STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

UNION TERRITORY, CHANDIGARH

Ms. Sunita Bhalla resident of House No.345, MDC,
Sector-4, Panchkula-134109, Haryana.

       ....Appellant/Complainant

Versus

1. United India Insurance Co. Ltd., Regd. & Head Office, 24, Whites Road, Chennai–600014, through its Manager.
2. United India Insurance Co. Ltd., Branch Office: 3, SCO No.855, (1^st Floor), Kalka Highway, NAC, Manimajra, Chandigarh-180017, through its Manager.

                          ...Respondents/Opposite Parties No.1 & 2

Appeal under Section 15 of the Consumer Protection Act, 1986.

BEFORE:  MRS. PADMA PANDEY, PRESIDING MEMBER

                MR. RAJESH K. ARYA, MEMBER

Argued by:  Sh. N.K. Bhalla, Advocate for the appellant.

PER PADMA PANDEY, MEMBER

              This appeal is directed against an order dated 31.05.2019, rendered by District Consumer Disputes Redressal Forum-I, UT, Chandigarh (hereinafter to be called as the District Forum only), vide which, it dismissed the complaint.

2.    The facts in brief, are that the Complainant’s husband Sh. Nirmal Kumar Bhalla had purchased a Mediclaim Policy No.11160 42816 P 108874709 from the Respondent/Opposite Party No.2, wherein the Appellant/Complainant was also covered. It was stated that the Complainant got her treatment from the Fortis Hospital, Mohali, from 10.08.2017 to 13.02.2018 (Annexure C-1), including the admission in the Hospital on 11.09.2017 (discharged on 11.09.2017). It was further stated that the Complainant incurred an expenditure of Rs.1,97,660/- (Annexure C-2), on her treatment and accordingly, the complainant sent the whole case to the Opposite Party No.3 i.e. MedSave Health Care (TPA), for the purpose of approval and reimbursement. It was further stated that the Opposite Party No.2 asked the complainant to submit the discharge summary in original to review the claim, which was duly submitted by her. It was further stated that the complainant was totally surprised to see that the Opposite Parties rejected her claim vide letter dated 28.06.2018 (Annexure C-4) on absolutely arbitrary and unfair grounds. It was further stated that the complainant sent a legal notice on 25.05.2018 vide Annexure C-3, but no reply was received. It was further stated that the aforesaid acts of the Opposite Parties, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant, was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), was filed.
3. The Opposite Parties No.1 & 2 in its written version admitted the factual matrix of the case and stated that the complainant got treatment of infertility, which was not covered under the policy and comes under the exclusion clause 4.9. It was further stated that the complainant was informed that claim filed by her was repudiated and closed as no claim vide letter dated 28.06.2018. It was further stated that there is no deficiency in service on their part, and the answering Opposite Parties had prayed for dismissal of the complaint.
4. Opposite Party No.3 proceeded ex-parte on 11.10.2018.
5. The complainant, filed rejoinder to the written statement of the Opposite Parties No.1 & 2, wherein she reiterated all the averments, contained in the complaint, and refuted those, contained in the written version of the Opposite Parties. 
6. The Parties, led evidence, in support of their case.
7.       After hearing the Counsel for the Parties, and, on going through the evidence, and record of the case, the District Forum, dismissed the complaint.
8.       Feeling aggrieved, the instant appeal, has been filed by the appellant/complainant.
9.       We have heard the Counsel for the complainant, and have gone through the evidence, and record of the case, carefully.
10.       After giving our thoughtful consideration, to the contentions, advanced by the Counsel for the complainant and the evidence, on record, we are of the considered opinion, that the appeal is liable to be dismissed at the preliminary stage, for the reasons, to be recorded hereinafter. 
11.             On going through the terms and conditions of the policy, in question, clause 4.9 under the heading “Exclusions” specifically deals with the condition(s)/disease(s) in respect which the insurance company was not 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.”

The appellant, in this case, had taken treatment relating to infertility which was excluded from coverage in the policy and accordingly the claim was denied by the respondent insurance company, and therefore, we find that the order passed by the District Forum, being based on the correct appreciation of evidence, and law, on the point, does not suffer from any illegality or perversity, warranting the interference of this Commission.

12.         For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed at the preliminary stage, with no order as to costs. The order of the District Forum is upheld, accordingly.
13.       Certified Copies of this order be sent to the parties, free of charge.
14.        The file be consigned to Record Room, after completion.

Pronounced.

24.06.2019

                                                              Sd/-                                                                                          

[PADMA PANDEY]

PRESIDING MEMBER

                                                                        Sd/-                              

[RAJESH K. ARYA]

 MEMBER

Gp

                                STATE COMMISSION

APPEAL No.121 of 2019

(Sunita Bhalla Vs. United India Insurance Co. & Ors.)

Argued by:

Sh. N.K. Bhalla, Advocate for the appellant.

Dated  the  24^th  day of  June, 2019

            Vide our detailed order of the even date, recorded separately, the appeal filed by the appellant/complainant has been dismissed at the preliminary stage, with no order as to cost and the order passed by the District Forum has been upheld.

            Sd/-                              Sd/-

Gp