Haryana

Kurukshetra

CC/444/2020

Mrs Ekta W/o Ram Phal - Complainant(s)

Versus

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

Suresh Kajal

25 Apr 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISISON, KURUKSHETRA

 

Complaint No. 444 of 2020

Date of institution: 23.12.2020

                                      Date of decision: 25.04.2024

 

Mrs. Ekta wife of Shri Ram Phal, resident of village Chharpura, Tehsil Thanesar, District Kurukshetra.

                                                                        …Complainant.

Versus

 

1.     Star Health and Allied Insurance Company Limited, No. 15, Sri Balaji Complex, 1^st Floor, Whites Lane, Royapettah Chennai, through Mrs. Radha Vijayaraghavan Grievance Redressal Officer, Corporate Grievance Department Star Health & Allied insurance company No.1, New Tank Street, Valluvar Kottam High Road, Chennai 600034, through its Managing Director/C.O.

2.     Star Health and Allied Insurance company Ltd. 2nd floor SCO No.184-185, Commercial Belts, Sector 17, HUDA, Jagadhari, near New Grain Market, Yamuna Nagar, through its Branch Manager.

3.     Star Health Insurance, SCO No.94, 1st floor, Sector 17, Kurukshetra, through its Branch Manager.

 

…Opposite parties

 

•  

NEELAM, MEMBER.

RAMESH KUMAR, MEMBER.

 

•  

Shri Gaurav Gupta, Advocate for the OPs.

             

• :     

                This is a complaint under Section 35 of the Consumer Protection Act.

2.             Briefly stated, it is the case of the complainant that She, her husband and her son involved in a family Health of Optima Insurance with the OPs vide policy No. P/211120/01/2020/006397 w.e.f. 22.11.2019 to 21.11.2020 and they renewed the said policy with regular payment of installments.  It is alleged by the complainant that she had admitted in the hospital due to some problem and doctor had advised her to operate her and told the expense of Rs.2,55,000/-.  The complainant requested the OPs to pay the same amount and they assured that the said operation is fall under the said policy and they will pay the whole amount to the complainant. On assurance of the OPs, on 03.03.2020, the complainant herself operated and requested the Ops to deposit the said amount, but the OPs refused to pay the same. After that, the complainant had deposit Rs.1,91,750/-in the hospital from his own pocket.  After requesting several times by the complainant to the OPs, the OPs paid Rs.1,07,000/- on 22.06.2020 and 38,000/- on 02.11.2020 to the complainant and Rs.46,750/- is still pending towards the OPs.  The complainant requested several times to pay the remaining amount, the respondents postponing the said mater on pretext or the other and finally they refused to pay the remaining amount.  Hence this present complaint.

3.             On notice, opposite parties appeared and filed their written version raising preliminary objections with regard to maintainability; cause of action; locus standi; jurisdiction and concealment of true and material facts. On merits, it is submitted that she is not entitled to any relief. The insured Mr. Ramphal availed Family health Optima insurance policy covering Ramphal-self and Ekta spouse and Nischay as dependent child for the sum insured of Rs. 5,00,000/- vide policy No. P/211120/01/2020/006397 for the period from 22.11.2019 to 21.11.2020. It is further submitted that the terms and conditions of the policy were explained to her at the time of proposing policy and the same was served to her along with the policy schedule. The policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy.  It is further submitted that insured Mrs. Ekta was hospitalized at Forts Hospital Mohali from 03.03.2020 to 05.03.2020 for the treatment of B/L Varicose Vein. The insured requested for cashless authorized and subsequently submitted the claim for the reimbursement and submitted bill of Rs. 1,91,750/-. The claim was initially repudiated, however on representation, the claim was reviewed and based on the submitted documents, the claim was processed and an amount of Rs. 1,07,000/- was paid to insured through NEFT-N174201165967816 on 22.06.2020. The claim was processed based on the submitted documents for deduction reconsideration and the amount of Rs. 38,000/- again paid to insured through NEFT N307201293924234 on 02.11.2020. Hence, a total amount of Rs. Of Rs. 1,45,000/- paid to the insured and deduction made for Rs. 46,750/-.

4.             Learned counsel for the complainant has tendered into evidence affidavit Ex.CW1/A and documents Ex.C-1 to Ex.C-19 and closed the evidence on 17.03.2023 by suffering separate statement.

5.             Learned counsel for the opposite parties has tendered into evidence affidavit Ex.RW1/A and documents Ex.R-1 to Ex.R-12 and closed the evidence on 24.08.2023 by suffering separate statement.

6.             We have heard the learned counsel for both the parties at length and have gone through the record available on the file carefully.

7.             Shri Gaurav Gupta, Advocate for the OPs has argued that the amount of Rs.1,45,000/- has already paid by the OPs to the complainant. One bill of Rs.45,000/- is pending. He further argued that the same shall be reimbursed on deposit of original bills to the OPs within 15 days from today. On the other hand, ld. counsel for the complainant Suresh Kajal has undertaken to deposit the bill of Rs.45,000/- to the opposite party within 15 days from today. Nothing remains more to be adjudicated  non-compliance of court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. File be consigned to the record room after due compliance.     

 

Announced in open Commission:

Dated:25.04.2024                                                                        

 

(Dr. Neelima Shangla)            

                                                                President,

                                                                DCDRC, Kurukshetra.

 

 

(Neelam)                (Ramesh Kumar)

Member                   Member