Haryana

Jind

CC/12/2013

Abhishek Bansal - Complainant(s)

Versus

The Star Health And Allied Insurance - Opp.Party(s)

Sh K.R. Sharma

28 Jun 2016

ORDER

BEFORE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, JIND.
                            Complaint No. 12 of 2013
                            Date of institution:-17.1.2013
                            Date of decision:- 1.8.2016
Abhishek Bansal son of Sh. Brij Mohan Bansal son of Sh. Tej Ram Bansal c/o Shadi Ram Bihari Lal old anaj mandi, Jind, Tehsil and District Jind. 

                                       ...Complainant.
Versus
The Star Health and Allied Insurance Company Ltd. KRM Centre, VI floor No.2, Harrington road, Chetpet, Chennai-600031 through MD/Manager. 
Smt. Renu Jindal c/o Ram Parkash Ram Kumar old anaj Mandi, Jind, Tehsil and District Jind-126102, Haryana. 
                                          …Opposite parties.
Complaint under section 12 of
                Consumer Protection Act, 1986.

Before: Sh. Dina Nath Arora, President.    
            Smt. Bimla Sheokand, Member.
            Sh. Mahinder Kumar Khurana, Member.
            
Present:-    Sh. K.R. Sharma Adv. for complainant. 
        Sh. P.S. Duhan, Adv. for opposite party No.1.
            Sh. Rajiv Kumar Adv. for opposite party No.2. 
            
Order:-
        In nutshell, the facts of the complaint are that the complainant had obtained a Family Health Optima Insurance Policy for a sum of Rs.2,00,000/- vide policy No.P-161113/01/2012/002135 valid w.e.f. 13.12.2011 to 12.12.2012 from opposite party No.1 
            Abhishek Bansal Vs. Star Health etc.
                        …2…
through opposite party No.2 previous policy number was P/161113/01/2011/002420 in his name and in the name of his wife Smt. Mamta Bansal and son Nitin Bansal. The complainant has deposited the regular premium amount. By virtue of the above said policy the expenses incurred by the complainant on his treatment, on the treatment of his wife and son, the opposite parties are liable to be reimbursed during the currency of policy. Smt. Mamta Bansal wife of complainant fell ill and she took her treatment from N.C. Institute of Medical Care and Research, Model Town, Hissar , she remained admitted from 21.8.2012 to 24.8.2012 and spent a sum of Rs.13,496/- for treatment. Thereafter, the complainant lodged a claim of Rs.13,496/- with the opposite parties vide claim No.0075356 and submitted all the necessary documents. The opposite parties have wrongly repudiated the claim of the complainant vide letter dated 21.9.2012. The complainant served a legal notice dated 11.10.2012 through his counsel Sh. Kamal Raj Sharma Adv. upon the opposite parties but all in vain. Deficiency in service on the part of the opposite parties is alleged. It is prayed that the complaint be accepted and opposite parties be directed to pay  Rs.13,496/- as claim amount, a sum of Rs.50,000/- as compensation on account of mental pain and agony, a sum of Rs.5,500/- as counsel fee  as well as to pay a sum of Rs.11,000/- as litigation expenses to the  complainant. 
2.    Pursuant to notice, the opposite parties have appeared and filed the  separate written reply. Opposite party No.1 has contended in the preliminary objections i.e. the complainant has no locus-standi to file 
            Abhishek Bansal Vs. Star Health etc.
                        …3…
the present complaint and complaint is false and frivolous. On merit, it is contended that the company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by any insured person in connection with or in respect of convalescence, general debility, mental disorder, run down condition or rest cure, congenital external disease or defect or anomalies, sterility venereal disease, intentional self injury and use of intoxicating drugs/alcohol and as per the discharge summary the patient was admitted for generalized body pains and treated conservatively. She was admitted with history of fall and subsequent pain in low back body she was investigated and found to be Vitamin D deficient. All other investigations were normal. Neurology consultation was done and physiotherapy given and treated with injection Arachidol IM stat-6Lakhs IV given (Vitamin D) and thus under Exclusion No.11 the company is not liable to make any payment under this policy. So the answering opposite party has rightly repudiated the claim of the complainant vide letter dated 21.9.2012. Therefore, there is no deficiency in service on the part of the answering opposite party. Dismissal of complaint with cost is prayed for. 
3.    Opposite party No.2 has contended that he  has not  provided any services or sold any goods to the complainant so the answering opposite party is not responsible of the above said policy in question. The complainant purchased the Star Health and Allied Insurance Company Ltd. and there is no legal relationship between the 
            Abhishek Bansal Vs. Star Health etc.
                        …4…
complainant and answering opposite party. The alleged claim/reply/repudiation letters may be the communications between the complainant and Star Health and Allied Insurance Company Ltd. and the answering opposite party is not aware of the same. Therefore, there is no deficiency in service on the part of the answering opposite party. Dismissal of complaint with cost is prayed for. 
4.    In evidence, the complainant has  produced  his own affidavit Ex. C-1, postal receipt Ex. C-2 and Ex. C-4 copy of legal notice dated 11.10.2012 Ex. C-3, copy of policy schedule Ex. C-5, copy of claim form Ex. C-6, copy of receipt Ex. C-7, copies of cash memos and bills Ex. C-8 to Ex. C-12 and closed the evidence.  On the other hand, the opposite party  No.1 has produced the affidavit of Sh.Rajnish Kohli Ex. OP-1, Family Health Optima Insurance Policy-schedule  Ex. OP-2, copy of discharge card issued by Jindal Institute of Medial Sciences Ex. OP-3, copy of medical history  and duration  of Mamta patient Ex. OP-4, copy of repudiation letter dated 21.9.2012 Ex. OP-5, copy of  reply of notice dated 11.10.2012 Ex. OP-6 and copy of postal receipt Ex. OP-7 and closed the evidence. 
5.    We have heard Ld. counsel of all the parties and also perused the record placed on file. The counsel for complainant argued that the complainant had obtained one Family Health Insurance Policy  from opposite party No.1. It is further argued that his wife Smt. Mamta Bansal  fell ill and spent a sum of Rs.13,496/- for her treatment. But the opposite party No.1 has repudiated the claim of the complainant 

            Abhishek Bansal Vs. Star Health etc.
                        …5…
vide letter dated 21.9.2012 on false and frivolous ground and prayed for allowed the complaint.
6.    On the other hand, counsel for opposite party No.1 argued that the claim of the complainant was rightly repudiated as per terms and conditions of the policy because the general debility is not covered under this policy for which the complainant admitted in the hospital and got treatment and counsel for opposite party No.1 prayed for dismissal of complaint.  The counsel for opposite party No.2 argued that she has not provided any services or sold any goods to the complainant and as such the opposite party No.2 is not responsible of the above said policy in question. 
7.    After hearing Ld. counsel of all the parties the forth most question arises before us whether the claim of the complainant was  rightly rejected by the opposite party No.1 or not and complainant’s wife  for which  ailment she took treatment and incurred Rs.13,496/- are covered under the terms and conditions of the policy. We have gone through the Discharge summary Ex. OP-3 and history given by the treating doctor Ex. OP-4 as per record,  the complainant’s wife was admitted for generalize body pains and treated conservatively. She was admitted history of fall and subsequent pain in low back body. She was investigated and found to be Vitamin-D deficient. All other investigations were normal. Neurology consolation was done and physiotherapy given and treated with injection to treat the deficiency of vitamin-D. The condition No.11 of the Insurance Policy which is reproduce below:- “ The company shall not be liable to make any 
            Abhishek Bansal Vs. Star Health etc.
                        …6…
payments under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of convalescence, general debility, mental disorder, run down condition or rest cure, congenital external disease or defect or anomalies senility venereal disease, intentional self injury and use of intoxicating drugs/alcohol”. 
As per discharge summary Ex. OP-3 the patient was finally found to be Vitamin-D deficient for which she/insured was treated. From the perusal of the Ex. OP-4 the treating doctor remarks that in the patient history that the insured have back pain generalized body  aches from the last 2½ years. As per language of  medical-generalized body aches/pains is not a particular disease. In the present complaint, the insured has not suffered with any specific ailment. 
8.    In view of the facts discussed above, we are of the opinion that the complainant is not suffered from any particular disease and as per  condition No.11 of the policy the claim of the insured is not covered. Hence, there is no deficiency in service on the part of the opposite parties. Resultantly, the complaint of the complainant is dismissed with no order as to costs. Copies of order be supplied to the parties under the rule. File be consigned to the record-room after due compliance.
Announced on: 1.8.2016  
                                              President,
       Member       Member                 District Consumer Disputes                                          Redressal Forum, Jind

              Abhishek Bansal Vs. Star Health etc.
                        
                
Present:-    Sh. K.R. Sharma Adv. for complainant. 
        Sh. P.S. Duhan, Adv. for opposite party No.1.
            Sh. Rajiv Kumar Adv. for opposite party No.2. 
            
 
                Arguments heard.  To come up on  1.8.2016 for orders.

                                       President,
            Member            Member                     DCDRF,Jind
                                       28.7.2016

Present:-    Sh. K.R. Sharma Adv. for complainant. 
        Sh. P.S. Duhan, Adv. for opposite party No.1.
            Sh. Rajiv Kumar Adv. for opposite party No.2. 
            
 
        Order announced. Vide our separate order of the even date, the complaint is dismissed. File be consigned to the record room after due compliance. 

                                                                                             President,
            Member            Member                     DCDRF,Jind
                                           1.8.2016