STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA, PANCHKULA
First Appeal No.49 of 2022
Date of Institution: 17.02.2022
Date of Decision: 04.03.2022
Care Health Insurance Limited (Formerly Religare Health Insurance Co. Ltd.), Registered Office 5th Floor, Chawla House, Nehru Place, New Delhi-110019, through its Authorized Person.
….Appellant
Versus
Suman Lata Wife of Shri Abhishek Singla, R/o 9/33, Ram Rai Gate, Jind.
……Respondent
CORAM: Mr.A S Narang, Judicial Member.
Mr. Suresh Chander Kaushik, Member.
Present:- Mr. Jatin Sehrawat, proxy counsel for Shri Paras Money Goyal, counsel for the appellants.
O R D E R
A.S. NARANG, JUDICIAL MEMBER:
(The matter has been heard through virtual hearing).
Care Health Insurance Limited (Appellant) has filed this appeal against the order dated 07.12.2021, whereby the District Consumer Disputes Redressal Commission, Jind (DCDRC) has allowed the complaint filed by the complainant (Suman Lata) against it.
2. Complainant had filed the complaint before the DCDRC with the averments that on 12.02.2015, her husband purchased the health insurance policy bearing No.10209798 for a sum of Rs.5,00,000/- from the appellant. He had paid premium of Rs.5,678/-. The policy was effective from 12.02.2015 to 11.02.2016. Her name was included in the policy on 12.02.2019 for a sum of Rs.5,00,000/- by paying premium of Rs.10,837/- for the period 12.02.2019 to 11.02.2020 and the policy was renewed continuously till 11.02.2021. She suffered some health problem and she approached Akarsh Hospital, Hisar on 18.07.2020. Dr. Meenakshi Goyal advised her for some pathological tests and diagnosed as submucous fibroid in fallopian tube and advised surgery to remove those fibroids. She remained indoor patient on 23.07.2020 to 26.07.2020. Thereafter, she lodged the claim with the appellant. However, they repudiated the same on the ground “treatment of infertility” and the same was not covered under the health insurance policy.
3. After hearing counsel for the parties and perusing the evidence of record, the DCDRC allowed the complaint and directed the appellant to pay Rs.33,421/- to the complainant so incurred on her treatment alongwith interest @ 9% p.a, to pay Rs.3300/- as compensation on account of mental agony and physical harassment and to pay Rs.2200/- as litigation expenses.
4. Aggrieved by the order passed by the DCDRC appellant has filed this appeal.
5. We have heard Mr. Jatin Sehrawat, proxy counsel for Mr. Paras Money Goyal, counsel for the appellant.
6. Assailing the impugned order, Mr. Sehrawat has submitted that the complainant had got the treatment for infertility, which is not covered by the health insurance policy. Unfortunately, at the time of at the time of arguments, the DCDRC did not consider this fact. He further argued that the parties are governed by the terms and conditions of the policy. As per the terms and conditions of the policy, treatment of infertility is not covered.
7. However, at the time of arguments we enquired from Mr. Sehrawat whether the complainant has got any child or not. We also enquired when she was married. Mr. Sehrawat could not give any reply to the same. It appears that the insurance company in order to repudiate the claim has set-up a false claim. Fibroids may cause infertility in case a policy holder is getting treatment for fibroid, it cannot be said that she is getting treatment for infertility. There is no merit in the present appeal. Accordingly, we dismiss the same.
7. Statutory amount of Rs.20,981/- deposited by the appellants at the time of filing the present appeal be disbursed to the appellant as per rules, against proper receipt and identification after the expiry of the period of filing of appeal/revision, if any.
Pronounced in open court.
Suresh Chander Kaushik A S Narang
March 04th, 2022 Member Judicial Member
Addl. Bench Addl. Bench
R.K
