Delhi

West Delhi

CC/12/697

PREETI DEVI - Complainant(s)

Versus

STAR HEALTH & ALLIED INSURANCE - Opp.Party(s)

27 Mar 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (WEST)

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

 

CASE NO. 697/2012

 

1. Smt. Preeti Devi

W/o Late Sh. Raj Kumar Dubey

 

2. Baby Kajol

(Through its MotherPreeti Devi)

 

Both R/o A-701, Prabha Apartment,

Sector -23, Plot No-11

Dwarka   New Delhi                                       ..…. Complainants

 

VERSUS

 

 

1. The  Star Health  and allied insurance Co. Ltd.

Branch Office- Janak Puri,

Plot No. 4 , 3^rdFloor, Block,

Community Centre, Janak Puri,

New Delhi-110058.….. Opposite Party No. 1.

 

 

2. The Star  Health  and allied  insurance Co. Ltd.

Reg. Office at:-

          1, New Tank Street

          Valluvar Kottam High Road

          Nungambakkam,

• Chennai- 600034

 

 

 

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 purchased Family Health Insurance Policy from the respondent on 10.02.2010   for his wife and minor daughter.  The complainant further got the policy renewed on the same terms and conditions on 10.02.2011. It is further averred in the complaint  that in the month of May, 2011 the complainant  after  celebrating the Birth party of his daughter Complainant   had gone  in the un-Conesus  position  and was not in the  position to  talk to his family  members.  He was taken to Kukreja Hospital and was admitted  and it was known that  due  to suddenly raised  high blood   pressure the complainant faced the said situation.  Due to massive increase in blood pressure complainant faced paralyses attack  as a result  both the kidnies of complainant  got damaged.  The complainant  further stated that his wife Smt. Preeti Devi  was also  got  operated in Kukreja Hospital  due to sudden uterine  bleeding after being admitted in Hospital on 06.12.2011 and spent Rs. 65,000/-  on the operation.  Upon filing claim for the said amount the OPs refused the payment on unjustified grounds and for the treatment taken by complainant the respondent had only reimbursed an amount of   Rs. 83,790/- and did not pay for the treatment  of dialysis which was regularly done twice or trice in a week.  The complainant submitted three bills of total amounting to Rs. 1,07,866/- alongwith original  medical papers to OP but they  did not make the payment.  Hence the present complaint.

 

2. OP  filed written statement  by taking  preliminary objection that complainant false, frivolous, vague , baseless  and misconceived  because the complainant was  admitted in Kukreja  Hospital  on 08.05.2011  and discharged on 16.05.2011 with the diagnosis  of  Right Gangleo  Capsual Bleed(CVA)  and Left Hemipegia.  The respondent  had already  reimbursed  Rs. 83,790/-  to the complainant towards treatment of  Right Gangleo  Capsual Bleed(CVA)  and Left Hemipegia being acute medical emergency.   However, the treatment taken for Kidney Disease which is chronic in nature  and the complainant is symptomatic prior  to inception of the Insurance Policy was not payable. It has been further stated that claim of complainant’s wife  was repudiated on the ground of the Exclusion Clause 3 of the policy because complainant was not entitled  to the claim as per  terms and conditions.  It is prayed that application should be dismissed.    

3.     Complainant has filed his affidavit affirming the facts alleged in the complaint.  He mentioned documents Ex-CW1/A to Ex-CW1/K. On the other hand Sh.  Rajnish Kohli, Assistant Vice President for OP  filed affidavit in evidence on behalf of O.P testifying all the facts as stated in the written statement.  Both parties also filed its respective written submission. 

4.     We have heard the complainant in person and   Ld. Counsels for OP.

 

5.     We have gone through the controversy reveals around the issue as  to whether the complainant  is entitled to the claim sought or not. The policy is not in dispute.  The treatment received by complainant and his wife is also not in dispute.   It is also not disputed that OP has already made part payment of claim filed by complainant for his treatment.  The remaining amount was disallowed by OPs on the ground that kidney disease was pre-existing  before he commencement of policy.   It is now well settled law that if he insurance company takes the ground of pre-existing disease, a duty is cast upon it to prove the pre-existing disease by producing cogent and valid medical evidence pertaining to the insured.   The pre- existing disease cannot be treated by merely saying so.  OP has not placed on record any medical evidence regarding pre-existing disease. So far as the claim of complainant and his wife is concerned the OP rejected the same on the ground of Exclusion Clause-3.  It is also now well settled law that insurance company can rely on the terms and conditions if the same were duly  supplied to the insured at the time of inception  of the policy .  We have  gone through  the policy  issued by OP and it  does not contain any terms and conditions of the policy. The OP has prepared a separate                      full-fledge document containing  numerous terms and conditions which were never furnished to the  complainant.  Generally the Insurance Companies take up the plea of terms and conditions when a lawful claim is filed against it.  The amount of insurance is based on mutual bona-fide of the parties  where both parties  should be honest and thruthful to each other

6.     Keeping in view the discussion stated above, we are of the considered view  that  OP has rejected the claim of the complainant on flimsy ground, therefore, we pass  award  of Rs. 1,07,866 /- in favour of  complainant to be paid by OP  within 45 days from receipt of this order failing which  interest @ 6% from the date of institution  of complaint till realization shall be levied.  We have also awarded a sum of Rs. 7,500/- towards  mental agony, harassment  and litigation expenses.

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

File be consigned to the record room. 

Announced this__27TH____ day of __March ___ 2019.

 

( K.S. MOHI )                (PUNEET LAMBA)                                                                                    

PRESIDENT                        MEMBER