Punjab

Sangrur

CC/276/2018

Nishu Gupta - Complainant(s)

Versus

Star Health & Allied Insurance Co. Ltd. - Opp.Party(s)

Smt. Pooha B.Bhatt

19 Dec 2018

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.  276

                                                Instituted on:    15.06.2018

                                                Decided on:       19.12.2018

 

 

Nishu Gupta W/o Rajesh Kumar Arya, Ward No.14-B, House No.345, Arya Samaj Block, Tehsil Dhuri, District Sangrur.

                                                        …Complainant

                                Versus

 

1.     Star Health and Allied Insurance Company Limited, Branch Manager, 1^st Floor, Above IDBI Bank, Sunami Gate, Sangrur 148 001.

2.     Star Health and Allied Insurance Company Limited, Branch Manager, Ludhiana 2716, 1^st Floor, Gagan Complex, Backside Majestic Park Plaza Hotel, Gurudev Nagar, Pakhowal Road, Ludhiana 141 001.

3.     Star Health and Allied Insurance Company Limited, Regd. And Corporate Office: 1, New Tank Market, Valluvar Kottam High Road, Nungambakkam, Chennai 6000034 through its M.D.

                                                        ..Opposite parties

 

 

For the complainant          :       Ms.Pooja Bahuguna Bhatt, Adv.

For Opp.parties                        :       Shri Rohit Jain, Adv.

 

Quorum:   Inderjeet Kaur, Presiding Member

                Vinod Kumar Gulati, Member

       

Order by : Inderjeet Kaur/Vinod Kumar Gulati, Members.

 

 

1.             Smt. Nishu Gupta, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant is a consumer of the OPs by purchasing an insurance policy, namely, Family Health Optima Insurance Plan for herself, her husband namely Rajesh Kumar Arya and minor son of the complainant namely Aryaman Garg for Rs.5,00,000/- bearing policy number P/211223/01/2018/000433 for the period from 28.3.2017 to 27.3.2018 by paying the requisite premium of Rs.8665/- to the OPs.  Further case of the complainant is that the complainant got her policy renewed for the period from 28.3.2018 to 27.3.2019 by paying the requisite premium of Rs.11,506/- to the Ops.

 

The case of the complainant is that she was got operated for removal of hernia on 9.3.2018 at Vinayak Hospital, Sunam, where she was admitted on 14.3.2018, but the complainant did not submit any claim as it was not payable within 24 months of the commencement of the policy.  Further case of the complainant is that thereafter she felt severe pain in her abdomen and due to that pain the complainant was admitted in Dayanand Medical College and Hospital, Ludhiana where SUBACUTE INTESTINAL OBSTRUCTION WITH ILEA STRICTURE WAS DIAGNOSED and the complainant was admitted in the hospital on 30.3.2018 and was discharged on 12.4.2018 where she underwent intestine surgery.  Thereafter the complainant lodged the claim with the OPs for Rs.1,55,138/-, but the claim of the complainant was repudiated by the Ops vide letter dated 10.5.2018 on the ground that the surgery underwent by the complainant was in furtherance of the Hernia that was removed on 9.3.2018. This observation of the opposite party is totally wrong and baseless as the attending doctor at the DMC&H has opined that the pain in the abdomen of the patient can not be ruled out to be an outcome or complication in furtherance of hernia alone, there are other reasons also. Furthe, there is no mention in the policy about the grounds on which opposite party has repudiated the claim. Further, it is not mentioned that surgery of intestine is not covered in this policy. The opposite party in order to save its skin has presumed the fact regarding the pain in the abdomen to be the complicated form of hernia, which is not true. The deponent had demanded the scanned copy of the report on the basis of which the opposite party had reached the conclusion, but the opposite party failed to give the satisfactory reply to the query of the deponent. The deponent had to pay an amount of Rs. 155138/- in total to the hospital, which the deponent is entitled to receive from the Ops. The complainant has alleged the observation of the OPs as wrong and without any basis.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant the insurance claim of Rs.1,55,138/-  along with interest @ 18% per annum from the date of treatment till realisation and further claimed compensation and litigation expenses.

 

3.             In reply of the complaint filed by the OPs, preliminary objections have been taken up on the grounds that the complainant has no locus standi to file the present complaint, that the complaint is not maintainable, that the claim of the complainant was processed and repudiated as per the terms and conditions of the policy.   On merits, it is admitted that the complainant had purchased the policy in question for Rs.5,00,000/-  for the period from 28.3.2017 to  27.3.2018 and got renewed thereafter.  It is further averred that the complainant was operated for removal of Hernia on 9.3.2018 at Vinayak Hospital, Sunam and the complainant was admitted, operated and discharged on 14.3.2018, but no claim was payable for removal of hernia within 24 months from taking the policy and the complainant never applied for the insurance claim.  Thereafter the complainant was admitted at Dayanand Medical College and Hospital Ludhiana, where SUBACUTE INTESTINAL OBSTRUTION WITH ILEAL STRICTURE WAS DIAGNOSED and she remained admitted from 30.3.2018 to 12.4.2018 and thereafter the complainant lodged the claim as per the requirement of the OP i.e. one claim as per the requirement of the OP by the complainant/insured and the insurance company and the Op repudiated the claim of the complainant vide letter dated 10.5.2018 on the ground that the surgery underwent by the complainant was in furtherance of the Hernia that was removed on 9.3.2018.  But, the other allegations levelled in the complaint have been denied in toto.

 

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-64 copies of documents and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OPs/1 to Ex.OPs/13 copies of documents and affidavit and closed evidence.

 

5.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties.

 

6. It is admitted fact that the OPs repudiated the claim of the complainant vide letter dated 10.5.2018 on the basis observation of the discharge summary of the DMC Hospital Ludhiana that the insured patient underwent hernia surgery three months back and treatment for SAIO is the complication of hernia, which is during the second year of the policy and as per waiting perios.3(ii) of the policy issued to you, the Company is not liable to make any payment in respect of any expense incurred by the insured person for treatment of the above mentioned ailment during the first two years of continuous operation of the insurance cover. We have gone through the discharge slip of the Vinayak Hospital Sunam dated 14.03.2018 Ex.C-4 and found that nowhere it has been mentioned that the patient underwent hernia operation in the above hospital.  Further going through the discharge summary of the DMC Hospital, Ex.C-5, it is mentioned that the patient was diagnosed as a case of SAIO and the medical opinion submitted by the patient from the DMC Hospital Ex.C-11 suggests that SAIO can be due to many causes aetiology unknown. No medical expert report/opinion has been placed on the record by the Ops to support its case for repudiation of the claim on the above ground.

 

7. As per the extract downloaded from the google internet( Copy of which is placed in the file), Sub acute intestinal obstruction is an enigma. Intestinal obstruction can be defined as impairment to the abnormal passage of intestinal contents that may be due to either mechanical obstruction or failure of normal intestinal morality in the absence of an obstructing lesion. Intestinal obstruction is the most common surgical disorder of the small intestine. SAIO implies incomplete obstruction.  It is one of the important causes of morbidity and mortality in the surgical practice.  The latter is true in patients presenting as sub-acute intestinal obstruction (SAIO) with atypical features that cause delay in diagnosis. Diagnosis is difficult and in about 50% of cases, it is made intra-operatively. Delayed diagnosis, co-morbidities and advanced age are the causes of the high related mortality rate.

 

8. From the above discussions and observations, it is clear that SAIO is not a complication and furtherance of the hernial problem.  As such, the complaint is allowed with directions to the Ops to pay to the complainant an amount of Rs.1,55,138 along with interest @ 9% per annum from the date of repudiation of the claim i.e. 10.5.2018 till realisation. We further direct the Ops to pay to the complainant an amount of Rs.5000/- as compensation for mental tension, agony and harassment and Rs.5000/- as litigation expenses. Compensation for mental harassment and agony of Rs. 5000/-(Rupees Five Thousand only) and litigation expenses of Rs. 5000/- (Rupees Five Thousand only) are allowed in favour of complainant and against Ops. Payment of awarded amounts of compensation and litigation expenses be made within 45 days from the date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

            Pronounced.

                        December 19, 2018.                                  

                                                        (Inderjeet Kaur)

                                                          Presiding   Member

 

 

 

                                                        (Vinod Kumar Gulati)

                                                                     Member