Haryana

Kurukshetra

CC/218/2019

Santosh Devi - Complainant(s)

Versus

TATA AIG Gen Ins - Opp.Party(s)

Sultan Singh

14 Jan 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL  COMMISSION, KURUKSHETRA.

                                                     Complaint Case No.218 of 2019

                                                     Date of institution: 29.05.2019

                                                     Date of decision:14.01.2022.

                         

Santosh Devi wife of Sh.Bhim Singh resident of VPO Barwa Tehsil Thanesar, District Kurukshetra.

                                                                …Complainant.

                        Versus

1.TATA AIG General Insurance Co.Limited, Peninsula Business Park, Tower A, 15^th Floor, G.K.Marg , Lower Parel, Mumbai – 400 013 through its Reginal Manager.

2. TATA AIG General Insurance Co.Limited, Health Claims HUB Suite #108, Ground Floor, Srinilaya-Cyber Spazio , Road No.2, Banjara Hills, Hyderabad – 500034 through its Divisional Manager.

3. TATA AIG General Insurance Co.Limited c/o Axis Bank Limited, Railway Road, Kurukshetra.                                  

                                                             ….Opposite parties.

                Complaint u/s 12 of the Consumer Protection Act.

Before:      Smt. Neelam Kashyap, President.

                Ms. Neelam, Member.

                Sh.  Issam Singh Sagwal, Member.

       

Present:     Sh.Sultan SinghSolra Advocate for the complainant.

                Sh.Gaurav Gupta Advocate for the Ops.

ORDER

                This is a complaint under Section 35 of the Consumer Protection Act, 1986 moved by complainant Santosh Devi  against  TATA AIG General Insurance Co.Limited etc. the opposite parties.

 

2.            It is stated in the complaint that the complainant had  obtained health policy/Hospitalization benefit policy from the OP bearing No.0285318745 with the sum assured Rs.2.00 lacs valid from 13.12.2018  to 12.12.2019 for herself and her family. The complainant is obtaining the health policy from the OP No.1 and 2 for the last many years. It is further submitted that the complainant was got admitted at Aggarwal Nursing HMome, Salarpur Road, Kurukshetra on 28.2.2019 and total abdominal  hysterectomy was diagnosed at the said hospital. The complainant was duly discharged on 6.3.2019. The complainant  was forced to pay Rs.51243/- by the Ops to the said hospital as the amount of treatment was not paid by the Ops and in such circumstances, the complainant had no option but to pay the said amount.  The said insurance policy is cash less one and the Ops were bound to pay the amount so incurred but it was not done so by thje Ops.  The complainant lodged the claim with the Ops vide claim No.190228000194 but the Ops lingered on the matter on one pretext or the other and ultimately rejected the claim of the complainant vide letter dated 28.2.2019 which amounts to deficiency in services on the part of the Ops.  Thus, the complainant  has filed the present complaint against the Ops alleging deficiency in services on the part of the Ops and prayed that the Ops be directed to  pay the claim amount of Rs.51, 243/- alongwith interest and compensation for the mental agony and harassment caused to her.

 

3.             Notice of the complaint was given to the Ops. Ops appeared and filed their written statement disputing the claim of the complainant. Obtaining of the insurance policy and treatment of the complainant has not been denied. It is submitted that the complainant registered the claim with the Ops and sent a request for cashless hospitalization for her alleged treatment for planned “Abdominal  Hysterectomy (Uterus  Removal Surgery) at Agarwal Nursing Home on 28.2.2019 alongwith a pre authorization form and Dr. Lal Path lab report dated 8.9.2018. On scrutiny  of the report dated 8.9.2018,  it was proved that the complainant underwent Uterus Biopsy on 8.9.2018, which is prior to inception of the policy. The treatment for hysterectomy is a result of pre existing condition and as such the claim of the complainant is not payable under “Pre existing Disease clause. Also the claim of the complainant was denied as Hysterectomy is not payable as per two years waiting period clause of the policy.  All other allegations made in the complaint have been denied specifically and it was submitted that the complaint is barred u/s 26 of the Consumer Protection Act and the present complaint is based on false and frivolous and incorrect and misleading facts and prayed for the dismissal of the present complaint.

 

4.             The complainant in support of her complaint has filed her affidavit Ex.CW1/A and tendered documents Ex.C-1 to Ex.C-41 and closed her evidence.

 

5.             On the other hand, Ops in support of their case have filed affidavit Ex.RW1/A and tendered documents Ex.R-1 to Ex.R-3 and closed their evidence.

 

6.             We have heard the learned counsel for the parties and gone through the case file very carefully.

 

7.             The learned counsel for the complainant while reiterating the averments made in the complaint has argued that complainant had  obtained health policy/Hospitalization benefit policy from the OP bearing No.0285318745 with the sum assured Rs.2.00 lacs valid from 13.12.2018  to 12.12.2019 for herself and her family. The complainant is obtaining the health policy from the OP No.1 and 2 for the last many years. It is further argued  that the complainant was got admitted at Aggarwal Nursing Home, Salarpur Road, Kurukshetra on 28.2.2019 and total abdominal  hysterectomy was diagnosed at the said hospital. The complainant was duly discharged on 6.3.2019. The complainant was forced to pay Rs.51243/- by the Ops to the said hospital as the amount of treatment was not paid by the Ops and in such circumstances, the complainant had no option but to pay the said amount.  The said insurance policy is cash less one and the Ops were bound to pay the amount so incurred but it was not done so by the Ops. The complainant lodged the claim with the Ops vide claim No.190228000194 but the Ops lingered on the matter on one pretext or the other and ultimately rejected the claim of the complainant vide letter dated 28.2.2019 which amounts to deficiency in services on the part of the Ops.Reliance has been placed on the law cited in the authorities NIC Vs. Mrs. Kalpana Verma and others  First Appeal No.227/2013 decided on 4.5.2021 (Hon’ble Delhi State Commission)  and Religare Health Insurance Company Limited Versus The Chairman, Permanent Lok Adalat and another CWP No.107 of 2020 decided on 7.1.2020 ((Hon’ble Punjab & Haryana High Court Chandigarh).

8.             On the other learned counsel for the Ops while reiterating the submissions made in the  written statement has argued that that the complainant registered the claim with the Ops and sent a request for cashless hospitalization for her alleged treatment for planned “Abdominal  Hysterectomy (Uterus  Removal Surgery) at Agarwal Nursing Home on 28.2.2019 alongwith a pre authorization form and Dr. Lal Path lab report dated 8.9.2018. On scrutiny  of the report dated 8.9.2018,  it was proved that the complainant underwent Uterus Biopsy on 8.9.2018, which is prior to inception of the policy. The treatment for hysterectomy is a result of pre existing condition and as such the claim of the complainant is not payable under “Pre existing Disease clause. Also the claim of the complainant was denied as Hysterectomy is not payable as per two years waiting period clause of the policy. Reliance has been placed on the authorities Satwant Kaur Sandhu Vs. New India Assurance Co.Limited (SC) Law Finder Doc Id # 203511, P.C.Chacko and another Vs.  Chairman  LIC of India and others (SC) Law Finder Doc Id # 134190 and M/s Industrial Promotion and Investment Corporation of Orissa Limited Vs. New India Assurance Co.Limited Civil Appeal No.1130 of 2007 decided on 22.8.2016 (SC).

9.             After hearing the learned counsel for the parties, we are of the view that from the perusal of report of Dr.Lal Pathlabs Ex.R-1 it is established that the complainant got this report conducted on 8.09.2018 whereby the complainant underwent Uterus Biopsy  and in this report it is reported as under:

                “i) Biopsy shows predominantly fibrinohemorrhagic material with

                fragmented endometrium showing extensive stromal

                decidualization with non-secretory glands.

                ii) No evidence of endometritis or grandfoma or atypia seen in

                this biopsy”  

                                The report Ex.R-1 is dated 8.09.2018 whereas the complainant took the insurance policy in question on 13.12.2018. The complainant  was admitted in the hospital on 28.2.2019 and was discharged on 6.3.2019 and she was diagnosed   Total Abdominal Hysterectomy. The cashless denial for hospitalization of the complainant under Pre-Authorization has been rightly denied by the Ops vide letter Ex.C-1. Thus, the complainant  is not entitled to any claim as per Section  3(c) of the Insurance policy obtained by her where under treatment of Hysterectomy including other diseases are not covered within two years of the inception of the said policy. Therefore, the denial letter Ex.C-1 has been rightly issued by the Ops. Therefore, having regard to the terms and conditions of the policy in question and in view of the  authorities cited on behalf of the Ops, the present complaint deserves to be dismissed.  The authorities cited on behalf of the complainant are not applicable to the facts and circumstances of the present complaint.

 

                In view of our above discussion and findings, we do not find any merit in the present complaint and the same is hereby dismissed without any relief to the complainant. Certified copy of this order be supplied to the parties concerned as per rules and the file be consigned to the record room after due compliance.

 

Announced in the open Commission.

Dated:14.01.2022.                                                 President.

 

                        Member             Member.