STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                         First Appeal No.209 of 2021

                                                Date of Institution: 20.09.2021

                                                               Date of Decision: 11.10.2023

Mr. Sarvjeet Bansal S/o Sh.Kashmiri Lal, H.No. DA-143, Railway road, Near Kathmandi Gate, Ward No.1, Samalkha, Distt. Panipat, 132101.

…..Appellant

Versus

1.      Star Health and Allied Insurance Company Ltd.  930/8, RJ Tower, 2^nd Floor, GT road, Opp. IB college, Panipat (Haryana).

2.      Star Health And Allied Insurance Co. Ltd. No.15, Sri Balaji Complex, 1^stFloor,White Lane, Royapettah, Chennai 600014.

…..Respondents

CORAM:    S.P.Sood, Judicial  Member

Present:-    Mr.Himanshu Bansal, Advocate for theappellant.

                   Mr. Satpal Dhamija, Advocate for the respondent.

                                                ORDER

S.P.SOOD, JUDICIAL MEMBER:

          The present appeal No.209 of 2021 has been filed against the order dated 05.08.2021 of the District Consumer Disputes Redressal Commission, Panipat (In short  now “District Commission”) in complaint case No.105 of 2019, which was allowed partly.

2.      The brief facts of the case are that complainantpurchased a Family Health Optima Insurance Revised Mediclaim policy in the year 2016 from the opposite parties. At the time of issuing of policy, the complainant was perfectly fit and fine.  However in the month of April 2018, complainant felt cough problem in his chest and approached to Ravindra Hospital Panipat for treatment. The treating doctor suggested him some medical tests.  For histreatment,  complainant spent huge amount and afterwards he filed claim with the answering OP, but, the OP denied for cashless treatment vide letter dated 25.04.2018.  Faced with this situation, he got issued a legal notice dated 29.01.2019 to the OP, but, OP neither made payment nor gave any reply.Thereafter he went to Nidaan Hospital Sonipat for some further tests and treatment where he remained admittedfrom 27.04.2018 to 30.04.2018. In May 2018, he went to GB Pant Hospital Delhi also for further treatment.  On 13.06.2018, he went to Medanta Hospital, Delhi for surgery and he gave the above said information to the OPs for cashless claim. The OPs also assured that they will reimburse all the expenses after treatment. The complainant spent huge amount on his treatment and finally requested to pay the claim amount, but, OPs refused to make payment.  Thus alleging deficiency in service on the part of the OPs, hence the complaint.

3       Notice being issued, OPsappeared and filed reply, submitting that the insured availed Family health optima insurance policy for the sum insured of Rs.3,00,000/- for the period from 01.07.2017 to 30.06.2018.  The claim of the complainant was rejected under the exclusion clause No.1 which states that insurance Co. will not be liable to make any payment under this policy in respect of any expenses incurred by insured for treatment of the pre-existing disease/ condition, until 48 months of continuous coverage has elapsed, prior to date of commencement of first year of policy on 30.06.2016. The patient was hospitalized at Dr.Ravindra Maternity and General Hospital on 24.04.2018. The insurance company was unable to determine the exact duration and choronicity of the cardiac ailment. The claim was denied, which was communicated to the insured through the treating hospital vide letter dated 26.04.2018. The patient was admitted in Medanta Hospital on 16.06.2018 and raised a pre authorization request for availing cashless facility but insurance company observed that patient was diagnosed with chronic rheumatoid arthritis. Again the claim of the complainant was denied, which was communicated to the complainant through treating ho