Haryana

Kurukshetra

169/2018

Anil Kumar - Complainant(s)

Versus

Star Health - Opp.Party(s)

G.S.Ratgal

24 Apr 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, KURUKSHETRA.

 

Complaint Case No.169 of 2018.

Date of instt: 08.08.2018. 

                                                                     Date of Decision: 24.04.2019.

 

Anil Kumar son of Sh. Ramesh Lal, resident of H. No.603, Sector-5, Urban Estate, Kurukshetra.

 

                                                ……..Complainant.

                        Vs.

1. Star Health and Allied Insurance Company Limited, SCO No.94, Ist Floor behind Hotel Silver Kurukshetra- 136118, through its Branch Manager.
2. Star Health and Allied Insurance Company Limited, No.15, Sri Balaji Complex, 1^st Floor Whites Lane Royapettah, Chennai- 600014 through its Managing Director.

..………Opposite parties.

 

Complaint under section 12 of Consumer Protection Act.                   

 

Before       Smt. Neelam Kashyap, President.

                Ms. Neelam, Member.

                Sh. Sunil Mohan Tirkha, Member.

 

Present:     Sh. G.S. Ratgal, Advocate for complainant.

Sh. Gaurav Gupta, Advocate for opposite parties.

           

ORDER     

 

                   This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Anil Kumar against Star Health and Allied Insurance Company Limited, the opposite parties.

2.            Brief facts of the present complaint are that the complainant purchased a mediclaim policy bearing No.P/211123/01/2018/000456 from the opposite party no.1 by paying Rs.15,287/- as premium and the said policy covers all family members of the complainant and all were issued cards under the same policy separately. The said policy was valid from 15.7.2017 to 14.7.2018. That in the month of October, 2017, the complainant fell ill and suffered from Dengue fever and he was got admitted in Atul Clinic, Kurukshetra on 17.10.2017 and was discharged on 20.10.2017. The complainant paid all the treatment expenses of the Doctor and other expenses from his own pocket and after that son of complainant namely Pratham was suffered from Dengue fever and he was also got admitted in the above said hospital on 25.10.2017 and was discharged on 27.10.2017 and complainant paid all the expenses of his son from his pocket. It is further averred that complainant paid a sum of Rs.19,060/- to the doctor for the treatment of himself and his son. The copies of the medical bills were issued and were duly signed by the doctor Atul Arora. It is further alleged that complainant applied for getting the aforesaid claim alongwith claim form and original medical bills with the ops but the ops repudiated the claim of complainant without any genuine cause and reason on the false, baseless ground and arbitrarily vide letter dated 15.12.2017. As such the ops have caused deficiency in service as well as harassment and mental agony to the complainant.  That the complainant requested the ops to admit the genuine claim of complainant and his son but the ops are adamant and flatly refused to admit the claim of complainant a few days ago. Hence, this complaint.

3.             Upon notice, opposite parties appeared and filed written statement taking certain preliminary objections. It is submitted that complainant submitted two claims in the 3^rd month of the policy. The insured Anil Kumar was admitted at Atul Clinic, Thanesar on 17.10.2017 for the treatment of dengue fever and submitted claim records towards reimbursement of medical expenses for Rs.11,381/-. It is further submitted that similarly, the insured Pratham was admitted at Atul Clinic, Thanesar on 25.10.2017 for the treatment of Dengue fever and submitted claim records towards reimbursement of medical expenses of Rs.7679/ On scrutiny of the claim records, it is observed that:

                .       The indoor case records of the above hospital are stereotyped, the patient age  and  IPD number not mentioned in indoor case records and hospital does not maintain IP and OP register.

                        Thus, there is a misrepresentation in the facts of the case. As per condition No.6 of the policy, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim. Hence, the claim was repudiated and the same was communicated to the insured vide letter dated 15.12.2017. It is further submitted that insured has submitted the representation towards reconsideration of both the claim. On perusal of the claim documents, query was raised to submit the complete set of indoor case papers with drug chart and temperature chart to assess the claim vide letters dated 16.6.2018, 1.7.2018 and 16.7.2018. But the insured has not submitted the same, thus the claim was closed vide letter dated 31.7.2018. Remaining contents of the complaint are also denied and prayer for dismissal of complaint made.

4.             Learned counsel for complainant tendered affidavit WEx.CW1/A and documents Ex.C1 to Ex.C14. On the other hand, learned counsel for ops tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R17.

5.             We have heard learned counsel for the parties and have perused the case file carefully.

6.             Admittedly, the complainant purchased a mediclaim policy bearing No.P/211123/01/2018/000456 from the opposite party no.1 by paying premium of Rs.15,287/- and the said policy covers all the four members of the complainant i.e. complainant himself, his wife Smt. Mehak, his son namely Pratam and daughter namely Bhavya as is evident from copy of proposal form and policy documents. The said policy was effective from 15.7.2017 to 14.7.2018. The medical records as well as receipts of Atul Clinic and receipts of Path Lab. Ex.C3 to Ex.C12 reveals that complainant Anil and his son Pratham suffered from dengue fever and got treatment from Atul Clinic. The complainant Anil Kumar was admitted in the said hospital from 17.10.2017 to 20.10.2017 whereas his son Pratham was admitted in the said hospital from 25.10.2017 to 27.10.2017. The complainant paid an amount of Rs.19,060/- for his treatment as well as treatment of his son and lodged the claim for the reimbursement of the said amount with the ops but the ops have repudiated the claim of the complainant vide letter dated 15.12.2017 on the ground mentioned above, but the treatment record available on file shows that names of complainant and his son are mentioned in the record. No other misrepresentation of facts have been pointed out by the opposite parties on which the ops have repudiated the claim of complainant. So, non payment of above said claim amount of Rs.19,060/- for the treatment of insured complainant and his son Pratham clearly amounts to deficiency in service on the part of opposite parties.

7.             In view of the above, we allow the present complaint and direct the opposite parties to pay the claim amount of Rs.19,060/- to the complainant within a period of 30 days from the date of receipt of copy of this order, failing which the complainant will be entitled to interest @9% per annum from the date of order till actual realization. We further direct the ops to pay a sum of Rs.5000/- as compensation for harassment, mental agony and litigation expenses.  A copy of said order be supplied to the parties free of cost.  File be consigned to record-room after due compliance.      

Announced in open court:

Dt.:24.4.2019d.  

                                                                        (Neelam Kashyap)

                                                                        President.

 

 

(Sunil Mohan Tirkha),           (Neelam)       

Member                             Member.