Haryana

Karnal

CC/352/2020

Deepa - Complainant(s)

Versus

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

D.S. Kajal

22 Sep 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 352 of 2020

                                                        Date of instt.10.09.2020

                                                        Date of Decision:22.09.2022

 

Deepa, aged 27 years, wife of Shri Manbir, resident of house no.144-K, village Badi Baghru, Sonepat, at present resident of police lines, Karnal (Mobile no.80533-00805).

 

                                               …….Complainant.

                                              Versus

 

1.     Star Health and Allied Insurance Company Ltd. through its Branch Manager, 2^nd floor, SCF-137, Sector-13, Urban Estate, near ICICI Bank, Karnal.

 

2.     Star Health and Allied Insurance Company Ltd., 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600 034.

 

                                                                      …..Opposite Parties.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

              Dr. Rekha Chaudhary…Member

 

 Argued by: Shri D.S. Kajal, counsel for complainant.

Shri Naveen Khetarpal, counsel for the OPs.

 

                    (Jaswant Singh President)

ORDER:  

  

                 The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that husband of complainant had purchased a Medical Term Policy bearing no.P/211114/01/2020/008707 alongwith his family members including his wife and son, commencing from 18.11.2019 to 17.11.2020. Unfortunately, on 25.08.2020, complainant fell ill and was admitted in Sanjeev Bansal Cygnus hospital, Karnal with the complaint of abdomen pain and recurrent vomiting and the complainant was diagnosed with acute severe gastritis with Dehydration and spent an amount of Rs.35633/- on her treatment. The complainant duly informed the OPs about her admission with abovesaid hospital and narrated the detail of illness, which was duly approved by the OPs to take treatment from the hospital and she remained admitted there from 25.08.2020 to 28.08.2020 as the policy in question was a cashless policy. The claim of the complainant was rejected by the OP no.2 and withdraw the approval given earlier, vide letter dated 29.08.2020, on the ground that no such treatment of Hiatus Hernia has been taken or diagnosed by the concerned hospital and treatment obtained by the complainant was of finally diagnosed as acute severe gastritis with Dehydration and expenses incurred thereon of Rs.35,633/- and the payment of the same was made by the complainant. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; limitation; jurisdiction and concealment of true and material facts. On merits, it is pleaded that the insured has availed the Family Health Optima Insurance Plan covering Mr. Manbir self, Mrs. Deepa spouse and Dharvik dependent child for the sum insured of Rs.5,00,000/-, vide policy bearing no. P/211114/01/2020/008707, valid for a period from 18.11.2019 to 17.11.2020 for the first time. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant alongwith the policy schedule. The policy is contractual in nature and the claims arising therein are subject to terms and conditions forming part of the policy. It is further pleaded that the insured Mrs. Deepa raised a request for pre-authorization for cashless treatment at Sanjiv Bansal Cygnus, Karnal on 26.08.2020 for the alleged treatment age with Dehydration and an amount of Rs.10,000/- was initially approved on 23.09.2019. Lateron, the pre-authorization was withdrawn vide letter dated 28.08.2020, details reproduced as under:-

“It is observed from the discharge summary dated 25.08.2020, the patient has been treated for the presenting complaints of the patient are upper abdomen pain and recurrent vomiting and endoscopy report shows presence of grade 2 hiatus hernia which has arisen within two years from the date of commencement of the first policy”.

As per waiting period 3.ii, the claim is not admissible for a period of two years from the date of inception of the first policy. A waiting period of 24 consecutive months of continuous coverage from the inception of this policy will apply to the following specified ailments/illness/diseases:-

a)     Treatment of Cataract and diseases of the anterior and posterior chamber of the Eye, Diseases of ENT, Diseases related to Thyroid, prolapse of intervertebral Disc. (other than caused by accident), Varicose veins and Varicose ulcers, Desmoid Tumor, Umbilical Granuloma, Umbilical Sinus, Umbilical Fistula, all Diseases of Prostate, Stricture Urethra, all Obstructive Uropathies all types of Hernia, Benign tumours of Epididymis, Spermatocele, Varicocele, Hydrocele, Fistula, Fissure in Ano, Hemorrhoids, Pilonidal Sinus and Fistula, Rectal Prolapse, Stress Incontinence and Congenital Internal disease/defect”.

Hence, the pre authorization request was rejected and same was informed to the insured, vide letter dated 29.08.2020. It is further pleaded that complainant has not submitted claim documents for reimbursement, hence is denied that the complainant incurred an amount of Rs.35,633/- towards the treatment. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for complainant has tendered into evidence affidavit of complainant Ex.C1, copy of insurance policy Ex.C2, copy of discharge summary Ex.C3, copy of provisional discharge Ex.C4, copy of rejection and withdrawal of approval Ex.C5, copy of medical bills details Ex.C6 and closed the evidence on 08.02.2022 by suffering separate statement.

5.             Learned counsel for OPs has tendered into evidence affidavit of I.P.C.Tripathy Ex.RW1/A, copy of terms and conditions of the insurance policy Ex.R1, copy of insurance policy Ex.R2, copy of proposal form Ex.R3, copy of request for cashless Ex.R4, copy of cashless authorization letter Ex.R5, copy of discharge summary Ex.R6, copy of letter with regard to rejection and withdrawal of approval given earlier Ex.R7 to Ex.R12 and treatment record Ex.R13 and closed the evidence on 09.05.2022 by suffering separate statement.

6.             We have heard the complainant and learned counsel for the parties and have perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that the husband of complainant purchased Family Health Optima Insurance Plan from the OPs. The said policy is cashless policy. On 25.08.2020 complainant was suffering from abdomen pain and recurrent vomiting and she was admitted in Sanjeev Bansal Cygnus Hospital, Karnal where the she remained admitted from 25.08.2020 to 28.08.2020. Complainant spent a total amount of Rs.35633/- on her treatment. Thereafter, complainant lodged the claim against the said policy and submitted all the relevant documents but OPs did not release the claim and refused to pay the same without any reason and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for OPs, while reiterating the contents of written version has vehemently argued that the case of the complainant falls under the waiting period of two years as per clause 3.ii of the policy. The claim of the complainant under the policy has been rightly repudiated as it was the case Hiatus Hernia. Expenses related to Hernia are payable after two years as per policy terms and conditions. This policy was in first year. So, the claim is not payable as per clause 3.ii and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, insured has availed the health insurance policy from the OPs. It is also admitted that complainant was admitted in Sanjeev Bansal Cygnus Hospital, Karnal from 25.08.2020 to 28.08.2020 during the subsistence of the insurance policy.

11.           The pre-authorization request of complainant has been denied by the OPs, vide letter dated 29.08.2020 Ex.R11, which reproduced as under:-

“the patient has been treated for the presenting complaints of the patient are upper abdomen pain and recurrent vomiting and endoscopy report shows presence of grade-2 hiatus hernia which has arisen within two years from the date of commencement of the first policy.

As per waiting period of 3.ii the claim is not admissible for a period of two years from the date of inception of the first policy”.

 

12.           The onus to prove her case lies upon the complainant, but complainant has miserably failed to prove her version by leading any cogent and convincing evidence. Rather OPs have placed on file, discharge summary Ex.C2 (Ex.R6) wherein it has been mentioned that complainant has taken a treatment for Hernia. As per terms and conditions of the insurance policy, the treatment of Hernia is covered only after two years from commencement of the insurance policy.

13.           In the present case, complainant purchased the policy in question on 18.11.2019 and as per terms and conditions of policy, the expenses for surgery of Hernia are payable after two years. Complainant admitted in the hospital on 25.08.2020 for Hernia disease in the first year of the policy. So, the claim is not payable as per waiting period of 3.ii of the policy. It is not a case of the complainant that OPs did not explain and supplied the terms and conditions of the policy. Thus, present complaint is devoid of any merits and same deserves to be dismissed and same is hereby dismissed. No order as to costs. The parties concerned be communicated the order accordingly, and the file be consigned to the record room, after due compliance.

Announced

Dated:22.09.2022.                                                                      

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

 

 

                (Vineet Kauhik)                 (Dr. Rekha Chaudhary)      

                      Member                               Member