Haryana

Bhiwani

CC/21/2023

Hemant - Complainant(s)

Versus

Star Health - Opp.Party(s)

A.S Ghangghas

12 Apr 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                             Consumer Complaint No. :  21 of 2023

                                                        Date of Institution           : 10.02.2023

                                                                  Date of order                  : 12.04.2024

 

Hemant son of Sh. Raj Kumar R/o H.No.1/8, Mal Godam Road, Near Hanuman Mandir, Krishna Colony, Bhiwani-127021 Tehsil an District, Bhiwani.

  

           ……Complainant.

 

Versus

 

1. Star Health and Allied Insurance Co. Ltd., Ashoka Plaza, 2^nd Floor, Rohtak-124001 through its authorized signatory.

 

2. Star Health and Allied Insurance Co. Ltd., New Tank Street, Valluvar Kottam, High Road, Nungambakkam, Chennai through its authorized signatory.

 

3. Star Health and Allied Insurance Co. Ltd., No.15, Sri Balaji Complex, Ist Floor, Whites Lane, Royapettah, Chennai-600014 through its Managing Director.

…… Opposite Parties.

 

COMPLAINT U/S 35 OF CONSUMER PROECTION ACT, 2019.

 

BEFORE:       Mrs. Saroj Bala Bohra, Presiding Member.

  Ms. Shashi Kiran Panwar, Member.

 

Present:-       Sh. Azad Singh Ghanghas, Advocate for complainant.

                    Sh. Avinash Sardana, Advocate for OPs.

 

ORDER:

 

Saroj Bala Bohra, Presiding Member:

 

1.                 In brief, facts of this case are that complainant purchased a Family Health Optima Insurance Policy from OP No.2 for a period from 29.12.2021 to 28.12.2022 by paying a premium of Rs.16,462/- wherein complainant himself, his wife Smt. Geeta, daughter Mehak and son Divyansh were covered. It has submitted that in November 2022, Smt. Geeta suffered from swelling and pain in her right side jaw, she was taken to Muskan Dental & Oral Health Care Centre, Bhiwani on 12.11.2022. Thereafter, she was taken to O.P. Jindal Institute of Cancer and Cardiac Research Hospital, Hisar and got admitted there and remained admitted there from 30.11.2022 to 03.12.2022 where an operation was performed and removed cyst from the right side jaw diagnosing it as Right Mandibular Mass. For this purpose, complainant incurred Rs.42,911/- but the OP insurance company did not make the payment of said amount despite lodging of claim in this regard rather repudiated the claim on ground that  as per Exclusion-Code Excl 32 of the policy, the company is not liable to make payment in respect of any expenses for dental treatment or surgery unless necessitated due to accidental injuries and requiring hospitalization (dental implants are not payable). Hence, the present complaint has been preferred by complainant alleging deficiency in service on the part of OPs resulting into monetary loss besides mental and physical harassment.  In the end, prayer has been made to direct the OPs to pay Rs.42,911/- alongwith interest @ 18% per annum from 03.12.2022 till realization of the amount. Further to pay Rs.50,000/- as compensation for harassment besides Rs.21,000/- as litigation expenses.

2.                 Upon notice, OPs appeared through counsel and tendered reply raising preliminary objections qua maintainability of complaint, deficiency in service, locus standi & cause of action and suppression of material facts. On merits, it is admitted that complainant and his family members were included in the health insurance policy upto Rs.5,00,000/- for the relevant period of time, subject to certain terms and conditions of the policy. Further, the OP insurance company after scrutinizing the request of complainant for cashless treatment, diagnosed as Cystic Mas, complainant was advised to revert with HPE report for further processing. Hence, the OP denied the approval for cashless the treating hospital was informed accordingly on 30.11.2022. However, the treatment taken by wife of complainant was excluded from the insurance cover. So, the claim of complainant was repudiated vide letter date 13.01.2023. As such, denied for any deficiency in service and prayed for dismissal of complaint with costs.

3.                 In evidence of complainant, his affidavit Ex.CW1/A alongwith documents Annexure C-1 to Annexure C-11 were tendered and then closed the evidence.

4.                 In evidence of OPs, affidavit of Mr. Sumit Kumar Sharma, Senior Manager of OP company as Ex. RW1/A alongwith documents Annexure R-1 to Annexure R-13 were filed and then closed the evidence.

5.                 We have heard learned counsels for the parties and perused the record carefully.

6.                 The case of complainant is that during the period of insurance policy, his wife fell ill and remained admitted in the concerned hospital and spent a sum of Rs.42,911/- but the OP insurance company did not reimburse the amount rather repudiated the claim of complainant vide letter dated 13.01.2023 (Annexure C-11). Ld. Counsel for complainant has argued that due to such act & conduct of OP, complainant has to suffer monetary loss as well as mental and physical harassment.

7.                 On the other side, learned counsel for OPs has argued that as per Exclusion-Code Excl 32 of the policy, the company is not liable to make payment in respect of any expenses for dental treatment or surgery unless necessitated due to accidental injuries and requiring hospitalization (dental implants are not payable). As such, complainant was not entitled to any amount from OP insurance company and claim was rightly rejected.

8.                 It is not in dispute that on the relevant period of time complainant’s wife was under the insurance cover. Complainant to prove his case has placed on record medical treatment record and bills Annexure C-2 to Annexure C-7 whereby it is evident that wife of complainant was admitted in the said hospital from 30.11.2022 to 03.12.2022 and complainant incurred a sum of Rs.42,911/- on the treatment. Perusal of insurance policy and its terms and conditions (Annexure R-3 & Annexure R-4) reveals that as per policy exclusion ‘dental implants are not payable’ but in the present case there was no implant of any tooth rather as per discharge summary (Annexure C-3) ‘Enoculation of mandibular cyst with biopsy was done on 01.12.2022.’

9.                 After hearing learned counsels for the parties and going through the record, we are of the view that OP insurance company has wrongly and illegally repudiated the claim of complainant just to cheat and harass the complainant which amounts to deficiency in service and mal-trade practice on their part resulting into monetary loss as well as mental and physical harassment.  Hence, the complaint is allowed and the OPs, jointly and severally, are directed to comply with the following directions within 40 days from the date of order:-

(i)       To pay a sum of Rs.42,911/- (Rs. Forty two thousand nine hundred eleven) to the complainant so incurred by him on the treatment of his wife alongwith simple interest @ 9% per annum from the date of filing of complaint till actual realization.

(ii)      To pay Rs.5,000/- (Rs. Five thousand) as compensation  on account of mental agony and physical harassment. 

3. To pay Rs.5500/- (Rs. Five thousand five hundred) as litigation expenses.

                    In case of non-compliance, all the awarded amounts shall further attract simple interest @ 12% per annum for the period of default. 

                    Further, the complainant shall be entitled to the execution petition under section 71 of Consumer Protection Act, 2019 and in that eventuality, the opposite party may also be liable for prosecution under Section 72 of the said Act which envisages punishment of imprisonment, which may extend to three years or fine upto rupees one lac or with both.  Copies of this order be sent to the parties concerned, free of costs.  File be consigned to the record room, after due compliance. 

Announced.

Dated: 12.04.2024