the hospital only at 4.00PM  and he has not got recorded any FIR or DDR regarding the said accident to prove that the complainant has received the said injury in accident. This lapse on the part of the complainant is fatal one and in the absence of any FIR or DDR it cannot be held that the complainant sustained the alleged injury in the accident  on 29.11.2021 especially when the complainant sustained injury on the very first day of commencement of the insurance policy.  Therefore, the OPs have rightly repudiated the claim of the complainant.

                    As discussed above, the complainant has failed to prove that he sustained the said injury in the accident on 29.11.2018 as no DDR or FIR has been got recorded by him regarding the said accident. So, as per waiting period 3(iii) of the policy as mentioned in the repudiation letter Ex.R-14, the said injury is not proved to be fresh after the policy and in such circumstances, the injury in question falls  in the waiting period 3(iii) and for such type of injury the company is not liable to pay because the company was only liable to pay for the treatment of such injury until  48 months of continuous coverage has been elapsed and the present injury allegedly took place within 24 hours of the online submission of the proposal form. Therefore, the said injury is proved to be pre existing and is not covered under the policy in question.

 

10.              In view of our above discussion, we do not find any merit in the present complaint and the same is hereby dismissed without any relief to the complainant. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

 

Announced in open commission:

Dt.:16.03.2021.                                                       (Neelam Kashyap)                                                                                                  President.

 

 

(Issam Singh Sagwal),              (Neelam)         

 Member                                     Member.