Order by:
Smt.Priti Malhotra, President
1. The complainants have filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant no.1 Surinder Kumar availed a health insurance policy covering himself and his family from Opposite Parties on 05.12.2019, vide policy no.P/211222/01/2023/008866 and the policy was valid upto 04.12.2023. Unfortunately, on 21.03.2023, the complainant no.2 fell ill and got admitted in Suresh Nursing Home Hospital under Consultant Doctor Chandan Singal and after treatment got discharged from the hospital on 26.03.2023. At the time of treatment and after discharge from the hospital, the complainants requested the Opposite Parties to pay the medical expenses including pre and post, to the complainants, but the Opposite Parties did not pay the expenses of treatment and thus, the complainants have to pay whole of the amount from his own pocket. After the treatment, the complainants submitted all the medical record with Opposite Parties as per their demand, but despite that the Opposite Parties have not paid any amount in lieu of medical expenses to complainants. Alleged that the complainants made a payment of Rs.28,675/- to the said hospital with regard to his treatment. Alleged further that the Opposite Parties vide letter dated 31.07.2023, repudiated the claim of the complainants on false and baseless reason. Hence, this complaint. Vide instant complaint, the complainants have sought the following reliefs:-
a) Opposite Parties may be directed to pay a sum of Rs.28,675/- alongwith interest @ 24% p.a. till its realization.
b) To pay an amount of Rs.30,000/- as compensation on account of mental tension and harassment and for deficiency in service.
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 complainants 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 complainants was denied by the answering Opposite Parties as per the insurance policy terms and conditions. Averred that the present complaint pertains to insurance claim under “Family Health Optima Insurance Plan-2021 bearing no.P/211222/01/2023/008866 valid from 05.12.2022 to 04.12.2023 covering the complainant self and his spouse Suman Sharma 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 Parties subject to the terms and conditions of the insurance policy. 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 insured had submitted the reimbursement of the medical expenses towards the treatment of Broncho Pneumonia at Suresh Nursing Home, Moga from 21.03.2023 to 26.03.2023. It is observed from the submitted medical records that the insured patient was admitted in the hospital on 21.03.2023 whereas the intimation regarding the admission was given to us only on 19.07.2023 which is after 120 days from the date of admission and documents were submitted on 26.07.2023 and as per policy condition- Standard Conditions – Clause- D- Notification of claim, the intimation has to be given within 24 hours of hospitalization. Thus, for the reasons stated above the Opposite Party-Insurance Company was unable to settle the claim under the above policy and the same was repudiated on dated 31.07.2023. Averred further that the instant complaint is neither maintainable in law nor on facts; 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 the case, the complainant no.1 has placed on record his affidavit 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, Senior Manager, Star Health & Allied Insurance Co. Ltd. as Ex.OP1,2/A alongwith copies of documents Ex.OP1,2/1 to Ex.OP1,2/6.
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 complainants are the holders of Insurance policy namely “Family Health Optima Insurance Plan Policy-2021” having no.P/211222/01/2023/008866 for the period 05.12.2022 to 04.12.2023 covering the complainants. It is also proved that during the policy period, the complainant no.2 suffered Broncho Pneumonia and got admitted in Suresh Nursing Home, Moga and remained admitted there for the period 21.03.2023 to on 26.03.2023. It is also proved on record that the claim lodged for the reimbursement of the expenses incurred by complainant no.2 was repudiated by the Opposite Parties vide letter dated 31.07.2023.
7. The Opposite Parties repudiated the claim of the complainant, vide letter dated 31.07.2023. 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 Broncho Pheumonia.
It is observed from the submitted medical records that the intimation regarding the admission was given to us only after 24 hours of hospitalization.
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. In the given eventuality, we deem it appropriate that the claim of the complainant be allowed.
9. Vide instant complaint, the complainants claimed the amount of Rs.28,675/-, but however, the complainants have placed on record medical bills more than the claimed amount. In these circumstances, we allow the amount as claimed by the complainant.
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.28,675/- (Rupees Twenty Eight Thousand Six Hundred Seventy Five only) to the complainants. However, keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. 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 this order, failing which, they are further burdened with Rs.5,000/- (Rupees Five 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 cost. File be consigned to record room after compliance.
Announced in Open Commission
