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 the complainant availed a health insurance policy from Opposite Parties, vide policy no.P/211222/01/2023/004873 for the period 29.08.2022 to 28.08.2023. Unfortunately on 06.03.2023, the complainant fell ill and he was admitted in Chitra Hospital, Ekta Complex, New CG road, Ahmedabad under Consultant Doctor Rohit Choudary and after the treatment the complainant got discharged on 09.03.2023. At the time of treatment and after discharging from the hospital the complainant requested the Opposite Parties to pay all the medical expenses including Pre and Post to the concerned hospital, but the Opposite Parties lingered on the matter on one pretext or the other and did not pay the expenses of the treatment and the complainant has to pay all medical expenses from his pocket. After discharging from the hospital, the complainant also submitted all the record of medical treatment with the Opposite Parties, but inspite of that Opposite Parties had not paid any amount in lieu of medical expenses to the complainant. Alleged that the complainant made the payment of Rs.52,652/- to the said hospital for his treatment. Alleged further that inspite of repeated requests, demands and representations, the Opposite Parties repudiated the claim of the complainant vide repudiation letter dated 25.03.2023 on 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/reimbursement medical claim of Rs.52,652/- with interest @ 24% p.a. till its realization.

b)      To pay an amount of Rs.30,000/- as compensation for mental tension and harassment.

c)       To pay an amount of Rs.2200/- as cost of the 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 the present complaint has been filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Party as per insurance policy terms and conditions and as per Exclusion Code No.36, the Opposite Parties is not liable to make any payment under the policy in respect of any hospitalization which are not medically necessary/does not warrant hospitalization. On  perusal of the submitted medical record the medical team of the Opposite Parties is of the opinion that the insured patient could have been managed as an outpatient and hospitalization of the insured was not warranted and necessary as the vital signs of the patient were stable throughout the period of hospitalization. Averred that the present complaint pertains to insurance claim under ‘Family Health Optima Insurance Policy-2021’ bearing No.P/211222/01/2023/004873 valid from 29.08.2022 to 28.08.2023 covering the Complainant for a sum of Rs 5,00,000/-. However it is submitted that 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 complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Averred further that the insured submitted the claim documents for the reimbursement of medical expenses towards the treatment of AFI for hospitalization from 06.03.2023 to 09.03.2023 at Chitra Hospital, Ahmedabad. On scrutiny of claim documents the medical team of the answering Opposite Party company observed that the insured patients vital signs were stable throughout the period of hospitalization and the insured patient could have been managed as an outpatient and hospitalization was not warranted. Thus based on these findings, the claim was repudiated vide letter dated 25.03.2023 as according to the Exclusion clause no.36 of the policy. Hence claim was finally rejected and it was conveyed to insured. As such, in terms of the said provision of the insurance policy, the insurance company have repudiated the claim of the complainant in 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 her case, the complainant has placed on record her affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C7.

4.       On the other hand, Opposite Parties has tendered into evidence affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1 to 3/A, Power of Attorney as Ex.OP1 to 3/B alongwith copies of documents Ex.OP1 to 3/1 to Ex.OP1 to 3/9.

5.         We have heard the ld. counsel for both the parties and also gone through the record.

6.       It is well proved on record that the complainant obtained the mediclaim policy namely ‘Medi Classic Insurance Policy (Individual)’ covering himself for the period 29.08.2022 to 28.08.2023 (Ex.C2) from the Opposite parties. Further it is also evident on record that during the policy coverage complainant fell ill and got admitted in Chitra Hospital, Ahmedabad on 06.03.2023 and discharged on 09.03.2023.

7.       The main dispute arises between the parties when the claim lodged by the complainant for the expenses incurred on the treatment was repudiated by the Opposite Parties on the ground that “insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted”

8.       In our considered opinion, the plea/defence taken by the Opposite Parties while repudiating the claim of the complainant that hospitalization of the insured patient is not warranted, is not justified. We surprised to note that how the officials concerned of the Opposite Parties mistook to conclude that hospitalization of the insured was not warranted. It is matter of common prudence that decision qua hospitalization is the sole prerogative of the doctor concerned to decide which is need based and not at the sweet will of the patient concerned. The above stand of the Opposite Parties in repudiating the claim of the complainant also reflects the mal functioning of the Opposite Parties, which divulges that they are concerned to grab the premiums only while issuing the policies and are not bothered to pay the genuine claims of the policy holders. 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 surprise 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. There is no report and opinion of the doctor concerned of the Opposite Parties opining that the hospitalization of the complainant 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 not sustainable. 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.52,652/-.  However, vide Bill Assessment Sheet Ex.OP1 to 3/9, the Opposite Parties assessed the Final Admissible Amount to the tune of Rs.46,513/-. Hence we allow the same.

10.     From the discussion above, we partly allow the complaint of the complaint and direct the Opposite Parties to pay a sum of Rs.46,513/- (Rupees Forty Six Thousand Five Hundred Thirteen only) to the complainant. For rejecting the genuine claim of the complainant, Opposite Parties are also directed to pay compository amount of Rs.10000/- (Rupees Ten Thousand only) towards compensation and litigation costs to the complainant. The pending application(s), if any also stands disposed off. 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 amount of Rs.5000/- (Rupees Five Thousand only) to be paid to the complainant in addition to the awarded amount. 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