Chandigarh

DF-I

CC/377/2018

Ms. Sunita Bhalla - Complainant(s)

Versus

United India Insurance Co. Ltd. - Opp.Party(s)

N.K. Bhalla

31 May 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

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Consumer Complaint No.	:	CC/377/2018
Date of Institution	:	08/08/2018
Date of Decision	:	31/05/2019

 

Sunita Bhalla, R/o H.No.345, MDC, Sector 4, Panchkula-134109, Haryana.

…..Complainant

 

V E R S U S

 

1.      United India Insurance Co. Limited, Regd. & Head Office, 24, Whites Road, Chennai – 600 014, through its Manager.

 

2.      United India Insurance Co. Limited, Branch Office: 3, SCO No. 855, 1^st Floor, Kalka Highway, NAC, Manimajra, Chandigarh, through its Branch Manager.

 

3.      MedSave Health Care (TPA), SCO No.66, Sector 40-C, 1^st Floor, Chandigarh, through its Manager.

…… Opposite Parties

QUORUM:	RATTAN SINGH THAKUR	PRESIDENT
	MRS.SURJEET KAUR	MEMBER
	DR.S.K.SARDANA	MEMBER

                               

ARGUED BY	:	Sh.N.K. Bhalla, Counsel for Complainant.
	:	Sh.M.L. Chaudhary, Counsel for OPs No.1 & 2.
	:	Opposite Party No.3 ex-parte.

 

PER SURJEET KAUR, MEMBER

1.         The facts, in brief, are that the husband of the Complainant Sh.Nirmal Kumar Bhalla had purchased a Mediclaim Policy from the Opposite Party No.2, wherein the Complainant was also covered. It has been averred that the Complainant got her treatment from the Fortis Hospital, Mohali, from 10.08.2017 to 13.02.2018, including the admission in the Hospital on 11.09.2017 (discharged on 11.09.2017). On her treatment, the Complainant incurred an expenditure of Rs.1,97,660/- (Bills Annexure C-2). Accordingly, the Complainant sent the whole case to the Opposite Party No.3 for the purpose of approval and reimbursement; whereafter, Opposite Party No.2 asked the Complainant to submit the discharge summary in original to review the claim, which was duly submitted by the Complainant. However, to the utter surprise of the Complainant, the Opposite Parties rejected her claim vide letter dated 28.06.2018 on absolutely arbitrary and unfair grounds. Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties, the complainant has filed the instant complaint.
2.         Notice of the complaint was sent to Opposite Parties seeking their version of the case. However, nobody appeared on behalf of Opposite Party No.3 despite service, therefore, it was proceeded ex-parte.
3.         Opposite Parties No.1 & 2 contested the complaint and filed their written reply, inter alia, admitting the basic facts of the case. It has been pleaded that the Complainant got treatment of infertility which was not covered under the policy and comes under the exclusion clause 4.9. Accordingly, the Complainant was informed that the claim filed by her was repudiated and closed as no claim vide letter dated 28.06.2018. Thus, pleading that there is no deficiency in service or unfair trade practice on their part, Opposite Parties No.1 & 2 have prayed for dismissal of the complaint.
4.         Controverting the allegations contained in the written statement and reiterating the pleadings in the Complaint, the Complainant filed the replication.
5.         The parties led evidence in support of their contentions.
6.         We have gone through the entire record and have also heard the arguments addressed by the Learned Counsel for the Parties.
7.          After giving our thoughtful consideration, to the rival contentions, advanced by the Complainant and Ld. Counsel for the Opposite Parties No.1 & 2, and the evidence, on record, we are of the considered opinion, that the Complaint is liable to be dismissed, for the reasons to be recorded hereinafter.
8.         The only grievance of the Complainant is that her medi-claim has been repudiated by the Opposite Parties on the flimsy grounds vide letter dated 28.06.2018. Per contra, Opposite Parties No.1 & 2 have contended that the claim was not payable as the treatment taken by the Complainant was for infertility, which was not covered under the policy and comes under the exclusion clause 4.9.
9.         For the purpose of adjudicating the matter, we advert to the terms & conditions of the policy. On meticulous perusal of the terms & conditions of the policy, placing on record by the Opposite Parties No.1 & 2 at Annexure R-1, we find that Clause 4.9 thereof under the heading ‘Exclusions’ specifically deals with the condition(s)/disease(s) in respect of which the OP-Insurance Company was not be liable to make any payment. The said Clause reads as under: -

“4.    Exclusions: The Company shall not be liable to make any payment under the policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of:-

4.1   xxxxx               xxxxx               xxxxx       xxxxx

xx    xxxxx               xxxxx               xxxxx       xxxxx

4.9   Convalescence, general debility; run-down condition or rest cure, Obesity treatment and its complications including morbid obesity, Congenital external disease/defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, Sterility, Venereal disease, intentional self injury and use of intoxication drugs/alcohol.”

                In this view of the matter, on conjoint reading of Clause 4.9 reproduced ibid along with the material placed before us, we feel that since in terms of Clause 4.9 (supra), the treatment related to infertility was excluded from coverage in the policy, as such we do not find any illegality in denial of the claim of the Complainant by the Opposite Parties.

10.         For the reasons recorded above, we do not find any shred of evidence to prove any deficiency in service or unfair trade practice on the part of Opposite Parties. Consequently, the Consumer Complaint fails and the same is dismissed, leaving the parties to bear their own costs.    
11.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
31/05/2019	[Dr.S.K.Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
	Member	Member	President
“Dutt”