Order by:
Smt.Aparana Kundi, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant no.1 availed an insurance policy for himself and his wife, vide policy no.211222/01/2023/007198 for the period 08.10.2022 to 07.10.2023 from Opposite Parties. Unfortunately on 07.02.2023, the complainant no.2 fell ill and got admitted in Mittal Hospital and Heart Center, Moga under consultant doctor Sanjeev Mittal and after the treatment she discharged from the hospital on 09.02.2023. At the time of treatment of complainant no.2, the complainant requested the Opposite Parties to pay the medical expenses to the concerned hospital, but the Opposite Parties did not pay the expenses of the treatment. Alleged that after discharged from the hospital, complainants submitted all the medical treatment record to Opposite Parties, but despite that the Opposite Parties have not paid any amount in lieu of medical expenses to the complainants. Alleged that the complainants made the payment of Rs.12,710/- from their own pockets. Thereafter vide letter dated 28.03.2023, the Opposite Parties repudiated the claim of the complainants on the basis of false and baseless reason. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay Rs.12,710/- alongwith 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.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 the present pre mature complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Party as per the policy terms and conditions. Averred that the present complaint pertains to insurance claim under ‘Star Group Health Insurance Policy’ bearing no.P/211222/01/2023/007198 valid from 08.10.2022 to 07.10.2023 covering self and his spouse Murti Devi for a sum of Rs 10,00,000/-. 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 said terms and conditions were handed over to the insured at the time of the contract. 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 Acute Abdomen for hospitalization from 07.02.2023 to 09.02.2023 at Mittal Hospital, Moga. On scrutiny of claim documents the medical team of the answering Opposite Party observed that the insured patient’s 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. Further the investigation reports had no signatures of any pathologist. Thus, based on these findings, the claim was repudiated vide letter dated 08.06.2023 as according to the Exclusion clause no.36 of the policy. Hence the claim was finally rejected and it was conveyed to insured. The claim was repudiated under the ambit of specific condition/exclusion code no.36 as mentioned under the policy terms and conditions. No deficient services have been rendered by the answering Opposite Parties as alleged by the complainants. 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 their case, the complainants have placed on record affidavit of complainant no.2 as Ex.C1 alongwith copies of documents Ex.C2 to Ex.C8.
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, 2/A alongwith copies of documents Ex.OP1, 2/1 to Ex.OP1, 2/8.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. The availing of insurance policy bearing no.P/211222/01/2023/007198 valid from 08.10.2022 to 07.10.2023 by the complainants and during the policy coverage, the admission of complainant no.2 in the Mittal Hospital, Moga for the period from 07.02.2023 to 09.02.2023 is admitted. Thereafter lodging of the claim for the reimbursement of the expenses incurred by the complainants with Opposite Parties is also not disputed. The only dispute arises between the parties, when the claim lodged by the complainant was repudiated by the Opposite Parties firstly on 28.03.2023, vide Ex.C6 and secondly on 08.06.2023 vide Ex.OP1,2/8.
7. The perusal of repudiation letter dated 28.03.2023 (Ex.C6) reveals that the Opposite Parties repudiated the claim of the complainants on the following grounds:-
“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of ACUTE ABDOMEN.
In order to process the claim, we had requested you to furnish the complete ICPs documents. We note that you have not furnished the required documents and details. In the absence of above documents/details, we are not able to further process your claim.
As per Condition No.13 of the above policy, the insured person has to submit all the required documents and details called for by us.
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.
After issuing the above repudiation letter, the Opposite Parties again after two and half months issued another repudiation letter dated 08.06.2023 (Ex.OP1,2/8), 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 ACUTE ABDOMEN.
We acknowledge a receipt of an email dated Nil, in response to our letter dated 28.03.2023, seeking re-consideration of your claim.
Our medical team has perused the representation and has noted the contents. The team has re-examined the claim records observed from the documents and details available with us that the insured patient’s vital are stable throughout the hospitalization for which the insured patient could have been treated as outpatient and hospitalization of the insured patient is not warranted.
As per Exclusion Code Excl 36 of the above policy, the Company is not liable to make any payment under this policy in respect of any hospitalization which are not medically necessary/does not warrant hospitalization.
8. In our concerted view, the demand of ICPs documents demanded by Opposite Parties vide letter dated 28.03.2023 is not genuine, as if the complainants are failed to supply the said documents, the Opposite Parties at its own can get the said documents from the concerned hospital, but there is no document showing that they ever approached the hospital for getting the said documents. Further the ground so taken by the Opposite Parties, vide letter dated 08.06.2023 for the repudiation of the claim is also not genuine, as doctor is the expert of his field and he can decide whether the admission of the patient is required or not. Further it is a 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. Moreover, as per the discharge summary Ex.OP1, 2/6, the complainant no.2 admitted in the hospital with complaints of Severe Abdomen Pain, associated recurrent vomiting, where she got herself checked from the doctor and diagnosed as Acute Abdomen and thereafter she at the decision of the doctor, who is expert in his field got admitted her in the hospital. Moreover, the insurance company has not placed on record any evidence or the report from any other doctor, which states that the patient can be treated as an outpatient and hospitalization of the insured patient is not warranted. Perusal of the record further reveals that the complainant no.2 is Super Senior Citizen above 70 years of age, so she cannot go for self medication, which proves to be very dangerous for her at this age and moreover the claim in question is for the meager amount of Rs.12,710/-. In these circumstances, the deficiency in service on the part of the Opposite Parties is writ large and repudiation of the genuine claim of the complainants by the Opposite Parties is highly unjustified.
9. Vide instant complaint, the complainant claimed the amount of Rs.12,710/-, which is duly proved on record vide Ex.C4 placed on record by complainant. Hence we allow the same.
10. From the discussion above, we partly allow the complaint of the complainants and direct the Opposite Parties to pay a sum of Rs.12,710/- (Rupees Twelve Thousand Seven Hundred and Ten only) to the complainants. Further Opposite Parties are directed to pay compository cost of Rs.10,000/- (Rupees Ten Thousand only) as compensation for harassing the Super Senior Citizen as well as for thrusting avoidable litigation. 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 cost Rs.10,000/- (Rupees Ten 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
