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 30.11.2017 and the said policy got renewed regularly. Earlier, the complainant availed the policy vide no.P/211222/01/2023/008838, which is valid upto midnight of 29.11.2023. Unfortunately on dated 30.03.2023, the complainant no.2 fell ill and got admitted in Suresh Nursing Home (wrongly mentioned in complaint as Sood Nursing Home), Moga and after treatment got discharged from the hospital on 03.04.2023. At the time of treatment and after discharging from the hospital, the complainant no.2 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 complainants submitted all the medical record to Opposite Parties as per their demand, but inspite of that the Opposite Parties did not pay any amount in lieu of medical expenses to the complainant. Alleged that the complainants have made the payment of Rs.29,600/- 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 complainant. However, vide letter dated 29.05.2023, 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.29,600/- 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 disclosed PED qua Ram Krishan only for hypertension & its complications, but not disclosed about other insured and the real facts are that the complainant namely Ram Krishan availed the ‘Family Health Optima Insurance Plan’ Policy No.P/211222/01/2023/008838 renewed for the period 30.11.2022 to 29.11.2023 and in this policy complainant Ram Krishan, his wife Kamal and children Divjot and Ruhani were insured for an amount of Rs.5 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 in dispute was registered vide claim no.CIR/2024/211222/0201011. After this the insured has submitted the claim documents in present case regarding the medical reimbursement expenses towards the treatment of wife of complainant at Suresh Nurshing Home on 30.03.2023 towards the treatment of Myoma Uterous. It is observed from the submitted medical record that the insured patient was admitted in the hospital on 30.03.2023 whereas the intimation regarding the admission was given only on 15.05.2023. So per standard conditions clause D intimation has to be given in 24 hours which is clear cut violation of the policy in question and very well in the knowledge of complainant hence claim was rejected vide repudiation letter dated 29.05.2023. Averred further that as per condition of the policy issued to the complainant or his family 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 and duly informed to the complainant. Averred further that there is delay of 45 days in intimation and claim of the complainant has rightly been repudiated as per Clause-D of standard condition, which is reproduced as under:-
Notification of Claim – Upon the happening of the event, notice with full particulars shall be sent to the company within 24 hours from the date of occurrence of the event irrespective of whether the event is likely to give rise to a claim under the policy or not.
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.C8.
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/211222/01/2023/008838 for the period 30.11.2022 to 29.11.2023 for self, his wife and two dependent children. It is also proved on record that during the policy coverage, complainant no.2 suffered ‘Myoma Uterus’ and got admitted in Suresh Nursing Home, Moga on 30.03.2023 and remained admitted there till 03.04.2023. 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 29.05.2023.
7. The record further reveals that the Opposite Parties repudiated the claim of the complainant vide letter dated 29.05.2023. 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 Myoma Uterus.
It is observed from the submitted medical records that the insured patient was admitted in the hospital on 30.03.2023 whereas the intimation regarding the admission was given to us only on 15.05.2023.
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. 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.29,600/-, 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.29,600/- (Rupees Twenty Nine Thousand Six Hundred only) to the complainants. 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
