Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 141.
Instituted on : 06.03.2017.
Decided on : 19.08.2019.
Manoj Singla age 47 years, s/o Sh. Chetan Parkash c/o M/s Ajay Electronics palace, Near CHC Market, Main Bazar, Julana District Jind.
………..Complainant.
Vs.
- Star Health Insurance Company Limited, 1, New Tank Street, Valluvar Kottam High Court, Nungambakkam, Chennai-600034.
- Star Health Insurance Company Ltd., 3rd Floor Ashoka Plaza, Delhi Road, Rohtak-124001.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
SH. VED PAL, MEMBER.
DR. RENU CHAUDHARY, MEMBER.
Present: Sh. Digvijay Jakhar, Advocate for the complainant.
Sh. Gulshan Chawla, Advocate for opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that the complainant has got himself insured with the opposite party vide policy no.P/2111118-1/2017/001262 for the period 17.08.2016 to 16.08.2017. That the proposal date is 26.07.2010 which is the date of inception of 1st policy and 6th renewal year. That the basic floater sum insured is Rs.500000/- with bonus Rs.155000/- and coverage limit Rs.655000/-. That in the 6th year i.e. 2016-17 the complainant fell ill and has to take his treatment from Neurogen Brain and spine Institute, Navi Mumbai. The complainant remained admitted there for the period 05.09.2016 to 10.09.2016 and was relieved on 11.09.2016. The complainant has spent Rs. 225000/- and some additional amount on his treatment. That complainant filed his claim with the opposite party alongwith relevant documents but the opposite party has repudiated the claim under the policy as per exclusion clause No.6 of the policy. That complainant issued a notice on 26.10.2016 through his counsel to the opposite party, the same was replied on dated 22.11.2016 and the claim was again repudiated on same grounds. That as per exclusion no.6 of the policy, the company is not liable to make any payment in respect to any expenses for run down condition or rest cure. However, the disease of the complainant and treatment taken by him are not covered under the exclusion clause. That the act of opposite parties is illegal and there is deficiency in service on the part of opposite parties. As such, it is prayed that opposite parties may kindly be directed to pay compensation of Rs.225000/- alongwith interest, compensation and litigation expenses to the complainant as explained in relief clause.
2. After registration of complaint, notice was issued to the opposite parties. Opposite parties in their reply has submitted that complainant has no locus-standi to claim any alleged sum assured, as the insurance policy was obtained by the DLI by misrepresenting the material facts in order to defraud the opposite party and as such the contract of insurance is void, and not tenable. It is denied that the treatment was not run down condition or rest cure. That as per discharge summary, the complainant was treated via Neuro Rehabilitation in the form of exercises. Rehabilitation/Convalescence is a treatment diagnosed to facilitate the process of recovery from injury/illness or diseases to a normal condition. Hence, the claim was repudiated on the ground of treatment towards convalescence only and not on the run-down or rest cure. That complainant is not entitled for any claim.. All the other contents of the complaint were stated to be wrong and denied and opposite parties prayed for dismissal of complaint with cost.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C6 and has closed his evidence on dated 07.09.2018. Learned counsel for the opposite parties has tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R9 and has closed his evidence on dated 18.01.2019.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present complaint, the claim of the complainant has been repudiated vide letter dated 22.11.2016 placed on record as Ex.C5 on the ground that : “As per Exclusion No.17 of the policy,” the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by the insured person in connection with or in respect of: Stem cell Therapy and related transplantation, chondrocycle implantation, immunotherapy, oral chemo Therapy”. Thus, the stem cell therapy and related transplantation was not payable. In this regard, contention of ld. counsel for the complainant is that the disease of the complainant and treatment taken by him are not covered under the exclusion clause. Moreover, no terms and conditions of the policy were ever supplied to the complainant and has placed reliance upon the ratio of law laid down by Hon’ble National commission in Oriental Insurance Co. Ltd. Vs. Satpal Singh & Anr. decided on 01.04.2014 in Revision Petition No.3165-3166.
6. After going through the file and hearing the parties, it is observed that no document has been placed on file by the opposite parties to prove that terms and conditions of the policy were ever supplied to the complainant. Hence the law cited above by ld. counsel for the complainant is fully applicable on the facts and circumstances of the case.
The treatment record itself shows that complainant had taken treatment from the concerned doctor regarding Adult autologous bone marrow derived MNC’s transplantation, neuroregenerative-neurosurgical and secondly Nero-rehabilitation. The bare perusal of discharge summary Ex.R5 and other documents placed on record by the complainant as well as the opposite parties itself shows that the treatment was taken regarding two ailments and a collective bill was issued for Rs.225000/-. The first treatment was given for Neuro-regenerative and neurosurgical but as per exclusion clause No.17, it has not been mentioned anywhere that this ailment is not covered or is under the exclusion clause of the policy. In our view, the complainant is entitled for the claim, whereas the neuro- rehabilitation is concerned, which is excluded under exclusion no.6 of the policy, we are of the view that the consolidated bill was issued and the same cannot be bifurcated at this stage. As per document Ex.R5, page no.8 itself shows that complainant had paid an amount of Rs.225000/- on dated 10.09.2016 to Neurogen Brain and Spine Institute on account of his treatment. Hence the claim has been repudiated by the opposite parties on flimsy grounds which is illegal and unjustified and the complainant is entitled for the alleged claim amount..
7. In view of the facts and circumstances of the case, complaint is allowed and we hereby direct the opposite parties to pay a sum of Rs.225000/-(Rupees two lac twenty five thousand only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 06.03.2017 till its realization and shall also pay a sum of Rs.5000/-(Rupees five thousand only) as compensation and litigation expenses to the complainant within one month from the date of decision.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
19.08.2019.
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Nagender Singh Kadian, President
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Ved Pal, Member.
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Renu Chaudhary, Member.
