Order by:
Smt.Aparana Kundi, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that the complainant purchased an insurance policy bearing No.211222/01/2020/004803 covering himself as well as his family for Rs.5,00,000/- from Opposite Parties on 10.09.2020. Unfortunately, complainant was suffered from high fever, viral pneumonia, breathlessness, hypertension and respiratory failure and he was got medically treated firstly from Sidhu Hospital and Diagnostic Centre, Ferozepur Road, Moga from 19.01.2022 and on the same day he was referred to Rajeev Hospital, Multispeciality Accident Care and Infertility Centre, Moga and was discharged on 24.01.2022. At the time of treatment of complainant and after discharging from the hospital, the complainant requested the Opposite Parties to pay the medical claim which includes Pre and Post medical expenses of the concerned hospital, but the Opposite Parties did not pay the expenses of the treatment and thus the complainant had to pay whole amount of medical expenses as well as medical bills from his own pocket. After discharging from the hospital, the complainant also submitted all the record of medical treatment to Opposite Party No.2 as per their demand but inspite of that Opposite Parties had not paid any amount in lieu of medical expenses to the complainant. As per the version of the complainant he made the payments of Rs.1,05,289/- i.e. Rs.5800/- to Sidhu Hospital and Diagnostic Centre, Ferozepur Road, Moga and Rs.46,000/- to Rajeev Hospital and Rs.53,489/- paid by the complainant on medical tests, medicines and diagnostic labs from his own pockets. Inspite of repeated requests demands and representations, the Opposite Parties did not pay the amount which was already paid by the complainant for his treatment to the above said hospitals. Hence this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to release the amount of Rs.1,05,289/- alongwith interest @ 24% p.a. till its realization.
b) To pay an amount of R.50,000/- as compensation on account of mental tension and harassment to the complainant.
c) To pay an amount of Rs.33,000/- as litigation expenses.
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 the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court; The complainant has concealed material facts and documents from this Commission as well as from the Opposite Parties, therefore the complainant is not entitled to any relief. Further alleged that complainant namely Sh.Arun Kumar availed the Family Health Optima Insurance Plan Policy No.P/211222/01/2022/004803 for the period 10.09.2021 to 09.09.2022 and in this policy Arun Kumar complainant and his wife Shimla Rani was insured for an amount of Rs.5 lakh. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to complainant alongwith the policy schedule. It is clearly stated in the policy schedule that “The Insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form and No pre-existing disease was declared by the insured. The claim in dispute is reported in the 2nd year of the policy and the claim was registered vide claim no.CIR/2022/211222/3944571 regarding the reimbursement of the medical expenses paid by complainant for taking treatment from Sidhu Hospital and Rajeev Hospital, Moga from the period 19.01.2022 to 24.01.2022 qua viral Pyhnemonia and claimed Rs.1,03,489/- as per claim. On perusal of claim form alongwith medical records like bills etc. submitted by the complainant, the medical team of the Opposite Parties is of the opinion that “The submitted medical records, the ICP are the Streo typed manner, some of the investigation reports are not signed and as per final bill HDU was charged while in icp recordsR-31 mentioned.” Moreover there was mismatching in treatment given in ICP and in discharge summary, oxygen details are not noted in the ICP records which amount to misrepresentation of facts. Further as per the vital charts the insured patient vital signs are stable throughout the period of hospitalization. Hence medical team is of the opinion that the hospitalization of the insured patient is not warranted for the above said diagnosis. Therefore, the claim of the complainant was rejected according to terms and conditions of the policy vide letter dated 23.06.2022 and duly informed to the complainant. Hence, the Opposite Parties are not liable to pay any claim. 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 tendered in evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C11.
4. To rebut the evidence of the complainant, Opposite Parties tendered in evidence affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OPs/1 alongwith copies of documents Ex.OPs/2 to Ex.OPs/9.
5. We have heard the counsel for the parties and also gone through the documents placed on record.
6. The main dispute between the parties is regarding the rejection of the claim lodged by the complainant. The claim lodged by the complainant for the reimbursement of the expenses incurred by him for his treatment was repudiated by the Opposite Parties, vide letter dated 23.06.2022 on the ground that “It is observed from the submitted medical records, the ICPs are the Stereotyped manner, some of the investigation reports are not signed and as per final bill HDU was charged while in ICP records R-31 mentioned; mismatching is noted in the vital parameter treatment given in ICP and discharge summary; oxygen details are not noted in the ICP records. Thus, there are discrepancies in the records which amount to misrepresentation of facts.” But the rejection of the claim of the complainant is not appears to be genuine, as the Opposite Parties have failed to prove their pleading by any cogent and convincing evidence on record i.e. affidavit of any doctor. Moreover, it is not very uncommon that the insurance companies would issue repeated advertisement in the newspaper and through electronic media, highlighting many financial and other benefits, inviting general public to go for insurance policies. However, whenever any claim, including most genuine claim is put by the insured for disbursement of the due amount most of the insurance companies would start finding fault with the insured on one pretext or the other, raising even the technical and totally unwarranted objections. That is how, this kind of approach adopt by the insurance companies, give rise to wholly unwarranted and avoidable litigation.
7. Further plea taken by the Opposite Parties is that as per the vital charts the insured patient’s vital signs are stable throughout the period of hospitalization and as per the medical team the hospitalization of the insured patient is not warranted for said diagnosis. We also do not agree with the aforesaid contention of ld. counsel for the Opposite Parties, as complainant is at the decision of the doctor, who being expert in his field will decide whether the complainant needs admission in hospital or not, as he knows what the problem is and in that problem what precautionary treatment he would give to his patients. Moreover, the insurance company has not placed on record any evidence or the report from any other doctor, which state that the hospitalization of the insured/patient is not warranted.
8. In the given circumstances, the repudiation made by Opposite Parties-Insurance Company regarding genuine claim of the complainant has been made without application of mind. It is usual with the insurance company to show all types of greener pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims.
9. Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant claimed the amount of Rs.1,05,289/- alongwith interest and the complainant has given the detail of said amount, vide Ex.C2. However at serial no.2 the complainant mentioned the amount of Rs.5800/-, but the bill shows that out of Rs.5800/-Rs.1800/- got discounted and complainant paid Rs.4000/- only. So, the total amount comes to Rs.1,03,489/-. The record further reveals that against the claimed amount, opposite parties assessed the amount of Rs.77,178/- vide Bill Assessment Sheet Ex.OPs/9, but they did not disclose and clarify the deduction made by them in the said sheet.
10. In view of the above discussion, we partly allow the complaint of the complainant and direct the Opposite Parties to pay an amount of Rs.1,03,489/- (Rupees One Lakh Three Thousand Four Hundred Eighty Nine only) for the expenses incurred by him on his treatment. Opposite Parties are further directed to pay compository amount of Rs.10,000/- (Rupees Ten Thousand only) towards compensation and litigation costs to the complainant. The compliance of this order be made by the Opposite Party within 45 days from the date of receipt of copy of this order, failing which, the Opposite Parties are burdened with additional amount of Rs.7000/-(Rupees Seven Thousand only) to be paid to the complainant 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
