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 no.1 availed an insurance policy for himself and his wife, vide policy no.211222/01/2022/008954 for the period 18.01.2023 to 17.01.2024  from Opposite Parties. Unfortunately on 10.02.2023, the complainant no.2 fell ill and got admitted in Astha Hospital, Moga under consultant doctor Nitin Mittal and after the treatment she got discharged from the hospital on 14.02.2023. At the time of treatment of complainant no.2, the complainant requested the Opposite Parties to pay the medical expenses to the concerned hospital, but the Opposite Parties did not pay the expenses of the treatment. Alleged that after discharged from the hospital, complainant no.1 submitted all the medical treatment record to Opposite Parties, but despite that the Opposite Parties have not paid any amount in lieu of medical expenses to the complainants. Alleged that the complainants made the payment of Rs.39,665/- from their own pockets. Thereafter vide letter dated 15.03.2023, the Opposite Parties repudiated the claim of the complainants 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 pay Rs.39,665/- alongwith interest @ 24% p.a. till its realization.

b)      To pay an amount of Rs.30,000/- as compensation for 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 pre mature complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Party as per the policy terms and conditions. Averred that the present complaint pertains to insurance claim under ‘Family Health Optima Insurance Plan’ bearing no.P/211222/01/2023/010961 valid from 18.01.2023 to 17.01.2024 covering self and his spouse Neelam Rani 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 Party subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over to the insured at the time of the contract. 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 insured submitted the claim documents for the reimbursement of medical expenses towards the treatment of Acute Bronchitis for hospitalization from 10.02.2023 to 14.02.2023 at Aastha Hospital, Moga. On scrutiny of claim documents the medical team of the answering Opposite Party observed that the insured patient’s vital signs were stable throughout the period of hospitalization and the insured patient could have been managed as an outpatient and hospitalization was not warranted. Further the investigation reports had no signatures of any pathologist. Thus, based on these findings, the claim was repudiated vide letter dated 15.03.2023 as according to the Exclusion clause no.36 of the policy. Hence the claim was finally rejected and it was conveyed to insured. The claim was repudiated under the ambit of specific condition/exclusion code no.36 as mentioned under the policy terms and conditions. The exclusion clause no.36 is reproduced as under:-

“The Company is not liable to make any payment under the policy in respect of any hospitalization which are not medically necessary/does not warrant hospitalization.”

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 his case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C8.

4.       On the other hand, Opposite Parties has tendered into evidence affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1 to 3/A, Power of Attorney as Ex.OP1 to 3/B alongwith copies of documents Ex.OP1 to 3/3 to Ex.OP1 to 3/11.

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

6.       The availing of insurance policy bearing no.P/211222/01/2023/010961 valid from 18.01.2023 to 17.01.2024 by the complainants and during the policy coverage, the admission of complainant no.2 in the Aastha Hospital, Moga for the period from 10.02.2023 to 14.02.2023. Thereafter lodging of the claim for the reimbursement of the expenses incurred by the complainants with Opposite Parties is not disputed.  The only dispute arises between the parties, when the claim lodged by the complainants was rejected by the Opposite Parties, vide letter dated 15.03.2023.

7.       The perusal of repudiation letter dated 15.03.2023 (Ex.OP1 to 3/10) reveals that the Opposite Parties repudiated the claim of the complainants on the following grounds:-

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

It is observed from the submitted medical records that the insured patient’s vital signs are stable throughout the period of hospitalization. Our medical team is of the opinion that the insured patient could have been treated as an outpatient and hospitalization of the insured patient is not warranted. Further investigation reports does not have pathologist signature.

As per Exclusion – Code Excl 36 of the above, policy, the company is not liable to make any payment under this policy in respect of any hospitalization which are not medically necessary/does not warrant hospitalization

We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.

8.       In our concerted view, the ground taken by the Opposite Parties for the repudiation of the claim as mentioned above said repudiation letter is not genuine, as doctor is the expert of his field and he can decide whether the admission of the patient is required or not. Further it is a matter of common prudence that decision qua hospitalization is the sole prerogative of the doctor concerned to decide which is need based and not at the sweet will of the patient concerned. Moreover, as per the discharge summary (Ex.OP1 to 3/7), the complainant no.2 admitted in the hospital with chief complaints of Cough, Difficulty in Breathing, where she got herself checked from the doctor and diagnosed as Acute Viral Bronchitis and thereafter she at the decision of the doctor, who is expert in his field got admitted in the hospital. Moreover, the insurance company has not placed on record any evidence or the report from any other doctor, which states that the patient can be treated as an outpatient and hospitalization of the insured patient is not warranted. In these circumstances, we are of the concerted view that the repudiation of the genuine claim of the complainants by the Opposite Parties is unjustified.

9.       Vide instant complaint, the complainant claimed the amount of Rs.39,665/-.  However, vide Bill Assessment Sheet Ex.OP1 to 3/11, the Opposite Parties assessed the Final Admissible Amount to the tune of Rs.35,415/-. Hence we allow the same.

10.     From the discussion above, we partly allow the complaint of the complainants and direct the Opposite Parties to pay a sum of Rs.35,415/- (Rupees Thirty Five Thousand Four Hundred Fifteen only) to the complainants. Further Opposite Parties are directed to pay compository cost of Rs.12000/- (Rupees Twelve Thousand only) as compensation as well as 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 Rs.10,000/- (Rupees Ten 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