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 family from Opposite Parties on 07.12.2021 and the said policy got renewed vide policy bearing no.P/211222/01/2023/009071, which is valid upto midnight of 06.12.2023. Unfortunately on dated 08.05.2023, the minor daughter of complainant namely Tanvi fell ill and got admitted in Suresh Nursing Home, Moga under Consultant Doctor Chandan Singal and after the treatment got discharged from the said hospital on 11.05.2023. At the time of treatment of daughter of complainant and after discharging from the hospital, the complainant 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 the treatment from the hospital, the complainant also 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 complainant has made the payment of Rs.17,800/- to the said hospital with regard to the treatment of daughter of complainant from this own pocket. The complainant 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 03.09.2023, 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.17,800/- alongwith interest @ 24% p.a. till its realization.
b) To pay a sum of Rs.20,000/- as compensation on account of mental tension, and harassment.
c) To pay Rs.15,000/- 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 violated the terms and conditions of policy in question and submitted that the complainant availed the ‘Young Star Insurance Plan’ Policy No.P/211222/01/2023/009071 renewed for the period 07.12.2022 to 06.12.2023 and in this policy complainant, his wife Sneh Rani, his dependent children Tanvi were insured for an amount of Rs.5 lakh. This policy is in continuation since 06.03.2021 Averred that 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 and no pre-existing disease was declared by the insured. The claim in dispute is reported in the second year of the policy and the claim was registered vide claim no.CIR/2024/211222/0585284. Averred that the insured has submitted the claim documents in the present case regarding the medical reimbursement expenses towards treatment taken by his child at Suresh Nursing Home for the period 08.05.2023 to 11.05.2023 towards the treatment of ‘AFI’. Averred further that it is observed from the submitted records that the insured patient was admitted in the hospital on 08.05.2023 whereas the intimation regarding the admission was given to Opposite Parties only on 03.08.2023 and as per Standard Conditions-Clause D the intimation has to be given within 24 hours of hospitalization, but the claim documents have been submitted to the Opposite Parties after 15 days of discharge from the hospital. Further, as per policy issued to the insured/complainant, Condition-Standard Conditions-Clause-C for reimbursement of claims, claims must be filed within 15 days from the date of discharge from the hospital. Hence without going into the merits of the case, the Opposite Parties repudiated the claim of the complainant as there was material infringement of the condition as regard to the claim intimation to be given to the insurance company for checking the genuineness/to confirm of the treatment being given to the complainant, which has not been adhered in the present matter. Hence, the claim of the complainant has rightly been repudiated in light of the terms and conditions of the policy. Averred further that on receipt of the summons from this District Commission, the claim was again received by the medical team of Opposite Parties and few discrepancies/inconsistencies are noted which are as under:-
i. There is no OPD treatment record provided and the D/S also does not mention any details. Hence need for admission not clear.
ii. Investigation reports are s/o Raised CRP, TLC, Widal +ve, but the same are not signed by Pathologist. No X-ray (Chest) done/provided.
iii. There are no ICP’s provided.
It is a clear case of late intimation, insufficient documents and discrepancies, amounting to misrepresentation of facts which is a clear cut violation of the terms and conditions of the policy. Hence the claim was rightly repudiated vide letter dated 03.09.202. As per condition of the policy issued to the complainant on the conditions that if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim hence the claim was rejected and duly informed to the complainant. 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.OP10 and affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. as 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 complainant availed health insurance policy namely ‘Family Health Optima Insurance Plan’ bearing no.P/211222/01/2023/009071 for the period 07.12.2022 to 06.12.2023 covering self, his wife Sneh Rani and his dependent child Tanvi were insured for a sum insured of Rs.5,00,000/-. It is also proved on record that during the policy coverage, daughter of the complainant suffered ‘Acute Febrile illness and severe bronchitis’ and got admitted in Suresh Nursing Home on 08.05.2023 and after the treatment got discharged from the hospital on 11.05.2023. 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 03.09.2023.
7. The Opposite Parties repudiated the claim of the complainant vide letter dated 03.09.2023. 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 AFI.
It is observed from the submitted medical records that the insured patient was admitted in the hospital on 08.05.2023 whereas the intimation regarding the admission was given to us only on 03.08.2023.
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.
Further the claim documents have been submitted to us after 15 days of discharge from the hospital on 11.05.2023.
Please note that as per policy issued to you, Condition- Standard Conditions-Clause C for reimbursement of claims time 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. However, no doubt that there is delay in intimation about the hospitalization of daughter of the complainant, which at the first instance is violation of terms and conditions of the policy and since it restricts the right of the Opposite Party-Insurance Company to make preliminary investigation to inquire about the genuinenity of the claim. At the same time 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. 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, but without compensation.
9. Vide instant complaint, the complainant claimed the amount of Rs.17,800/-, which is duly proved on record vide Ex.C4. Hence we allow the said amount of Rs.17,800/-.
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.17,800/- (Rupees Seventeen Thousand Eight Hundred only) to the complainant. 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 Party 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 complainant 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
