First Appeal No. 105 of 2014. Case: Star Health & Allied Insurance Co. Ltd. Vs Asha and Ors.. Haryana State Consumer Disputes Redressal Commission

Case NumberFirst Appeal No. 105 of 2014
Party NameStar Health & Allied Insurance Co. Ltd. Vs Asha and Ors.
CounselFor Appellant: Rajneesh Malhotra, Advocate and For Respondents: D.P. Chhachhia, Advocate
JudgesR.K. Bishnoi, Member (J) and Urvashi Agnihotri, Member
IssueConsumer Law
CitationII (2015) CPJ 78 (Har.)
Judgement DateJanuary 27, 2015
CourtHaryana State Consumer Disputes Redressal Commission

Order:

R.K. Bishnoi, Member (J)

  1. As per complainant her husband obtained medical insurance policy from appellant-opposite parties for the period 19.4.2010 to 18.4.2011 she was not suffering from any ailment before availing the policy. On 22.3.2011 she developed acute pain in the uterus and was admitted at Ahuja Hospital, Panipat where she remained admitted from 22.3.2011 to 28.3.2011 and Rs. 70,000 were spent on her treatment. It was assured by opposite party No. 2 that all the expenses of treatment would be reimbursed. As per that assurance medical policy was got renewed. Vide letter dated 23.5.2011 her claim was repudiated. Legal notice was also sent, but, to no result. Opposite parties controverted her averments and alleged that Mr. Deepak Kumar Thareja obtained the insurance policy for himself as well as his family members. He was explained about the terms and conditions of the insurance policy including exclusion clause at that time. Complainant was suffering from Fibroid Uterus since more than one year and was aware about the disease, but, was not disclosed at the time of obtaining insurance policy just to get false reimbursement. She was never assured that the reimbursement would be made if policy would be got renewed. Treatment obtained for Fibroid Uterus is not covered for the first two years as per exclusion clause No. 3 of the terms and conditions of the insurance policy. There was no deficiency in service on their part and her claim was rightly repudiated.

  2. After hearing both the parties, learned District Forum allowed the claim with following observations:

    We hereby allow the present complaint with a direction to opposite party to pay sum of Rs. 43,749 with interest @ 9% per annum from the date of filing the complaint till its realization. Cost of litigation quantified at Rs. 2,200 is also allowed to be paid by the opposite party to the complainant.

  3. Feeling aggrieved therefrom, the opposite parties have preferred this appeal on the ground that as per exclusion Clause No. 3 of the insurance policy claimant was not entitled for any compensation or reimbursement for the treatment of Fibroid Uterus with severe anemia.

  4. Arguments heard. File perused.

  5. Learned Counsel for the appellant-opposite parties vehemently argued that they repudiated the claim of the complainant as per Clause No. 3 of exclusion of insurance policy Ex. R-l and not Clause No. 1 pertaining to preexisting disease. As per Clause No. 3 she was not...

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