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 wife from Opposite Parties on 06.02.2011 and the said policy got renewed regularly. Earlier, the complainant availed the policy vide no.P/211222/01/2023/011722, which is valid upto midnight of 05.02.2024. Unfortunately on dated 26.04.2023, the complainant no.2 fell ill and got admitted in Sidhu Hospital, Moga and after treatment got discharged from the hospital on 27.04.2023. At the time of treatment and after discharge from the hospital, the complainants requested the Opposite Parties to pay all the medical expenses including Pre and Post to the complainants, 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 complainants 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 complainants have made the payment of Rs.25,000/- to the said hospital from their own pocket. The complainants requested many time to make the payment of claim, but the Opposite Parties refused to make the payment to the complainants. However, Opposite Party No.2 sent a mail dated 09.08.2023 stating the claim as closed on 12.06.2023. Alleged that due to above said indefinite services of Opposite Parties, the complainant 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.25,000/- 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 complainants are not entitled to any relief. The complainants have concealed the fact that they have violated the terms and conditions of policy in question. Averred that complainant no.1 namely Rajan Kumar availed the ‘Family Health Optima Insurance Plan’ Policy No.P/211222/01/2023/011722 renewed for the period 06.02.2023 to 05.02.2024 and in this policy complainant no.1 Rajan Kumar, his wife Ashu Gupta i.e. complainant no.2 and dependent child Sanchi Gupta were insured for an amount of Rs.5 lakh. The terms and conditions of the policy were explained to the complainants at the time of proposing the policy and same were served to the complainant alongwith policy schedule. The complainants 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 was registered vide claim no.CIR/2024/211222/0125159. After this the insured has submitted the claim documents in present case regarding the medical reimbursement expenses towards his treatment taken by him at Sidhu Hospital on 26.04.2023 to 27.04.2023 towards the treatment of ‘Acute Entertitis’. On perusal of claim documents, it was observed from the submitted medical records that there is a malafide intention of the complainants as the claim documents have been submitted to them after 15 days of discharge from the hospital. As per policy, Condition- Standard Conditions- Clause C for reimbursement of claims time limit claim must be filed within 15 days from the date of discharge from the hospital, hence the claim was rejected vide repudiation letter dated 20.11.2023. It is clear from the above that the complainants have filed this complaint vexatiously and frivolously for the sole purpose of harassing the Opposite Parties. Averred further that the complainants have 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.C8.

4.       On the other hand, Opposite Parties have placed on record affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. as Ex.OP1 alongwith copies of documents Ex.OP2 to Ex.OP11.

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 complainants availed health insurance policy namely ‘Family Health Optima Insurance Plan’ bearing no.P/211222/01/2023/011722 renewed for the period 06.02.2023 to 05.02.2024 for self, his wife and dependent child for a sum insured of Rs.5,00,000/-. It is also proved on record that during the policy coverage, complainant no.2 namely Ashu Gupta suffered ‘pain abdomen and loose motion’ and got admitted in Sidhu Hospital & Diagnostic Centre, Moga on 26.04.2023, where she was diagnosed as ‘DMD, IAIC  Entertitis IS Anemia’ and after the treatment got discharged from the hospital on 27.04.2023. It is also proved on record that after discharge from the hospital, the complainants lodged the claim for reimbursement of the expenses with Opposite Parties.  It is on record that Opposite Parties issued different letters on different dates to the complainant requiring certain documents. Thereafter vide letter dated 12.06.2023, the Opposite Parties rejected the claim of the complainant for want of documents. It is also on record that vide letter dated 16.11.2023 the Opposite Parties acknowledged the receipt of documents, which were required by them. However, thereafter vide letter dated 20.11.2023, the Opposite Parties repudiated the claim of the complainant on the ground that “the claim documents have been submitted to them after 15 days from the discharge from the hospital.

7.       For the sake of convenience, the repudiation letter dated 20.11.2023 is reproduced as under:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of Acutre Enteritis.

It is observed from the submitted medical records that the claim documents have been submitted to us after 15 days of discharge from the hospital on 27.04.2023.

Please note that as per policy issued to you, Condition – Standard Conditions- Clause C for reimbursement of claims time limit is claim must be filed within 15 days from the date of discharge from the hospital.

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.        The repudiation of the claim by the Opposite Parties on the abvoesaid ground is not genuine and this decision of ours is based upon the IRDA circular issued to the Insurance Companies stating that the genuine claims shall not be rejected on hyper technical grounds i.e. delay etc. which for the sake of convenience is reproduced as under:-

“INSURANCE REGULATORY AND DEVELOPMENT   AUTHORITY

Ref. IRDA/HLTH/MISC/CIR/216/09/2011 Dated:20.09.2011 CIRCULAR

To All life insurers and non-life insurers.

Re: Delay in claim intimation/documents submission with respect to

 i.         All life insurance contracts and 

ii.       All Non-life individual and group insurance contracts.

The Authority has been receiving several complaints that claims are being rejected on the ground of delayed submission of intimation and documents.

The current contractual obligation imposing the condition that the claims shall be intimated to the insurer with prescribed documents within a specified number of days is necessary for insurers for effecting various post claim activities like investigation, loss assessment, provisioning, claim settlement etc.  However, this condition should not prevent settlement of genuine claims, particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances.  

 The insurer’s decision to reject a claim shall be based on sound logic and valid grounds.  It may be noted that such limitation clause does not work in isolation and is not absolute.  One needs to see the merits and good spirit of the clause, without compromising on bad claims.  Rejection of claims on purely technical grounds in a mechanical fashion will result in policyholders losing confidence in the insurance industry, giving rise to excessive litigation.

Therefore, it is advised that all insurers need to develop a sound mechanism of their own to handle such claims with utmost care and caution. It is also advised that the insurers must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the insurers should satisfy themselves that the delayed claims would have otherwise been rejected even if reported in time.

The insurers are advised to incorporate additional wordings in the policy documents, suitably enunciating insurers’ stand to condone delay on merit for delayed claims where the delay is proved to be for reasons beyond the control of the insured.”

          In view of the circular mentioned above, it is quite clear that repudiation of the claim on hyper technical grounds in case of genuine claims is unreasonable and not sustainable. The insurer must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the insurers should satisfy themselves that the delayed claims would have otherwise been rejected even if reported in time. Further, in the instant case, the Opposite Parties have not challenged regarding the hospitalization and treatment undergone by complainant no.2 and has not raised any objection regarding the same. Furthermore, there is no iota of evidence in support of any ingenuinenity of the claim in question. Hence, Opposite Parties are found deficient in services while rejecting the claim of the complainant. In the given eventuality, we deem it appropriate that the claim of the complainant be allowed.

9.       Vide instant complaint, the complainant claimed the amount of Rs.25,000/-, which is duly proved vide copies of bills Ex.C4. Hence we allow the said amount.

10.     In view of the discussion above, we allow the instant complaint in part and direct the Opposite Parties to make the payment of Rs.25,000/- (Rupees Twenty Five Thousand only) to the complainant. Opposite Parties are further directed to pay compository costs of Rs.5,000/- (Rupees Five Thousand only) as compensation and litigation expenses to the complainants. The pending application(s), if any also stands disposed of. 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 of Rs.7,000/-(Rupees Seven 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