Order by:
Sh.Mohinder Singh Brar, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant availed a health insurance policy for himself and his family from Opposite Parties on 05.09.2023, bearing no.P/211222/01/2024/005413 and the said policy is valid upto 04.09.2024. Unfortunately on dated 19.10.2023, the son of the complainant namely Takash Kataria fell ill and got admitted in Suresh Nursing Home and after treatment got discharged from the hospital on 28.10.2023. At the time of treatment of the son of the complainant and after discharging from the hospital, the complainant requested the Opposite Parties to pay all the medical expenses including Pre and Post to the complainant, but the Opposite Parties lingered on the matter on one pretext or the other and did not pay the expenses of treatment. After discharge from the hospital, the complainant also submitted all the medical record to Opposite Parties as per their demand, but inspite of that the Opposite Parties had not paid any amount in lieu of medical expenses to the complainant. Alleged that the complainant has made the payment of Rs.46,000/- to the said hospital from his own pocket. The complainant requested many time to make the payment of claim, but the Opposite Parties refused to make the payment to the complainant. However, vide letter dated 17.11.2023, the Opposite Parties repudiated the claim of the complainant on the basis of false and baseless reason. Due to such act and conduct of the Opposite Parties, the complainant has suffered mental tension and harassment. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay an amount of Rs.46,000/- alongwith interest @ 24% p.a. till its realization.
b) To pay a sum of Rs.20,000/- as compensation on account of mental tension, and harassment.
c) To pay Rs.15,000/- 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 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 C.P. Act; 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. The complainant has concealed the fact that he has violated the terms and filed the present complaint only to harass the Opposite Parties. The real facts are that the complainant availed the ‘Star Health Assure Insurance Policy’ bearing No.P/211222/01/2024/005413 for the period 05.09.2023 to 04.09.2024 and in this policy complainant self, his wife Vanita Kataria and minor Taksh Kataria were insured for an amount of Rs.10 lakh. The terms and conditions of the policy were explained to the complainant at the time of proposing the policy and same were served to the complainant alongwith policy schedule. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Averred further that the claim was registered vide claim no.CIR/2024/211222/1033418. Averred further that the insured has submitted the claim documents in the present case regarding the medical reimbursement expenses towards treatment taken by his son Taksh Kataria at Suresh Nursing Home on 19.10.2023 to 28.10.2023 towards the treatement of Bronchopneumonia. Averred further that on scrutiny of claim documents, the Opposite Parties observed various discrepancies in the documents submitted to the company, the company find all the details regarding the investigation and treatment of the insured patient are not transparently evident. The full facts of the case may not have been presented. Hence the claim was rejected vide letter dated 17.11.2023 as per policy terms and conditions. Averred further that as per the medical team of Opposite Parties, there is no IPD number, no UHID number, no room number, no ward number and moreover no medicine purchase invoice. So due to above discrepancies, the claim is rightly repudiated by the Opposite Parties. Averred further that the complainant has no locus standi or cause of action to file the present complaint against the Opposite Parties; the complaint is not maintainable in the present form; the complainant has violated the terms and conditions of the 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 the case, complainant has placed on record his affidavit as Ex.C1 alongwith copies of documents Ex.C2 to Ex.C7.
4. On the other hand, Opposite Parties have placed on record copies of documents Ex.OP1 to Ex.OP9 and affidavit of Sh.Sumit Kumar Sharma, Authorized Signatory, Star Health & Allied Insurance Co. Ltd. as Ex.OP10.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. It is admitted and proved on record that the complainant availed health insurance policy namely ‘Star Health Assure Insurance Policy’ bearing no.P/211222/01/2024/005413 for the period 05.09.2023 to 04.09.2024 for self, his wife and one minor child for a sum insured of Rs.10,00,000/-. It is also proved on record that during the policy coverage, son of the complainant namely Taksh Kataria suffered ‘Bronchopneumonia’ and got admitted in Suresh Nursing Home, Moga on 19.10.2023 and after treatment got discharged from the hospital on 28.10.2023. It is also proved on record that the claim lodged for the reimbursement of the said hospitalization period was repudiated by the Opposite Parties, vide letter dated 17.11.2023 (Ex.OP9). The contents of which are reproduced as under:-
“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of Bronchpneumonia.
We observe various discrepancies in the documents submitted to us. We find all the details regarding the investigation and treatment of the insured patient are not transparently evident. The full facts of the case may not have been presented to us. Therefore, we regret we are not in a position to admit your claim, as per Specific Condition No.18 of the policy issued to you.
We therefore regret to inform you that for the reasons stated above we are unable to settle your claim under the above policy and we hereby repudiate your claim.
7. We have considered the rival contentions of the ld. counsels for the parties and have gone through the record. Careful perusal of the record reveals that in the indoor treatment chart there is no mentioning about the IPD number, UHID number, room number & ward number. Furthermore, son of the complainant admitted in the hospital for the period 19.10.2023 to 28.10.2023, but he has placed on record copies of the medicine bill of dated 28.10.2023 only and has not produced medicine bills of other dates, however perusal of the indoor treatment chart reveals that son of the complainant was given medicines and injections regularly from the date of admission i.e. from 19.10.2023. Further the indoor treatment chart is stereotyped i.e. having the same handwriting for the whole period from 19.10.2023 to 28.10.2023, which is impossible. Aforesaid facts create doubt about the genuinenity of the claim of the complainant. Hence, we are of the concerted view that Opposite Parties has rightly repudiated the claim of the complainant.
8. Sequel to the above discussion, the instant complaint is hereby dismissed. Keeping in view the peculiar circumstances of the case parties are left to bear their own costs. The pending application(s), if any also stands disposed of. Copies of the order be supplied to the parties free of costs. File be consigned to record room after compliance.
Announced in Open Commission
