Order by:

Smt.Priti Malhotra, President

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant availed Health Insurance Policy bearing no.P/211222/01/2022/005323  in the year 2021 and the same was renewed, vide policy no. P/211222/01/2022/006488 for the period from 25.09.2022 to 24.09.2023 for a sum of Rs.10,00,000/-. During the policy period complainant no.2 suffered swear pain in her chest on 12.02.2023 and got admitted in Sham Nursing & Heart Care Centre, Railway Road, Moga and got discharged on 14.02.2023 and Rs.15,150/- was incurred by the complainants. As per terms and conditions, the complainant no.1 submitted all original bills and another documents demanded by Opposite Party No.1 for the approval of cashless treatment, but the request for approval for cashless treatment was rejected by the Opposite Parties on 23.03.2023 on the ground that the insured patient could have managed as an outpatient and hospitalization of the insured patient is not warranted. The above said act on the part of the Opposite Parties caused mental tension and harassment to the complainant. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite party may be directed to pay Rs.17,790/- spent by the complainant during hospitalization.

b)      To pay an amount of Rs.50,000/- as compensation on account of damages, mental tension and harassment.

c)       To pay an amount of Rs.10,350/- as cost of complaint.

d)      And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that present complaint has been filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Parties as per terms and conditions and as per exclusion code no.36, the Opposite Party is not liable to make payment under the policy in respect of any hospitalization which are not medically necessary/does not warrant hospitalization. Further averred that the present complaint pertains to insurance claim under ‘Family Health Optima Insurance Plan’ bearing no.P/21122/01/2023/006488 valid from 25.09.2022 to 24.09.2023 covering the complainant no.1 self, his spouse Neeraj Garg and dependent child Hetansh Garg for a sum of Rs.10,00,000/-. However the aforesaid insurance policy was issued to the insured by the answering Opposite Party subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of the contract. Moreover the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same were served to the complainant along with policy schedule. Also it is clearly stated in the policy schedule. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Therefore it is submitted that in case if any liability would arise against the answering Opposite Party, then it would be subject to the terms and conditions of the insurance policy. Further averred that the insured submitted the claim documents for the reimbursement of medical expenses towards the treatment of Chest Pain for hospitalization from 12.02.2023 to 14.02.2023 at Sham Nursing Home and Heart Center, Moga. On scrutiny of claim documents, the medical team of the answering company observed that the insured patient could have been managed as an outpatient and hospitalization was not warranted. Based on these findings, the claim was repudiated vide letter dated 20.03.2023 according to the exclusion clause no.36 of the policy. Hence, the claim was finally rejected and it was conveyed to the insured. Further averred that as per the discharge summary and ICP, the vitals of the patient were stable throughout the treatment. Also the test reports are normal. As such, in terms of the said provision of the insurance policy, the insurance company has repudiated the claim of complainant in a proper manner, after due application of mind. No deficient services have been rendered by the answering Opposite Parties as alleged by the complainant. The claim in question was duly entertained, inquired into and after due application of mind the alleged claim has been repudiated on the basis of terms and conditions of the insurance policy. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove his case, complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C11.

4.       To rebut the evidence of the complainant, Opposite parties have placed on record affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1,2/A alongwith copies of documents Ex.OP1,2/1 to Ex.OP1,2/10.  

5.       We have heard the counsel for the parties and also gone through the documents placed on record.

6.       It is well proved on record that complainant no.1 availed ‘Family Health Optima Insurance Plan’ bearing no.P/21122/01/2023/006488 valid from 25.09.2022 to 24.09.2023 covering self and his spouse Neeraj Garg and dependent children Hetansh Garg for a sum of Rs.10,00,000/- and during the policy coverage complainant no.2 suffered swear pain in her chest on 12.02.2023 and got admitted in Sham Nursing & Heart Care Centre, Railway Road, Moga and got discharged on 14.02.2023. However, the claim lodged by the complainants for the reimbursement of the expenses incurred on the treatment of complainant no.2 was repudiated by the Opposite Parties vide letter dated 14.11.2022 and the said repudiation of the genuine claim of the complainant has been challenged through this complaint.

7.       Thorough perusal of the record reveals that Opposite Parties repudiated the claim on the ground that insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted.

8.       We are of the concerted view that the above stand of the Opposite Parties for repudiating the claim of the complainants is not genuine and also reflects the mal functioning of the Opposite Parties, who are concerned to grab the premiums only while issuing the policies and are not bothered to pay the genuine claims of the policy holders. Firstly the Opposite Parties in the present case have not placed on record any opinion/report of medical expert on the basis of which they have repudiated the claim in question. We surprised to note that how the officials concerned of the Opposite parties without any expert opinion come to the conclusion that hospitalization of the insured was not warranted i.e. was not required. It is hereby added that the decision to admit the patient when encounted with severe chest pain is the sole prerogative of the doctor concerned being expert in field to decide and not at the sweet will of the patient concerned. However reiterated that also there is no report and opinion of the doctor concerned of the Opposite Parties opining that the hospitalization of the complainant no.2 was not required. In the absence of any substantial evidence on record countering the genuine claim of the complainant, this complaint deserves to be allowed. To repudiate the claim solely on the ground that hospitalization was not required is baseless and absurd. We do not find any reasonable justification in repudiating the genuine claim of the complainant by opposite parties.

9.       Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant claimed the amount of Rs.17,790/- spent in the hospital. However, perusal of the record reveals that vide Bill Assessment Sheet Ex.OP1, 2/10, the Opposite Parties assessed the final admissible amount to tune of Rs.13,530/-. Hence we allow the same.

10.     From the above discussion, we partly allow the complaint of the complainants and direct the Opposite Parties to pay an amount of Rs.13,530/- (Rupees Thirteen Thousand Five Hundred Thirty only) to the complainants. Opposite Parties are also directed to pay compository costs of Rs.8,000/-(Rupees Eight Thousand only) as compensation and litigation expenses to the complainants. The pending application(s) if any, also stands disposed of. The compliance of this order be made by the Opposite Parties within 30 days from the date of receipt of copy of this order, failing which, the Opposite Parties are further burdened with additional cost of Rs.5,000/-(Rupees Five Thousand only) to be paid to the complainants for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission