BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no.282 of 2016
Date of Institution : 21.10.2016
Date of Decision : 14.06.2017.
Rajender Bajaj Advocate son of late Shri Bhagwan Dass, resident of House No.706, Sector 20, Part-II HUDA, Sirsa, Tehsil and District Sirsa.
….Complainant.
Versus
1. Star Health and Allied Insurance Company Limited, through its Chairman/ Managing Director, registered office at New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai- 600034.
2. Branch Manager, Star Health and Allied Insurance Company Limited SCO No.1149, second floor, CUE/1, Red Square Market, Hisar (Haryana).
3. Mohan Lal authorized agent of Star Health and Allied Insurance Company Limited at Sirsa having its office at Gali No.4, Lohia Basti Begu Road, Sirsa.
..…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SHRI RAGHBIR SINGH………………….PRESIDENT
SMT. RAJNI GOYAT ……….……………MEMBER.
SH. MOHINDER PAUL RATHEE……… MEMBER
Present: Sh. Rakesh Bajaj, Advocate for the complainant.
Sh. Mukesh Saini, Advocate for opposite parties no.1 & 2.
Opposite party no.3 already exparte.
ORDER
Case of complainant, in brief, is that he took family health optima insurance plan from ops’ company through its authorized agent i.e. op no.3 at Sirsa vide policy/ cover note No.P/211119/01/2015/000950 on 27.8.2014 for a period of one year i.e. from 27.8.2014 to 26.8.2015 and same was extended/renewed through new policy No.P/211119/012016/001635 for the period of one year w.e.f. 27.8.2015 to 26.8.2016. The sum assured was Rs.5,00,000/-, limit of coverage was Rs.6,25,000/- and the complainant accordingly paid an amount of Rs.15652/- for new policy. However, this policy was in continuation and renewal of previous mediclaim insurance policies as previously also the complainant took the mediclaim policies from the ops believing upon the assurance that as the policy is cashless policy and that the ops would cover all the risks and expenses in case of any medical aid/ facility availed by the complainant and his family members. It is further averred that under this policy, the complainant himself, his wife and two children are entitled to get the benefits. That during the period of insurance policy, Smt. Sweety Bajaj wife of complainant suddenly suffered from the problem of chest pain on 15.4.2016 in the late evening and she was taken to Holy Nursing Home, Sirsa but on 16.4.2016 in the morning at 9.00 a.m. again she was suffering from severe chest pain and as such the complainant took her at Delhi Heart Institute, Bathinda where she was admitted in I.C.C.U and undergone multiple tests and was admitted in the hospital by the doctors for further investigations and treatment and after going through the tests, she was discharged on 17.4.2016 at about 5.30 p.m. It is further averred that the complainant also informed the ops in this regard and requested the ops for the payment of hospital charges being the cashless policy and the ops also assured for the payment of the said hospital expenses direct to the authorities of the hospital but at that time the ops did not pay any amount. The complainant under the compelling circumstances have to deposit the expenses of the said hospital. That after discharge of his wife, the complainant applied for grant of mediclaim with the ops and filled medical reimbursement form as per the requirement of the ops and also submitted all the requisite bills and treatment record with the ops as required by them and requested for disbursement of the claim. The ops after receipt of necessary documents from the complainant assured him that within a short period they will disburse the claim amount and also assured to give all other benefits as provided under the mediclaim policy. It is further averred that since the day of submitting the requisite papers, the complainant has been taking rounds to the office of the ops regularly, but all the times the ops have put off the matter on one false pretext or the other and in this manner the ops proved to be deficient and negligent in providing the services to its customers. On 17.5.2016, the ops’ company demanded payment receipt in original and also demanded post cardiac details although the complainant submitted the original payment receipt at the time of submitting the documents but as per the requirement of company the complainant again obtained the payment receipt from the hospital and also submitted declaration that his wife suffered pain for the first time and prior to this she never suffered such kind of any pain or disease with original payment receipt on 27.5.2016. It is further averred that the ops just out of their oblique motive and to avoid their legal liability have repudiated the claim of the complainant by taking false and baseless stand that the investigation are not covered under the mediclaim policy. Due to the act and conduct of the ops, the complainant has suffered much mental tension, harassment and also suffered financial loss. Hence, this complaint for a direction to the opposite parties to disburse the mediclaim amount of Rs.30786/- alongwith interest thereon @18% per annum and to pay a sum of Rs.50,000/- as compensation for harassment and Rs.11,000/- as litigation expenses.
2. On notice, opposite parties appeared and filed written statement taking certain preliminary objections regarding suppression of material facts, cause of action, no consumer dispute, jurisdiction and locus standi etc. On merits, the factum of taking of above said insurance plan and its renewal has been admitted. It has been submitted that insured Ms. Sweety Bajaj was admitted in Delhi Heart Institute & Multispecialty Hospital, Bathinda for the treatment of chronic CAD. On receipt of the pre authorization request from the treating hospital, the answering ops have denied the cashless authorization on the ground that are within normal limits and hospitalization seems for evaluation only as same is not covered under cope of policy coverage. Hence the cashless authorization was denied and same was communicated to the treating hospital and the insured vide letter dated 17.4.2016. It has been further submitted that the insured has submitted claim records for reimbursement of hospitalization expenses for treatment of chronic liver disease, portal hypertension, grade 4 Oesophageal vertices. It is observed from the medical records that :
As per discharge summary, the insured patient was admitted on 16.4.2016 and discharged on 17.4.2016.
- Diagnosis: Unstable Angina, Coronary Artery Disease.
- History: Presented with the complaints of severe chest pain since yesterday evening and admitted in the hospital for evolution and further management.
ECG taken is normal.
All other investigation report shows normal. Thus, there is no active medical management.
It has been further submitted that as per Exclusion No.14 of the above policy, the company is not liable to make any payment for expenses incurred at hospital primarily for diagnostic, x-ray and laboratory examinations. It has been further submitted that the policy issued to the complainant under which the dispute has been raised is governed by limits of liability as per various clauses. Even admitting without conceding that the company is liable to pay the claim in terms of the contract of insurance issued to the claimant, the maximum quantum of liability under the terms of the policy shall be Rs.29,866/-. Remaining contents of the complaint have also been denied and dismissal of the complaint has been prayed for.
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Announced in open Forum. President,
Dated: 14.6.2017. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member.
