DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
PATIALA.
Consumer Complaint No.250 of 23.10.2015
Decided on: 26.7.2017
Narinder Kumar son of Sh.Lal Chand, resident of House No.858A, Street No.8, Tripuri Town, Patiala.
…………...Complainant
Versus
- Star Health and Allied Insurance Co.Ltd., Corporate Office: # 1, New Trank Street, Valluvarkottam High Road, Chennai-600034, through its Managing Director.
- Star Health and Allied Insurance Co.Ltd.,SCO No.70, Sector Floor, Opposite Tata Indicom, New Leela Bhawan, Patiala-147001, through its Manager.
…………Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
QUORUM
Smt. Neena Sandhu, President
Smt. Neelam Gupta, Member
ARGUED BY:
Sh.A.S.Kathuria,Adv.counsel for complainant.
Sh.Munish Mittal,Adv. counsel for Opposite parties.
ORDER
SMT.NEENA SANDHU, PRESIDENT
Sh.Narinder Kumar, complainant has filed this complaint under Section 12 of the Consumer Protection Act,1986 ( hereinafter referred to as the Act) against the Opposite Parties (hereinafter referred to as the O.Ps.) praying for the following reliefs:-
- To pay Rs.54,960/-, incurred on his treatment, alongwith interest @9% per annum w.e.f.31.5.2015, the date of discharge of the complainant from the hospital, till its realization.
- To pay Rs.2,00,000/- as compensation for causing mental agony and physical harassment
- To pay Rs.25,000/- as litigation expenses and
- To grant any other relief,which this Forum may deem fit.
2. In brief, the case of the complainant is that he got himself insured with the OPs vide policy bearing No. P/700002/01/2016/006707, for the period from 22.4.2015 to 21.4.2016, for the sum assured of Rs.2,00,000/-.The said policy was purchased by him through on-line and the payment of the premium was made through credit card of HDFC Bank Ltd..Immediately, after the purchase of the policy, he was got medically checked up by the OPs on 9.5.2015, from Gian Chest Hospital, Patiala and found fit. On 29.5.2015, he suffered from severe pain in his abdomen and was taken to Columbia Asia Hospital, Patiala, where he was admitted vide MRN: PATL-0000073698 and was discharged on 31.5.2015.Surgery was also got conducted upon him there. He spent Rs.54,560/- on his treatment. He lodged the claim with the OPs vide No.CLI/2016/700002/0053696 alongwith relevant papers. But the OPs wrongly repudiated the claim vide letter dated 30.6.2015 with the observation that, ‘as per Exclusion No.3 of the insurance policy, the company is not liable to make any payment in respect of any expenses incurred by the insured person on the diseases which are not covered under the said clause, during first two years of continuous operation of insurance cover’. Finding no alternative, he got sent the legal notice dated 20.8.2015 upon the OPs asking for the payment of Rs.54,960/-alongwith interest and also to pay compensation alongwith litigation expenses but the OPs did not respond the same. The act and conduct of the OPs amounted to deficiency in service, which caused mental agony and physical harassment to him. Hence this complaint.
3. On being put to notice, OPs appeared and filed the written version having taken preliminary objection that the case of the complainant is not covered under the policy of the company and is liable to be dismissed. On merits, it is admittred that the complainant got himself insured with the OPs in the month of April,2015 and the date of inception of the policy was 22.4.2015 which is valid upto 21.4.2016 for the sum assured of Rs.2,00,000/-.As per medical record the present case is of Renal Calculi, which falls under second year exclusion, as such cash less authorization was rejected and was duly communicated to the treating hospital and the insured vide letter dated 30.5.2015. There is no deficiency of service on the part of the OPs. After denying all other averments made in the complaint, it was prayed to dismiss the complaint.
4. On being called to do so, the ld. counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant alongwith documents Exs.C1 to C17 and closed the evidence.
The ld.counsel for the OPs has tendered in evidence affidavit of Sh.Rajnish Kohli, Asstt. Vice President Claims Star Health Ex.OPA alongwith documents Exs.OP1 to OP15 and closed the evidence.
5. We have heard the ld.counsel for the parties, gone through the written arguments filed by the ld.counsel for the parties and have also gone through the record of the case, carefully.
6 The ld. counsel for the complainant has submitted that the complainant purchased a health insurance policy in question from the OPs, on 22.4.2015 valid upto 21.4.2016 for the sum assured of Rs.2,00,000/-. Immediately, after issuing the said policy, the Ops got medically examined the complainant on 9.5.2015, and he was found fit. On 29.5.2015, he suffered from severe pain in his abdomen and was taken to Columbia Asia Hospital, Patiala, and was remained there up till 31.5.2015, where surgery was conducted upon him. An amount of Rs.54560/- was spent by him on his treatment. Intimation regarding taking treatment was duly given to the Ops. He lodged the claim with the Ops alongwith requisite documents. However, the Ops vide letter dated 30.6.2015, have repudiated the claim on the ground that the disease of the complainant is not covered under clause (3) of the terms and conditions of the insurance policy. By not paying the amount for the expenses incurred by him on his treatment, the Ops have committed illegality, which tentamounts to deficiency in service .
7. The ld. counsel for the Ops has submitted that the complainant has taken the treatment for renal calculi and as per exclusion clause No.3 of the terms and conditions of the policy, the Ops are not liable to pay any amount, incurred by the complainant for the treatment taken by him and they have rightly repudiated the claim of the complainant vide letter dated 30.6.2015,Ex.C3.
8. Admittedly the complainant had taken the insurance policy in question on 22.4.2015 which was valid upto 21.4.2016. From the medical certificate, attached with Ex.C9, issued by the concerned doctor of Columbia Asia Hospital, Patiala, it is evident that complainant was admitted in the said hospital on 29.5.2015 and was diagnosed pain abdomen with (L) HDVN with (L) Lower Ureteric Calculi with B/L Renal Calculi. Under the head Nature of surgery/treatment given for present ailment, it is written as , ‘ cystoscopy /URS lower/ DJ stenting U/L’. The complainant was discharged from the said hospital on 31.5.2015. We have also gone through the terms and conditions of the insurance policy,Ex.OP15. As per Exclusion clause 3, which reads as under:
“The Company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of:
- …………………
- …………………
- During the First Two years of continuous operation of insurance cover
- ……………..
- All treatments(conservative, interventional, laparoscopic and open) for Hepatobiliary gall bladder and pancreatic calculi and genitourinary calculi
-
-
Since in the present case, it is apparent that surgery was conducted ,for removal of renal calculi and for DJ stenting at the end of the month of May,2015, just after one month of inception of the policy, i.e. 22.4.2015, therefore, as per exclusion clause No.3 of the policy, as referred above, the insurance company is not liable to make any payments under this policy, in respect of any expenses whatsoever incurred by the complainant and has righty repudiated his claim . In this view of the matter, we do not find any merits in the complaint. Consequently, we dismiss the same without any order as to costs. Certified copies of the order be sent to the parties free of cost under the Rules. Thereafter file be indexed and consigned to the record Room.
ANNOUNCED
DATED: 26.7. 2017
NEENA SANDHU
PRESIDENT
NEELAM GUPTA
MEMBER
