DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

Smt. Satya Bala Jindal w/o Sh. Jitender Jindal r/o H.No.172/19, Vivekanand Nagar, Jind.

                                      ---Complainant.

Versus

1.                 Star Health & Allied Insurance Co. Ltd., Plot No.257, Sector 44C, Chandigarh through its Branch Manager

2.                 Star Health & Allied Insurance Co. Ltd., Corp. Office : 1, New Tank Street, Valluvarkottam High Road, Chennai-600034 through its Managing Director.

---Opposite Parties.

BEFORE:  SHRI LAKSHMAN SHARMA                 PRESIDENT

                   SMT. MADHU MUTNEJA                       MEMBER

                   SHRI JASWINDER SINGH SIDHU       MEMBER

Argued by:  Sh. Tejinder Singh, Adv. for the complainant

                        Sh. Nitesh Singhi, Adv. for the OPs.

PER LAKSHMAN SHARMA, PRESIDENT

1.                           Smt. Satya Bala Jindal has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the Act only) praying for the following reliefs :-

(i)                to pay Rs.20,124/- on account of expenses incurred by the complainant on her treatment alongwith interest;

(ii)             to pay Rs.50,000/- on account of mental pain and agony;

(iii)           to pay Rs.11,000/- as litigation expenses.

2.                           In brief, the case of the complainant is that she got her health insured from the opposite parties for the period 11.9.2009 to 10.9.2010.   Policy No.P/161113/01/2010000871 was issued to her. She paid premium of Rs.5,967/-.  

                   It has been pleaded by her that on 9.12.2009 she suffered from ‘Multiple Fibroid Uterus Symptomatic’ disease.  She was admitted in Maharaja Aggarsain Hospital, Jind where she was treated and was operated upon.  She was discharged on 14.12.2009.  Since then she is on medicines.

                   It has further been pleaded by the complainant that after discharge from the hospital, she filed claim for indemnification of the expenses incurred by her.  However, the opposite parties did not settle the claim till the filing of the complaint.  It has further been averred that she served a legal notice dated 16.9.2010 but to no effect. 

                   Thus, according to the complainant, non settlement of the claim amounts to deficiency in service.  Hence this complaint has been filed seeking the reliefs mentioned above.

3.                           In the written statement filed by the opposite parties, it has been admitted that the health of the complainant was insured for the period 11.9.2009 to 10.9.2010.  It has further been admitted that the complainant was admitted in the hospital on 11.9.2009 for her treatment of ‘fibroid uterus’ and she had undergone hysterectomy.  According to the opposite parties, as per exclusion clause No.3 of the policy, the complainant was not entitled for indemnification of the expenses incurred by her for hysterectomy during the first two years of continuous operation of the insurance cover.  According to the opposite party, in view of the above said clause of the policy, the claim was repudiated vide letter dated 25.7.2010. It has been pleaded that the repudiation of the claim is in accordance with law and there is no deficiency in service on the part of the opposite parties. 

In these circumstances it has been prayed that the complaint be dismissed.

4.                           We have heard the learned counsel for the parties and have gone through the documents on record.

5.                           Learned Counsel for the complainant has drawn our attention to the discharge certificate dated 14.12.2009 (P-2) issued by Maharaja Agarsen Hospital, Jind wherein it has been mentioned that there is no complaint of any past history of the disease.  It has also been mentioned in this document that the present ailment is not a complication of any pre-existing disease.  Relying upon these observations in the discharge certificate, it was vehemently argued by the ld. Counsel for the complainant that as there was no pre-existing disease, so the complainant was entitled for indemnification of the expenditure incurred by her on her treatment. 

6.                           On the other hand, the ld. Counsel for the opposite parties has vehemently argued that the claim of the complainant has been repudiated in view of exclusion clause No.3 of the policy.  Annexure R-7 is the repudiation letter dated 25.7.2010. Relevant portion of the same reads as under :-

“As per the medical certificate, attached to and forming part of the claim form, issued by the treating doctor, the patient was admitted for treatment of fibroid uterus and the patient had undergone hysterectomy.  As per exclusion No.3 the Company is not 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 hysterectomy during the first two years of continuous operation of insurance cover.”

7.                           The complainant himself has placed on record the terms and conditions of the policy. Clause 3 of the policy, under the heading ‘exclusions’ reads as under :-

“The company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by an insured person in connection with or in respect of :

xxxx                xxxx                xxxx

3.         During the First two Years of continuous operation of Insurance cover, the expenses on treatment of Cataract, Hysterectomy for Menorrhagia or Fibromyoma, Knee Replacement Surgery (other than caused by an accident), Joint Replacement Surgery (other than caused by an accident), Prolapse of intervertibral disc (other than caused by an accident), Varicose veins and Varicose ulcers.  If these diseases are pre-existing at the time of proposal they will not be covered even during the subsequent period of renewal too.”

From a bare perusal of this clause it is apparent that the opposite parties are not liable to indemnify the complainant for the expenditure incurred by her for undergoing hysterectomy in the first two years.  Admittedly, the policy was taken by the complainant for the first time. So, it is her first year of the insurance and the aforesaid clause is squarely applicable to her case.

8.                           In view of the clause reproduced above, the claim has been rightly repudiated.  So, there is no deficiency in service on the part of the opposite parties.  Hence the present complaint is dismissed with no order as to costs.

9.                           Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

26.9.2012.

Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

 (MADHU MUTNEJA)

MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER