Chandigarh

DF-II

CC/1002/2019

Awadhesh Singh - Complainant(s)

Versus

The Star Union Dai-ichi Life Insurance Co. Ltd. - Opp.Party(s)

Naresh Dilawari Adv.

31 Aug 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

Consumer Complaint No.	:	1002 of 2019
Date of Institution	:	01.10.2019
Date of Decision	:	31.08.2022

 

            

Awadhesh Singh S/o Sh. Arjun Singh presently residing at # 15, near Railway Station, Village Daria, Chandigarh 160101.

…..Complainant

V E R S U S

1. The Star Union Dai-ichi Life Insurance Co. Ltd through its Manager/authorized officer, SCO 830 (FF), NAC Manimajra, Chandigarh 160101.
2. The Manager, The Star Union Dai-inchi Life Insurance Co. Ltd. SCO 830, (FF), NAC Manimajra, Chandigarh 160101.

                          …….Opposite Parties

BEFORE: SMT.PRITI MALHOTRA, PRESIDING MEMBER

         SH. B.M SHARMA, MEMBER

Argued by: -

Sh.Naresh Dilawari, Adv, for complainant.

Sh.Gaurav Bhardwaj, Adv, proxy for Sh.S.R.Bansal, Adv., for OPs.

     

PER PRITI MALHOTRA, PRESIDING MEMBER

1.        Briefly stated, the case of the complainant is that he purchased Health Insurance Policy No. 00968614 from the OPs commencing from 31/5/2016 for sum assured of Rs.5.27 lakhs @ monthly premium of Rs.2126/-  are being regularly paid.  The policy was valid for 10 years and as per policy terms, the amount equal to 100% of sum assured was payable on claim. In September 2018, he suffered health problem regarding urinary disorder and admitted at Chanakya Hospital, Patna on 27.9.2018 and discharged on 6.10.2018. and incurred Rs.80,000/- towards medicines and treatment etc.  After discharge from Chanakya Hospital, Patna, he stayed at Hotel and again felt uneasiness. On 8.10.2018, he was taken to Indira Gandhi Institute of Medical Sciences, Patna where he remained admitted from 19.12.2018 to 31.12.2018. He incurred medical expenses of approximately Rs.1.00 lakhs including medicine, treatment as well as hotel expenses etc. at IGIMS, Patna.  Subsequently, Thereafter, he submitted the claim form with requisite documents to the OPs on 08.05.2019 and also to the surveyor appointed by the OPs on 26.07.2019. However, the opposite parties illegally repudiated the claim vide letter dated 8.8.2019. Alleging that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice, the complainant has filed the instant complaint.
2.         In their written statement, the OPs have admitted that the  complainant took the insurance policy No. 00968614 viz. ‘SUD Life Aarogyam Plan’ from the company and that the complainant was treated for urinary Tract Infection with urosepsis with Urethral Stricture with Type-II Diabetes Mellitus with Bilateral Hydrocele. It has been denied that the said ailment was covered as per the list of critical illness aliments mentioned in the policy and, they are liable to pay the sum assured. As per OPs, the complainant was provided a free look period of 30 days from the date of receipt of the policy, to opt to cancel the policy in case there are any discrepancies in the policy.  However, the complainant failed to approach within the free look period with any grievances with respect to the terms and conditions of the policies, thereby implying that the terms and conditions of the policy were in order. On 27.5.2019, the complainant submitted claim stating that he was admitted in Chanakya Hospital Patna for treatment of Urinary disorder form 27.09.2019 to 06/10.2018 and thereafter, form 8.10.2019 to 31.12.2018 in Indra Gandhi Institute of Medical Sciences, Patna. It has further been stated that the parties to the said contract are bound by its terms and conditions. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service on their part, a prayer for dismissal of the complaint has been made.
3.         The complainant filed rejoinder to the written reply of the Opposite Parties controverting their stand and reiterating his own.
4.         We have heard the Counsel for the contesting parties  and have gone through the documents on record as well as written submissions.
5.         From the pleadings of the parties and the documentary evidence on record, it is clear that the complainant obtained the policy in question from the OPs and he remained admitted in Chanakya Hospital Patna for treatment of Urinary disorder from 27.09.2019 to 06/10.2018 and thereafter, from 8.10.2019 to 31.12.2018 in Indra Gandhi Institute of Medical Sciences, Patna.  It is also not in dispute that the claim submitted by the complainant was repudiated by the OPs vide its letter dated 08.08.2019 on the ground that the condition claimed is not covered event as per the critical illness contract.
6.         Pertinently, all the major/critical and ailment(s) are covered under the terms and conditions of the insurance policy issued to the LA. However, to our astonishment the claim of the complainant submitted alongwith requisite documents with the OPs for release of the sum assured to the tune of Rs.5,27,000/- under the insurance policy on account of the treatment of the ailment i.e. urinary disorder for which the complainant took the treatment from the hospitals aforesaid has been rejected. In our considered opinion, the claim of the complainant does not fall within the parameters of the terms and conditions of the insurance policy and has wrongly and illegally been rejected by the OPs vide letter dated 08.08.2019. By rejecting the genuine claim of the complainant, the OPs have committed deficiency in service.
7.      In view of the above discussion, the consumer complaint deserves to succeed and the same is accordingly partly allowed qua OPs.  The OPs are directed as under :-
   1. To refund sum assured of Rs.5.27 lakhs to the complainant.
   2. To pay to the complainant Rs.15,000/- as compensation for mental agony and harassment.
   3. To pay to the complainant Rs.10,000/- as costs of litigation.
8.      This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of additional amount of Rs. 5000/- to the complainant.
9.      Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

 

Announced 31/08/2022
	Sd/- (PRITI MALHOTRA) PRESIDING MEMBER
	Sd/- (B.M.SHARMA) MEMBER