BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 317 of 2017
Date of Institution : 05.12.2017
Date of Decision : 13.03.2019
Jagdish Chander son of Shri Hazari Ram resident of House No.214, Sector 20, HUDA, Sirsa.
……Complainant.
Versus.
- Star Health & Allied Insurance Co. Ltd., through its Branch Manager, Office at Ground Floor, Opp.Shakti Motor,Near IDBI Bank, Sirsa-125055.
- Star Health & Allied Insurance C.Ltd. Through its EO/authorized signatory/person Registered & Corporate Office: 1, New Tank Street, Valluvar Kotam High Road, Nungambakkam, Chennai-600034.
- Star Health & Allied Insurance Company Ltd., through its authorized signatory/person,corporate office- Claims Department: KRM Center, 6th Floor, No.2 Harrington Road, Chetpet, Chennai 600031.
...…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. Lucky Duggal, 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 Family Health Optima Insurance Plan policy No.P/211121/ 01/2017/001952 dated 18.02.2017 and paid the premium to the tune of Rs.12,759/-. That the complainant felt ill and due to infection in stomach he remained under treatment from Vishvas Psychiatric & De-Addiction Hospital, Sirsa for a long period and spent Rs.38,000/- on his treatment. As per terms and conditions of the policy, he approached the office of Op No.1 and also deposited all the requisite documents besides completing all the formalities for reimbursement but the Ops have lingered on the matter on one pretext or the other and not settled/paid the maturity amount of the plan to the complainant despite the fact that the policy plan of the complainant has already been matured. The act and conduct of the Ops clearly amounts to deficiency in service on their part as the Ops did to adhere to the claim of the complainant and it is presumed that the claim has been repudiated without assigning any reason because the Ops have flatly declined for indemnifying the claim. That the complainant also got sent a legal notice to the ops on 13.11.2017 but to no effect. Hence, this complaint.
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 Branch Office of answering ops has issued Family Health Optima Insurance Policy vide policy No.P/211121/01/2017/001952 for the period 18.02.2017 to 17.02.2018 covering Jagdish Chander self, Mrs. Vijay Luxmi spouse, for the sum insured of Rs.5,00,000/-. The insured complainant/Jagdish was hospitalized at Vishwas Psychiatric & Deaddiction Hospital-Sirsa on 29.03.2017 for the treatment of Bipolar Mood Disorder and submitted claim records for reimbursement of medical expenses but on scrutiny of above said claim records, it was observed that As per discharge summary, the patient admitted with complaints of talking excessive, Decrease Sleep, wandering away behavior, angry, abusive and diagnosed as Bipolar Mood Disorder and as per Exclusion Clause No.6 of the above said policy, the company is not liable to make any payment in respect of expenses incurred at hospital for treatment of psychiatric and behavioral disorder and hence, the claim was repudiated vide letter dated 02.06.2017 which was duly communicated to the complainant/insured. There is no deficiency in service on the part of Ops and the claim has rightly been repudiated. Objections about maintainability, cause of action, locus standi, jurisdiction, complainant does not fall within the purview of consumer and he has not approached to this Forum with clean hands etc. have been taken. Other pleas mentioned in the complaint have been controverted and prayer for dismissal of the complaint has been made.
3. Thereafter, both the parties have led their respective evidence. The complainant produced his affidavit Ex.CW1/A besides documents Ex.C1 to Ex.C14. On the other hand, ops produced affidavit of Sh. N.Gopalan Ex.RW1 and documents Ex.R1 to Ex.R9.
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 furnished his affidavit Ex.CW1/A wherein he has reiterated all the averments made in his complaint. The complainant has also placed on record copies of documents Ex.C1 to Ex.C14 as mentioned above. On the other hand, the opposite parties have furnished affidavit of Sh. N.Gopalan, Chief Manager as Ex.RW1 in which he has reiterated the averments of the written statement. The OPs have also furnished copies of documents as Ex.R1 to Ex.R9.
6. It is admitted fact on record that the complainant had purchased Family Health Optima Insurance Policy from the opposite parties vide policy No.P/211121/ 01/2017/001952 dated 18.02.2017 and paid the premium to the tune of Rs.12,759/-. It is also proved fact on record that complainant felt sick and suffered with the serious infection in his stomach and remained under treatment from Vishvas Psychiatric & De-Addiction Hospital, Sirsa for a long period. He has claimed a sum of Rs.38,000/-approximately incurred by him on account of medicines, doctor fees as well as on other expenses. After discharge from the hospital, the complainant has lodged claim with the Ops and submitted all the requisite documents but however, the claim of the complainant was repudiated by the Ops vide repudiation letter Ex.R9 on the ground that As per exclusion No.6 of the above said policy, the company is not liable to make any payment in respect of expenses incurred at hospital for treatment of psychiatric and behavior disorder. The perusal of the discharge summary Ex.R3 reveals that provisionally and finally the disease of the complainant was diagnosed as Bipolar mood disorder current episode mania. The Clause 6 of the terms and conditions of the policy, which has been placed on file as Ex.R1, is hereby reproduced as under:
6. Convalescence, general disability, run-down condition or rest cure, nutritional deficiency states, psychiatric, mental and behavioral disorders, congenital external disease of defects of anomalies, venereal disease and sexually transmitted diseases, intentional self injury and use of intoxicating drugs/alcohol, smoking and tobacco chewing.
The perusal of the proposal form Ex.R8 reveals that the complainant has made declaration that he is not suffering from any disease though he was suffering from disease Bipolar mood disorder current episode mania. So, it appears from the evidence led by the Ops that the Ops has rightly repudiated the claim of the complainant and there is no deficiency in service on the part of Ops and the complaint does not appear to be maintainable, as such, same is hereby dismissed with no order as to costs. 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:13.03.2019. District Consumer Disputes
Redressal Forum, Sirsa
Member Member
DCDRF, Sirsa DCDRF, Sirsa
