Haryana

Karnal

CC/367/2021

Sheela Devi - Complainant(s)

Versus

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

Balvinder Singh

02 Aug 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No. 367 of 2021

                                                        Date of instt.30.07.2021

                                                        Date of Decision:02.08.2023

 

Sheela Devi aged about 30 years wife of Shri Rinku Singh, resident of VPO Kutail, tehsil and District Karnal. Aadhar no.6581 5966 1921.

 

                                                …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Co. Ltd., # SCF-137, 2^nd floor, near ICICI Bank, Sector-13, Urban Estate, Karnal-132001, through its Branch Manager.

 

2. Star Health and Allied Insurance Co. Ltd. # no.15, Shri Balaji Complex, 1^st floor, Whits Lane, Roy Apettah, Chennai-600014 through its MD. CEO/authorized signatory.

 

…..Opposite Parties.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.

              Shri Vineet Kaushik……Member

      Dr. Rekha Chaudhary…….Member

                   

Argued by: Shri Balwinder Singh, counsel for the 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 complainant had purchased a Health Insurance Policy in the name and style of ‘Accident Care Individual Insurance Policy’ bearing no.P/211114/02/2021/000826 from the OPs by paying premium amount of Rs.3460/-. The said policy was valid from 19.01.2021 to 18.01.2022, for the sum insured of Rs.15,00,000/- and the said policy also cover the husband of complainant namely Rinku Singh. On 25.01.2021, complainant fell down from the stairs of Smt. Jai Devi Memorial Nursing Home, Sonepat, while attending her husband Rinku Singh who was admitted in the said hospital. Due to such accidental fall, complainant had suffered pain continuous, not able to sit, lie down and stand. After the accident, complainant was brought to Jai Devi Memorial Nursing Home, Sonepat, where the concerned doctor after fulfilling the formalities of admission started treatment of the complainant and thereafter complainant was discharged from the aforesaid hospital on 28.01.2021. Complainant spent Rs.29,179/- on her treatment. Doctors also prescribed the complainant bed rest from 20.02.2021 to third week of March, 2021. In the meanwhile, complainant lodged the claim with the OPs for reimbursement of the abovesaid amount but OPs did not pay the same on one pretext or the other. Apart from the said amount, OPs are also liable to pay an amount of Rs.90,000/-to the complainant on account of Temporary Total Disablement for a period of total six weeks. Further, as per terms and conditions of the policy, OPs are also liable to pay cash benefit of Rs.4000/- for total four days on account of stay of the complainant as indoor patient. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence complainant filed the present complaint, seeking direction to the OPs to pay Rs.1,23,179/- from the OPs alongwith compensation of Rs.1,00,000/- on account of mental pain, agony and harassment and Rs.22000/- towards the litigation expense.

 2.            On notice, OPs appeared and filed its written version, raising preliminary objections with regard to maintainability; cause of action; locus standi; mis-joinder and non-joinder of necessary parties and concealment of true and material facts. On merits, it is pleaded that insured Mrs. Sheela Devi took Accident Care Individual Insurance Policy covering herself for the sum insured of Rs.15,00,000/-. Complainant preferred claim in the 6^th day of the policy. The complainant submitted the claim documents seeking Temporary Total Disablement benefit for treatment of PIVD L4-L5, LS-SI with right lower limb radiculopathy on 25.01.2021 at Shrimati Jai Devi Memorial Hospital- Karnal, vide claim no.CIR/2021/211114/02/2222024. On scrutiny the claim documents, it is observed from the MRI report dated 26.01.2021 that:

.       Lumbarization of Si vertebra-transitional anomaly. Mild scoliotic deformity noted at lumbar spine with convexity towards the left side.

.       Degenerative spondylotic changes in lumbar spine with marginal endplate osteophytes, facetoarthropathy, ligamentum flavum hypertrophy and desiccated multiple intervertebral discs.

.       Moderate narrowing of bony spinal canal noted at L1-2 and L2-3 levels with diffuse disc bulge indenting over the anterior thecal sac with impingement of left traversing and left exiting nerve roots.

.       Mild narrowing of bony spinal canal noted at L3-4 level with diffuse discbulge indenting over the anterior thecal sac with impingement of existing nerve roots on right side.

.       Moderate narrowing of bony spinal canal noted at L4-5 level with diffuse disc bulge indenting over the anterior thecal sac with impingement of traversing nerve roots on both sides.

.       Moderate narrowing of bony spinal canal noted at L5-Si level with bilateral paracentral annular tear and diffuse disc bulge indenting over the anterior thecal sac with impingement of bilateral traversing nerve roots and left existing nerve roots.

From the above findings, it is noted that the complainant was diagnosed as PIVD L4-L5, LS-Si with right lower limb radiculopathy which is a medical condition and not due to trauma/accident. Thus, the claim towards Temporary Total Disablement cannot be entertained. Hence, the claim was repudiated and the same communicated to the complainant, vide letter dated 20.03.2021. The relief sought by the complainant for Rs.29,179/- towards medical expenses, Rs.90,000/- towards temporary total disablement and cash benefits were not payable for the abovesaid reasons. 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.             Complainant has tendered into evidence her affidavit Ex.CW1/A, copy of claim form Ex.C1, copy of discharge summary Ex.C2, copy of discharge advice Ex.C3, copy of OPD slip Ex.C4, copy of MRI report Ex.C5, copy of Kayra Clinical Laboratory Report regarding Hemogram Ex.C6, copy of Kayra Clinical Laboratory Report regarding Liver Ex.C7, copy of Kayra Clinical Laboratory Report regarding kidney Ex.C8,  copy of insurance policy Ex.C9, copy of medical bills Ex.C10, copy of OPD slip dated 09.02.2021 Ex.C11, copy of OPD slip dated 20.02.2021 Ex.C12, copy of OPD slip Ex.C13, copy of OPD card Ex.C14, copy of medical certificates dated 29.01.2021 and 18.02.2021 Ex.C15 and Ex.C16 and closed the evidence on 01.07.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.RW1/A, copy of proposal form Ex.R1, copy of policy schedule Ex.R2, copy of terms and conditions of the policy Ex.R3, copy of field visit report Ex.R4,l copy of claim form Ex.R5, copy of discharge summary Ex.R6, copy of MRI report Ex.R7, copy of repudiation letter dated 20.03.2021 Ex.R8 and closed the evidence on 24.04.2023 by suffering separate statement.

6.             We have heard the learned counsel for the parties and 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 complainant had purchased a Health Insurance Policy from the OPs. On 25.01.2021, complainant fell down from the stairs of Smt. Jai Devi Memorial Nursing Home, Sonepat, while attending her husband Rinku Singh who was admitted in the said hospital. Due to said accident, complainant was admitted in said hospital and was discharged on 28.01.2021. Complainant spent Rs.29,179/- on her treatment. Doctors also prescribed the complainant bed rest from 20.02.2021 to third week of March, 2021. Complainant lodged the claim with the OPs for reimbursement of the abovesaid amount but OPs did not pay the same. Apart from the said amount, complainant prayed for an amount of Rs.90,000/- on account of Temporary Total Disablement for a period of total six weeks and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that complainant took Accident Care Individual Insurance Policy covering herself for the sum insured of Rs.15,00,000/-. Complainant preferred claim in the 6^th day of the policy. The complainant submitted the claim documents seeking Temporary Total Disablement benefit for treatment of PIVD L4-L5, LS-SI with right lower limb radiculopathy on 25.01.2021 at Shrimati Jai Devi Memorial Hospital- Sonepat. The complainant was diagnosed as PIVD L4-L5, LS-Si with right lower limb radiculopathy which is a medical condition and not due to trauma/accident. Thus, the claim towards Temporary Total Disablement cannot be entertained. Hence, the claim was repudiated, vide letter dated 20.03.2021 and prayed for dismissal of the complaint.

9.             Admittedly, complainant has availed the health insurance policy from the OPs. It is also admitted that during the subsistence of the insurance policy complainant was hospitalized in Jai Devi Memorial Home, Sonepat.

10.           The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.R8 dated 20.03.2021 on the ground, which is reproduced as under:-

“we have processed the claim records relating to the above insured-patient seeking Temporary Total Disablement benefit for treatment of PIVD L4-L5, Ls-SI with right lower limb radiculopathy.

It is observe from the discharge summary that the insured patient is diagnosed as PIVD L4-L5, LS-SI with right lower limb radiculopathy which is a medical condition not due to trauma/accident.

We are, therefore, unable to settle your claim under the abovesaid policy and we hereby repudiate your claim”.

 

11.           The complainant has alleged that she fell down from the stairs of Smt. Jai Devi Memorial Nursing Home, Sonepat, while attending her husband Rinku Singh who was admitted in the said hospital. The onus to prove her case was relied upon the complainant but she has miserably failed to prove the same by leading any cogent and convincing evidence. To prove her version, complainant has not placed on file any medical record of her husband. Complainant has also not placed on file any proof that she fell down the stairs of Smt. Jai Devi Memorial Nursing Home, Sonepat. Complainant has also not placed on file any medical record with regard to her Temporary Total Disablement. Rather, as per MRI report, complainant was diagnosed as PIVD L4-L5, LS-Si with right lower limb radiculopathy which was a medical condition and not due to trauma/accident. Hence, we are of the considered view that OPs have rightly repudiated the claim of the complainant. Thus, we found no deficiency in service on the part of the OP, while repudiating the claim of the complainant.

12.           Thus, in view of the above, present complaint is devoid of any merits and same deserves to be dismissed and the same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated:02.08.2023 

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)

                    Member                         Member