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 has been purchasing a health insurance policy covering himself as well as his family members from opposite parties continuously since the year, 2018 and lastly the said policy renewed vide policy bearing No. P/211222/01/2022/006560 for the period 11.11.2022 to 10.11.2023 for Rs. 10,00,000/-. Unfortunately on 01.05.2023, the minor daughter of the complainant namely Ahana Gupta fell ill and she was got admitted and medically treated firstly from Ankur Kids Superspecility Hospital, Jalandhar and got discharged on 02.05.2023. Thereafter, the daughter of the complainant got admitted in Sigma Hospital, Jalandhar on 02.05.2023 and was discharged on 06.05.2023 from the said hospital. At the time of treatment of daughter of the complainant and after discharging from the hospital, the complainant requested the opposite party no.2 to pay the medical expenses including Pre and Post, to the concerned hospital, but the opposite parties lingered on the matter on one pretext or the other and did not pay the expenses of the treatment and thus the complainant had to pay whole of the amount of medical expenses as well as medical bills from his own pocket. After discharging from the hospital, the complainant also submit all the medical record with regard to the treatment taken by his daughter with opposite parties as per their demand but inspite of that the opposite parties had not paid any amount in lieu of medical expenses. Alleged that the complainant made the payment of Rs.58,203/- to the said hospital from his own pockets. The complainant requested many time to make the payment of claim but the opposite parties refused to make the payment to complainant and repudiated the claim of the complainant vide repudiation letter dated 28.06.2023 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 release the amount of Rs.58,203/-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.

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 complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Party on the ground as per insurance policy terms and conditions and as per Condition - Standard Conditions- Clause D- Notification of claim, the intimation has to be given within 24 hours of hospitalization. It is observed from the submitted medical records that the insured patient was admitted in the hospital on 02.05.2023 whereas the intimation regarding the admission was given to them only on 29.05.2023. Averred that the present complaint pertains to insurance claim under Family Health Optima Insurance Plan Policy-2021 bearing No. P/211222/01/2023/008082 valid from 11/11/2022 to 10/11/2023 covering the Complainant himself and his spouse Vinod Kaushal and Ananya Gupta and Ahana Gupta dependent children, 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 OP subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of the contract. Moreover the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same were served to the complainant along with policy schedule. Further averred that the insured has submitted the reimbursement of the medical expenses towards the treatment WALRI at Sigma Hospital, Jalandhar on 02.05.2023. It is observed from the submitted medical records that the insured patient was admitted in the hospital on 02.05.2023 whereas the intimation regarding the admission was given to them only on 29.05.2023. So, 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 28.06.2023; the instant complaint is neither maintainable in law nor on facts and the same is liable to be dismissed in limine; no deficient services have been rendered by the answering opposite parties as alleged by the complainant. The claim in question was duly entertain, inquired into and after due application of mind the alleged claim has been repudiated on the basis of terms and conditions of insurance 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 his case, the complainant has placed on record affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C8.

4.       To rebut the evidence of complainant, ld. counsel for the Opposite Parties has placed on record affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1/A, Power of Attorney Ex.OP1,2/B alongwith copies of documents Ex.OP1/1 to Ex.OP1/9.

5.         We have heard the ld. counsel for both the parties and also gone through the record.

6.       As it comes out from the complaint and reply placed on record by both the parties that the policy availed by the complainant covering his family is admitted, admission of the patient for the period 02.05.2023 to 06.05.2023 at Sigma Hospital is admitted, Medical expenses incurred on the treatment is also admitted by Opposite Parties. The only ground for repudiation of the claim of the complainant by the Opposite Parties is that “insured patient was admitted in the hospital on 02.05.2023 whereas the intimation regarding the admission was given to them on 29.05.2023. However, when everything was admitted and the repudiation only on the ground of late intimation seems not genuine on the part of the Opposite Parties. It seems that insurance company repudiated the claim just for the sake of repudiation whereas they have not placed on record any evidence which clearly shows that due to late intimation any loss or any fraud committed to insurance company by the complainant. Rather by repudiating the genuine claim of meager amount of Rs.58,203/-, Opposite Parties proved their deficiency in service.

7.       Moreover, Opposite Parties have taken the plea that as per the terms and conditions of the policy, the complainant is not entitled to the claim as claimed.  But the Opposite Parties could not produce  any evidence to prove that terms and conditions of the policy were ever supplied to  the complainant insured, when and through which mode? It has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insurance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company. From the perusal of the entire evidence produced on record by the Opposite Party,  it is clear that Opposite Party  has failed to prove on record that they did supply the terms and conditions of the policy to  the complainant insured. As such, these terms and conditions, particularly the exclusion clause of the policy is not binding upon the insured.

8.       In view of the above discussion, we are of the opinion that the Opposite Parties have wrongly and illegally repudiated the claim of the complainant.

9.       Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant claimed the amount of Rs.58,203/-. being the amount of medical expenses. However, vide Bill Assessment Sheet Ex.OP1,2/9, the Opposite Party assessed the final admissible amount to the tune of Rs.49,668/-. Hence we allow the same.

10.     Sequel to the above discussion, we partly allow the complaint of the complainant and direct the Opposite Parties to pay an amount of Rs.49,668/- (Rupees Forty Nine Thousand Six Hundred Sixty Eight only) to the complainant. Opposite Parties are also directed to pay compository costs of Rs.12,000/-(Rupees Fifteen Thousand only) as compensation for unnecessary harassment and thrusting avoidable litigation to the complainant. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 45 days from the date of receipt of copy of this order, failing which, the Opposite Parties are further burdened with additional cost of Rs.10,000/-(Rupees Ten 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 costs. File is ordered to be consigned to the record room.

Announced on Open Commission