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 on 09.01.2022, the complainant got admitted in Aastha Hospital, Dutt Road, Moga due to Covid-19 disease. The mother of complainant namely Raj Rani Bansal and Sister namely Sonia Bansal were also got admitted in the same hospital on 09.01.2022 due to same problem. Both Raj Rani and Sonia Bansal have medical insurance of United India and their claim have already been released by the United India Insurance Co. on 16.03.2022 of Rs.1,00,222/-, 04.04.2022 of Rs.26,343/-, 07.03.3033 of Rs.14.03.2022 of Rs.22,646/-. The complainant remained in hospital from 09.01.2022 to 15.01.2022 due to above said problem of Covid-19 and claim amount was of Rs.63,183/- under the policy no.P/211222/01/2021/009370. The complainant got treatment from Dr.Nitin Mittal of Aastha Hospital, Dutt Road, Moga. All the original bills, prescription slips of doctor and other relevant document regarding the treatment of complainant was submitted to Opposite Parties. Thereafter, the complainant visited the Opposite Parties number of times and made requested to pay the claim amount, but the Opposite Parties rejected the claim of the complainant vide letter dated 24.03.2022 on the ground that there is multiple gross discrepancies which amounts to mis-representation of facts. Alleged that the complainant replied to the said query and doctor Nitin Mittal has also verified that same is human error but nothing has been mis-represented. Alleged that earlier the complainant got him medical insured from Untied India Insurance Co. Ltd. and from the last 3-4 years, he has been purchasing the insurance policies from the Opposite Parties. The complainant also served a legal notice upon the Opposite Parties, but to no effect. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay Rs.63,183/- alongwith interest @ 18% p.a. from 09.01.2022 till the date of payment.
b) To pay an amount of Rs.50,000/- as compensation harassment and for deficiency in service.
c) To pay an amount of Rs.35,000/- 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 question of law and facts are involved in the present complaint, which is not possible in summary procedure under C.P. Act and appropriate remedy, if any lies only in civil court; the complainant has concealed material facts and documents from this Commission as well as from the Opposite Parties. Submitted that the complainant namely Mr.Pankaj Bansal availed ‘Family Health Optima Insurance Plan’ bearing no.P/211222/01/2021/009370 for the period 31.03.2021 to 30.03.2022 covering self, his wife and dependent children for an amount of Rs.10 lakhs. This policy is ported from UII to their company. Terms and conditions 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 in the 3rd year of the policy, the insured has submitted the claim documents in the present case regarding the medical reimbursement expenses towards the treatment of complainant taken by him at Aastha Hospital, Moga from 09.01.2022 to 15.01.2022 towards the treatment of Covid-19. It was observed from the claim documents that there are multiple gross discrepancies which amounts to misrepresentation of fact, hence claim was rejected vide repudiation letter dated 24.03.2023 as per condition no.1 of the policy. Averred that the complainant is not the consumer of Opposite Parties; the complainant has no locus standi or cause of action to file the present complaint; the complaint is not maintainable in the present form. 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.C7.
4. On the other hand, Opposite Parties has placed on record copies of documents Ex.OP1 to OP10 and affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP11.
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 as well as reply placed on record by both the parties that a policy bearing no.P/211222/01/2021/009370 covering complainant self, his wife and his dependent children for an amount of Rs.10 lakhs was purchased by complainant. The hospitalization of the complainant at Aastha Hospital, Moga for the period from 09.01.2022 to 15.01.2022 for the treatment of Covid-19 is proved on record. It is also proved on record after discharge from the hospital, the complainant lodged the claim with Opposite Parties for the reimbursement of the medical expenses incurred by him, but the Opposite Parties vide letter dated 24.03.2022 repudiated the claim of the complainant.
7. The contents of repudiation letter dated 24.03.2022 placed on record by Opposite Parties (Ex.OP10) is reproduced as under:-
We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of Covid-19.
It is observed from the claim documents that there are multiple gross discrepancies which amounts to misrepresentation of facts.
As per terms and conditions of the policy issued to you, 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.
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. Here it is pertinent to mention that the Opposite Parties alleged that there are multiple gross discrepancies and misrepresentation of the facts in the documents submitted by the complainant, but they failed to explain clearly which document shows the same. Moreover, if there is any doubt regarding misrepresentation, then the Opposite Parties can enquire the same from the hospital itself rather in this case complainant himself replied the objections raised by the Opposite Parties and Dr.Nitin Mittal (who gave treatment to the complainant) had also verified that the same is a human error and nothing has been misrepresented. Hence, in the absence of any concrete evidence, the repudiation of the claim of the complainant on discrepancy and misrepresentation of facts by the Opposite Parties is unjustified.
9. Vide instant complaint, the complainant has claimed the amount of Rs.63,183/-, but the bills placed on record Ex.C4 (page no.21, 22, 23, 42 & 43) shows the amount of Rs.61,583/- only. Hence we allow the same.
10. In view of the discussion above, we partly allow the instant complaint and direct Opposite Parties to make the payment of Rs.61,583/- (Rupees Sixty One Thousand Five Hundred Eighty Three only) alongwith interest @ 6% p.a. from the date of filing of the complaint i.e. 06.09.2023 till its actual realization to the complainant. Further Opposite Parties are directed to pay compository cost of Rs.10,000/- (Rupees Ten Thousand only) as compensation and litigation expenses 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 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.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
