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 a health insurance policy for himself and his family from Opposite Parties on 08.06.2021, bearing no.P/211222/01/2023/002063 and the said policy got renewed from time to time and now the latest policy is valid upto 07.06.2023. Unfortunately on dated 03.02.2023, the complainant got admitted in Aastha Hospital, Moga, under Consultant Doctor Nitian Mittal and after the treatment got discharged from the said hospital on 04.02.2023. After discharge from the said hospital, the complainant also went to other hospitals and took treatment as per the suggestions and directions of other doctors. At the time of treatment of 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 the treatment from the hospitals, 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.39,193/- to the said hospitals with regard to his treatment from this 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 27.06.2023, the Opposite Parties repudiated the claim of the complainant. 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.39,193/- alongwith interest @ 24% p.a. till its realization.
b) To pay a sum of Rs.30,000/- as compensation on account of mental tension, and harassment.
c) To pay Rs.22,000/- 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 conditions of policy in question and no PED disclosed. The real facts are that the complainant availed the ‘Family Health Optima Insurance Plan Policy No.P/211222/01/2023/002063 for the period 08.06.2022 to 07.06.2023 and in this policy complainant, his wife Shallu Bansal and two dependent children namely Shankha Bansal and Vansh Bansal were insured for an amount of Rs.5 lakh. This policy is in continuation since 06.03.2021 Averred that 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 in dispute is reported in the second year of the policy. The claim was registered vide claim no.CIR/2024/211222/0367494 and the said policy got started from 08.06.2021. Averred that the insured has submitted the claim documents in the present case regarding the medical reimbursement expenses towards his treatment taken by him at Aastha Hospital on 03.02.2023 to 04.02.2023 towards the treatment of ‘Epistaxis’. After receiving claim form, it is observed from the claim documents that above said treatment has been taken by complainant in the hospital on 03.02.2023 to 04.02.2023 and intimation to this effect was given only on 20.06.2023 and as per standard conditions clause D the intimation has to be given within 24 hours of hospitalization, thence the claim was rejected vide repudiation letter dated 27.06.2023 which is clear cut violation of the terms and conditions of the policy in question and came under standard conditions. Averred that as per condition of the policy issued to the complainant on the conditions that if there is any misrepresentation and violation made by whether the insured person or on behalf of insured person, the insurance company is not liable to pay any claim, hence the claim was rejected vide repudiation letter dated 27.06.2023 and duly informed to the complainant. Averred further that the complainant was admitted in the hospital on 03.02.2023 whereas the intimation was given on 20.06.2023 and documents were submitted on 26.06.2023 which is after 137 days and 143 days respectively from the date of admission. Hence, the claim of the complainant has been rightly repudiated in the light of terms and conditions of the policy. 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.OP8 and affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. as Ex.OP9.
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 ‘Family Health Optima Insurance Plan’ bearing no.P/211222/01/2023/002063 for the period 08.06.2022 to 07.06.2023 for self, his wife and two dependent children for a sum insured of Rs.5,00,000/-. It is also proved on record that during the policy coverage, complainant suffered ‘Nasal bleeding’ and got admitted in Aastha Hospital, Moga on 03.02.2023, where he was diagnosed as ‘Epistaxis’ and after the treatment got discharged from the hospital on 04.02.2023. 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 27.06.2023.
7. The record further reveals that the Opposite Parties repudiated the claim of the complainant vide letter dated 27.06.2023. 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 Epistaxis.
It is observed that from the submitted medical records that the insured patient was admitted in the hospital on 03.02.2023, whereas the intimation regarding the admission was given to us only 20.06.2023.
Please note that as per policy issued to you, Condition- Standard Conditions-Clause D- Notification of claim, the intimation has to be given within 24 hours of hospitalization.
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.
8. We have given the due consideration to the admitted and proved facts on record and also considered the rival contentions of the ld. Counsels for both the parties and have gone through the record meticulously. The only contention raised by ld. counsel for the Opposite Parties with regard to repudiation of the claim is that there is a delay in intimation of claim. Insured patient was admitted in the hospital on 03.02.2023 and intimation of the admission given on 20.06.2023, but observing the delay in intimation, we deem it appropriate that the claim be settled on non standard basis, which is 75% of the claimed amount. In this regard, we are supported with judgment in case titled National Insurance Company Limited versus Kamal Singhal IV (2010)CPJ297 (NC) wherein the Hon'ble National Consumer Disputes Redressal Commission, New Delhi relying upon various decisions of the National Consumer Disputes Redressal Commission in the matter of (1) National Insurance Company Ltd. v. J. P. Leasing & Finance Pvt. Ltd. (RP No. 643/2005), (2) Punjab Chemical Agency v. National Insurance Company Ltd. (RP No. 2097/2009), (3) New India Assurance Co. Ltd. v. Bahrati Rajiv Bankar, (RP) No. 3294/2009) and (4) National Insurance Company Ltd. v. Jeetmal, (RP No.3366/2009) and also judgment of the Hon'ble Apex Court in the matter of Insurance Company Versus Nitin Khandewal IV (2008) CPJ 1(SC), held the breach of condition of the policy was not germane and also held further that : “ the appellant Insurance Company is liable to indemnify the owner of the vehicle when the insurer has obtained comprehensive policy to the loss caused to the insurer”. The Hon'ble Supreme Court has further held that; “even assuming that there was a breach of policy, the appellant Insurance Company ought to have settled the claim on “non-standard basis.” Hon'ble Apex Court in back drop of these features, in these cases, allowed 75% of the claim of the claimant on the “non-standard basis”. This view was again reiterated by the Hon'ble Apex Court in the matter of Amalendu Sahoo versus Oriental Insurance Company Limited. II(2010) CPJ 9(SC)=II (2010)SLT 672. Hon'ble National Commission in the case National Insurance Company Limited versus Kamal Singhal referred to above relying upon the law laid down by the Hon'ble Supreme Court has held that;
“there being a long line of decisions on this score, we have no option but to uphold the finding of Fora below with modification that the claim be settled on 'non-standard' basis”, in terms of the guidelines issued by the Insurance Company. In case petitioner company fails to carry out the direction contained therein, the amount payable on 'non-standard' basis, shall carry interest @ 6% p.a from the date of expiry of six weeks till the date of actual payment”.
9. Perusal of the record reveals that the bill dated 04.02.2023 raised for treatment in question is Rs.13,200/- only, but however the complainant has also placed on record copies of variant bills pertaining to tests got conducted and bills regarding medicines purchased, but there is no record revealing any of the prescription being given by any of the doctor to purchase the said medicines and no reference has been made by any of the doctor to conduct the said tests, for which, the amount has been claimed by the complainant. In our considered opinion, the complainant is only entitled for the reimbursement of the expenses incurred on the treatment for during hospitalization for the period 03.02.2023 to 04.02.2023, which as per bill dated 04.02.2024 is Rs.13,200/- only. Hence we allow 75% of the said amount of Rs.13,200/-.
10. Enlightened by the judgements referred above and from the discussion above, we allow the instant complaint in part and direct the Opposite Parties to make the payment of Rs.9900/- (Rupees Nine Thousand Nine Hundred only) i.e. 75% of the amount of Rs.13,200/- as per final bill dated 04.02.2023 to the complainant. Opposite Parties are further directed to pay compository costs of Rs.3500/- (Rupees Three Thousand Five Hundred only) as compensation and litigation expenses to the complainant. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Party within 30 days from the date of receipt of this order, failing which, they are further burdened with Rs.5,000/- (Rupees Five 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 cost. File be consigned to record room after compliance.
Announced in Open Commission
