Delhi

West Delhi

CC/14/138

Jitender Kumar Arora - Complainant(s)

Versus

Star Health & Alied Insurance - Opp.Party(s)

12 Jul 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (WEST).

150-151; COMMUNINTY CENTER; C-BLOCK; JANAK PURI; NEW DELHI

CASE NO. 138 /2014

Sh. Jitender Kumar Arora,

R/o H.No. 584, Pocket C,

Group –III, Janta Flats,

Hasthsal, Uttam Nagar,

New Delhi -110059                                                    ..…. Complainant

VERSUS

Star Health and Allied Insurance Company Ltd.

Branch Office:-

 

Plot No. 4, 3^rd Floor, B-Block

Community Centre Janak Puri

New Delhi-110058

 

Also at:-

 

Head Office :-

KRM  Centre 6^th Floor No. 2

Harrington Road, Chetpat

Chennai-600031                                                       ….Opposite Party

 

O R D E R

 

K.S. MOHI, PRESIDENT

 

The complainant has filed the present complaint against the O.P under section 12 of Consumer Protection Act, 1986. The complainant had  obtained  Health  Insurance Policy in the year 2005  with The New India  Assurance Company Ltd.  and in November, 2013  complainant  was approached by representative of OP  to discuss about  Health Insurance Portability Scheme with terms and conditions  of NIACL which  he took in    2005  and in the same terms would continue to apply for the policy being issued by OP.   It is further stated on 27.12.2013 complainant   approached the Indian Spinal Injury Centre with his wife because she had developed some breathing problem.  Doctor of Indian Spinal Injury Centre asked complainant to admit his wife urgently to carry out tests in order to detect the possible reasons of breathing problem.  The complainant   approached OP for Pre-Authorization  for Cashless  treatment   which was denied on the ground   that on scrutiny  of details the claim, it was not admissible because she  was a  known case of kyphoscoliosis and bronchial asthma  which was not disclosed at the time of  policy.  The case of the complainant is that his wife was earlier admitted for this disease in 2012 and the claim was duly paid by the old service provider.  The complainant further stated  that on 26.02.2014 complainant approached  Dr. K.K. Choudhary at Primus Super Specialty Hospital  at Chanakya Puri, as he had  fallen  from the bike  2-3 days ago and was  experiencing a great pain  in his upper back and shoulders  as a result, he was admitted in the hospital on 26.02.2014 and  certain tests were conducted.  The same day complainant requested OP for cashless treatment which was also denied stating that complainant was seeking conservative management.  Further MRI report established that complainant needed surgical intervention as early as possible.  The complainant sent all the documents to the OP on which OP raised certain queries.  The complainant replied that he was not aware of his condition for canal stenosis and that he never received any treatment  for the same in the past.   But despite  all this OP repudiated claim of complainant vide letter dated 27.02.2014 stating that on  scrutiny of documents, MRI report showed disc deccication   ligamentum  flavum  hypertrophy  which could be  long standing, no past treatment  papers were provided hence cashless facilities  was denied.  After refusal of cashless authorization complainant had to  bear medical expenses from his  own pocket amounting to Rs. 28,000/-. The OP rejected the claim without any justification and committed deficiency in service hence the present claim.

2.     OP filed written statement by admitting the insurance policy for the period from 16.12.2013 to 15.12.2014 covered complainant, his wife and children for a sum of Rs. 5,00,000/-. Further  admitted that pre authorization of complainant was denied on the ground that the complainant was a known case of kyphoscoliosis and bronchial asthma which was  not disclosed at the time of policy also complainant has not  submitted the relevant documents regarding treatment of complainant at  Primus Super Specialty Hospital  at Chanakya Puri when the cashless facility was denied on the ground that as per the MRI was denied on the ground that as per the MRI the patient  had evidence  if degenerative disk  disease on merits.  OP denied the contents of complaint.

3.     Complainant has filed his affidavit affirming the facts alleged in the complaint. He mentioned documents in support of his evidence Ex CW 1  to Ex CW 13.   On the other hand Shri  Rajnish Kohli, Assistant  Vice President filed affidavit in evidence on behalf of O.P testifying all the facts as stated in the written statement. He  mentioned documents OPW1/A to OPW 1/J .  Both parties also filed its respective written submission. 

4.     We have heard the counsel for the parties and perused the record.

5.     It  needs to be clarified  at the out set  that the complainant has not placed  on record  the medical treatment and the medical  bill  pertaining to the  treatment of his wife, therefore, the claim filed for his wife cannot be entertained.  Further,  the complainant has filed his  treatment documents from  Primus Super Specialty Hospital  at Chanakya Puri and medical bills for Rs. 27,638/-.   The refusal of claim on  behalf of OP  appears to be imaginary  and wholly  improper.  The MRI report of complainant has not been considered by the OP and repudiated the claim on flimsy and whimsical grounds.  Hence it amounted to deficiency in service.

7.     Keeping in view the discussion stated above, we  allow the complaint    and  pass an award  for a sum of Rs. 27,638/- in favour of complainant and further we award Rs.10,000/- as compensation for harassment, mental agony and litigation expenses to be paid by OP within 45 days from the date of receipt of this order failing which failing which OP shall be liable to pay interest @ 6% p.a. from the date of filing of the complaint till actual realization.

Copy of this order be sent to the parties as per rules.

File be consigned to the record room. 

 

Announced this____12TH__ day of __July _____ 2019.

 

( K.S. MOHI )                                                     (PUNEET LAMBA)                     

PRESIDENT                                                              MEMBER