Haryana

Kurukshetra

CC/224/2019

Smt Rita Rani - Complainant(s)

Versus

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

Girdhari lal

24 Nov 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL  COMMISSION, KURUKSHETRA.

                                                               Complaint Case No.224 of 2019

                                                               Date of institution: 3.06.2019

                                                               Date of decision: 24.11.2021

                              

Smt.Rita Rani aged about 52 years, w/o Sh.Rajesh Kumar resident of house No.1104/5A, near Devi Mandir Pipli, Tehsil Thanesar District Kurukshetra (M) 93553-24313.

                                                                …Complainant.

                             Versus

Star Health and Allied Insurance Co.Ltd. No.15, Sri Balaji Complex, 1^st floor, Whites Lane, Royapettah, Chennai through its Branch Manager/Authorized person/Signatory at SCO No.94, 1^st Floor, Sector 17, Behind Bikaner Sweets, Kurukshetra, Tehsil Thanesar Distt. Kurukshetra.

….Opposite party.

                   Complaint u/s 12 of the Consumer Protection Act.

Before:        Smt. Neelam Kashyap, President.

                   Ms. Neelam, Member.

                   Sh.  Issam Singh Sagwal, Member.

         

Present:      Sh. Girdhari Lal, Advocate for complainant.   

                   Sh.Gaurav Gupta, Advocate for opposite party.

ORDER

                   This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Rita Rani against  Star Health Allied Insurance Co.- the opposite party.

2.                It is stated in the complaint that  the complainant purchased a medical claim policy No., Product name Family Health Optima Insurance – 2017, policy period  30.09.2017 to 29.09.2018. It is averred that the complainant suffered from pain in the episgatrium and got admitted in the specialized hospital Kurukshetra Nursing Home  Thanesar  for treatment on 5.09.2018 and she was discharged from the hospital on 5.09.2018 and in this regard she deposited cash amount of Rs.32049/- vide receipt No. 486.  Thereafter, the complainant submitted her claim for reimbursement of the expenditure incurred by her and also furnished all the original b9ills with the OP. The OP kept lingering on the matter on one pretext or the other and ultimately sent letter dated 24.10.2018 stating that they have processed the  claim records relating to the insured seeking reimbursement of hospitalization expenses for treatment of ? acute pancreatitis old case of cholescystectom . The insured had undergone treatment for acute pancreatitis which is during the second year of the policy as per waiting period 3(ii) of the policy  for which the complainant is not liable to pay the expenses, which amounts to deficiency in services on the part of the OP.  Thus, the complainant has filed the present complaint alleging deficiency in services on the part of the OP and prayed that the OP be directed to pay the claim amount of Rs.32049/- to the complainant alongwith compensation for the mental harassment and agony caused to her and the litigation expense.

3.                          Upon notice OP appeared and filed written statement disputing the claim of the complainant.  Issuance of the insurance policy, ailment of the complainant and submission of the claim and its repudiation has been admitted by the OP. It is submitted that  terms and conditions of the policy were explained to the complainant at the time of propos9ing the policy and same was served to the complainant alongwith the policy schedule. Moreover, it is clearly stated in the policy schedule that “the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form.  The insured Smt.Rita Rani was admitted in the hospital at Kurukshetra Nursing Home Thanesar (M CL+OG) on 28.8.2018 and discharged on 5.09.2018) for the treatment of Cholesctectomy presently? Acute  Pancreatitis.  The insured submitted pre authorization request to avail cashless treatment.  On scrutiny of the same, it is observed that the insured patient was acute pancreatitis, which has arisen within two years from the date of inception of the policy. Thus, the pre authorization was rejected and the same was informed to the insured vide letter dated 30.8.2018. Subsequently, the insured submitted the claim for reimbursement of medical expenses of Rs.32049/-. On scrutiny of the same, it was observed that “ as per discharge summary of the above hospital the insured patient has undergone treatment for acute pancreatitis.  As per waiting period no.3(ii (b) A waiting period of 24 consecutive months of continuous coverage from the inception of this policy will apply to the following specified ailments/illness/diseases.                 

               “All treatments (conservative, interventional, laparoscopic and open) related to Hepato-pancreato-billary disease including Gall bladder and Pancreatic calculi . All types of management for kidney and Genitourinary treat calculi.”

                    It is submitted that as the insured was admitted for Pancreatic related ailment in the second year of the policy, which is not covered as per terms and conditions of the policy till two years of continuous coverage of policy.  Thus, the claim of the complainant was repudiated and the same was informed to the insured vide letter dated 24.10.2018. Thus, it is submitted that there is no deficiency in services on the part of the OP and prayed for dismissal of the complaint.

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

5.                On the other hand, OP in support of its case has filed affidavit Ex.RW1/A and tendered documents Ex.R-1 to Ex.R-13 and closed its evidence.

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

7.                The learned counsel for the complainant while reiterating the averments made in the complaint has argued that complainant purchased a medical claim policy No. Product name Family Health Optima Insurance – 2017, policy period  30.09.2017 to 29.09.2018. It is argued that the complainant suffered from pain in the episgatrium and got admitted in the specialized hospital Kurukshetra Nursing Home  Thanesar  for treatment on 5.09.2018 and she was discharged from the hospital on 5.09.2018 and in this regard she deposited cash amount of Rs.32049/- vide receipt No. 486.  Thereafter, the complainant submitted her claim for reimbursement of the expenditure incurred by her and also furnished all the original bills with the OP. The OP kept lingering on the matter on one pretext or the other and ultimately sent letter dated 24.10.2018 stating that they have processed the  claim and the same is not covered under the terms and conditions of the policy.

8.       On the other hand, learned counsel for the Ops while reiterating the contentions made in the complaint has argued that the complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form.  The insured Smt.Rita Rani was admitted in the hospital at Kurukshetra Nursing Home Thanesar (M CL+OG) on 28.8.2018 and discharged on 5.09.2018) for the treatment of Cholesctectomy presently? Acute  Pancreatitis.  The insured submitted pre authorization request to avail cashless treatment.  On scrutiny of the same, it is observed that the insured patient was acute pancreatitis, which has arisen within two years from the date of inception of the policy. Thus, the pre authorization was rejected and the same was informed to the insured vide letter dated 30.8.2018. Subsequently, the insured submitted the claim for reimbursement of medical expenses of Rs.32049/-. On scrutiny of the same, it was observed that “ as per discharge summary of the above hospital the insured patient has undergone treatment for acute pancreatitis.  As per waiting period no.3(ii (b) A waiting period of 24 consecutive months of continuous coverage from the inception of this policy will apply to all treatments (conservative, interventional, laparoscopic and open) related to Hepato-pancreato-billary disease including Gall bladder and Pancreatic calculi . All types of management for kidney and Genitourinary treat calculi.Thus, it is argued that there is no deficiency in services on the part of the Ops and prayed that the present complaint may kindly be dismissed.Reliance has been placed on the authorities M/s Suraj Mal Ram Niwas Oil (P)Limited Vs. United India Insurance Co.Limited  Law Finder Doc Id # 219912 and  United India Insurance Co.Limited Versus M/s Harchand Rai Chandan Lal Law Finder Doc Id # 79540.

9.                After hearing both the learned counsel for the parties, we are of the considered view that there is force in the arguments advanced by the learned counsel for the complainant. The ailment and treatment and obtaining of insurance policy are not in dispute. The complainant has stressed that vide Ex.C-18, Rita Rani(complainant) wife of Rajesh Kumar underwent cholecystectomky two years back, but her present complaint  was acute pancreatitis, the two do not seem to related with each others. We have perused the repudiation letter Ex.C-19 dated 24.10.2018 and also perused the terms and conditions of the insurance policy.   OP has  mentioned in the repudiation letter Ex.C-19 “ As per waiting period .3(ii) of the policy the company is not liable to make any payment in respect of any expenses incurred by the insured person for treatment taken by the complainant.  Thus, it is argued on behalf of the OP that as per condition  No.3 (ii)(b) “all  treatments  (conservative, interventional, laparoscopic and open) related to Hepato-pancreato-billary disease including Gall bladder and Pancreatic calculi . All types of management for kidney and Genitourinary treat calculi. It is further argued on behalf of the OP that the treatment  diagnosed as O/C  Cholesctectomy presently ? ACU TE ) Pancreatitis and  taken by the complainant is not covered under the terms and conditions of the  policy because  the insured/complainant has undergone  treatment for acute pancreatitis which is during the second year of the policy. But we are not convinced with the argument advanced on behalf of OP because  the perusal of proposal form Ex.R-1 shows that the period of insurance started on 20.09.2016. Further in the policy Ex.R-2 the date of inception of the  first policy is given as  30 Sep. 2016. In mark “A: i.e. Customer Identity Card,  validity is shown from  30.09.2016. Likewise in the policy schedule Ex. R-3, the  date of inception of the first policy is 30.09.2016 and the date of treatment is 28.08.2018 i.e. after a period of more than two years from the date of stating of the insurance. Therefore, the condition No. 3 (ii)(b) (Waiting) is not applicable to the present case because said condition is  applicable only for two years and as such the claim of the complainant been wrongly with held.  Further, the fact that the insurance stated from 30.09.2016 is proved by the document of OP i.e. Proposal form and on the one hand the OP is stating that the treatment in question took place within one year of the policy and on the other hand from their own document  Ex.R-1 it is proved that the treatment took place after the two years of the inception of the policy. This act of the OP shows that the OP is knowingly and intentionally harassing the insured person and OP is liable to pay compensation to the complainant on this account. Therefore, for not making the payment of the claim amount of Rs.32049/- is deficiency in services on the part of the OP.  In  view of the facts and circumstances of the present case and the authorities relied upon on behalf of the complainant, we are of the view that the complainant is entitled to relief. The authorities relied on behalf of the OP are not applicable to the facts and circumstances of the present case.

10.              In view of our above findings and observations,  we accept the present complaint and direct the OP to make the payment of Rs.32049/- to the complainant alongwith interest  @ 6% per annum  from the date of filing of the present complaint i.e. 3.06.2019 till its actual realization. The  OP shall also pay a sum of Rs.30,000/- to the complainant for causing him intentional harassment and agony and a sum of Rs.5000/- for the litigation expenses.  The OP is further directed to make the compliance of this order within a period of 30 days from the date of this order, failing which the complainant shall be at liberty to initiate proceedings u/s 25/27 of the Consumer Protection Act.  Certified copy of the order be supplied to the parties concerned free of costs and the file be consigned to the record room after due compliance.

Announced in the Open Commission

Dated: 24.11.2021.       

                                                                                       President.

 

                                           Member         Member.