Haryana

Charkhi Dadri

CC/11/2021

Rinku - Complainant(s)

Versus

Manager, Star Health and Allied Insurance Company, - Opp.Party(s)

Sh. Ravinder Kumar

08 Nov 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, CHARKHI DADRI.

         

                                                                   Complaint No.: 11 of 2021.

                                                                    Date of Institution: 21.01.2021.

                                                                   Date of Decision:  08.11.2024.

Rinku son of Shri Parkash Samaspuria, permanent resident of ward No. 4, old Anaj Mandi, Charkhi Dadri, Tehsil & District Charkhi Dadri.

                                                                             ….Complainant.

                                                                                       

                                      Versus

1.       Manager, Star Health and Allied Insurance Company, Branch office Ashok Plaza, 3^rd floor, Delhi Road, Rohtak-124001.

2.       Star Health and Allied Insurance Company through its MD/CEO, Regd and Corporate office 1 New Tank Street, Valluvar Kottam High Road, Ungamabakkam, Chennai-600034.

                                                                              …...Opposite Parties.

 

                    COMPLAINT UNDER THE CONSUMER PROTECTION ACT.

 

Before: -      Hon’ble Shri Manjit Singh Naryal, President.

Hon’ble Shri Dharam Pal Rauhilla, Member.

 

Present:       Shri Ravinder Kumar, Advocate for the complainant.

Shri Rajinder Verma, Advocate for the OPs.

 

ORDER

                   Brief facts of the case are that the complainant had purchased a Medical Policy No. P/211118/01/2018/004515 valid from 28.12.2017 to 27.12.2018 for a basic floater sum of Rs.4,00,000/- with limit of coverage 540000/-.  It is averred that in the month of May, 2018, complainant fell ill due to Fever and body pain and was admitted in Medanta, the medicity hospital on 18.5.2018 and a sum of Rs. 1,47,581/- was claimed by the hospital from the OPs being cashless health insurance policy, but the same was denied and the complainant was advised to submit reimbursement bills.  It is further averred that the complainant had completed all the formalities for reimbursement of Rs.1,47,581/- and deposited all the original bills including treatment history with the OP No.1 and he was assured that amount would be paid within a month after processing the claim.  It is further averred that the complainant had requested the OPs to pay the claim many times, but to no effect.  It is further averred that the complainant had got served a legal notice dated 26.11.2020 upon the OPs, but the OPs did not pay the claim.  Hence, it amounts to deficiency in service on the part of OPs.  Hence, this complaint.

2.                On notice, OPs appeared and filed contested written statement.  It is alleged that the proposal of the complainant was accepted and insurance policy No. P/211118/01/2016/002025 was issued in which basic floater sum insured was Rs. 4 lacs for a period of one year w.e.f. 28.12.2015 to 27.12.2016, which was further renewed and lastly w.e.f. 28.12.2017 to 27.12.2018 and policy No. P/211118/2018/004512 was issued to him in which basic floater sum insured was Rs.4 lacs.  It is averred that one request for cashless hospitalization for medical insurance policy was received from Medanta, the Medicity, Gurugram mentioning therein that patient Rinku was admitted in the hospital on 18.5.2018 and desease of insured was mentioned as chronic diarrhea and immune deficiency disorder.  It is further averred that a revised request for the same was also received on 18.5.2018.  It is further averred that after receiving the request for cashless health insurance treatment, the OPs had sent letter to Medanta, the Medicity, Gurguram on the same day for providing some information.  It is further averred that the competent authority of the OPs observed from the submitted documents that the patient had past history of abdominal TB in 2013, but as per query reply, it was mentioned as no past history of TB and also previous treatments for chronic diarrhea and abdominal TB not provided even after repeated queries.  It is further averred that the above discrepancies were noted and hence the pre authorization request was denied to hospital on 21.5.2018.  It is further averred that the complainant had submitted claim documents on 23.6.2018 for reimbursement of medical expenses and on scrutiny, it was observed that

          ‘Although the present admission of the insured patient is for treatment of chronic diarrhea and immune deficiency disorder, it is observed from the consultation report dated nil of Dr. Randhir Sud from the treatment hospital submitted during cashless proceedings that the insured has history of abdominal tuberculosis in the year 2013’.

                    It is further averred that the insured patient had chronic diarrhea for the past one year.  It is further averred that despite letter sent dated 6.7.2018, 21.7.2018, 5.8.2018 and 20.8.2018, the insured had not submitted past treatment records of abdominal TB and chronic diarrhea, which amount to non-cooperation by the insured.  It is further averred that at the commencement of policy i.e. 28.12.2015 to 27.12.2016, the insured had not disclosed history/health details in proposal form, which amounts to misrepresentation/non-disclosure of material facts, which is breach of condition No. 6 of the policy.  It is further averred that the competent authority of the OPs after going through the claim papers available on file and after due application of mind and taking into consideration the terms and conditions of the policy had repudiated the claim of the complainant vide letter dated 29.8.2018.  It is further averred by the OPs that the insurance policy in question is governed by limits of liability as per its clauses and that without prejudice to whatever stated in their this written statement, even assuming without conceding that the company is liable to pay the claim in terms of the contract of insurance issued to the claimant, the maximum quantum of liability under the terms of the policy shall be Rs.1,20,615/-.  Therefore, there is no deficiency in service on the part of the OPs and prayed for dismissal of complaint with costs.

3.                The complainant and the OPs in support of their respective averments tendered documentary evidence alongwith their respective affidavits and adduced certain documents.  Reference of the relevant record is given in this order.   

4.                 We have heard the counsel for the parties and gone through the case file thoroughly and after hearing the rival contentions of the parties, we are of the convinced view that the present complaint has merit and the same deserves acceptance for the reasons mentioned hereinafter.

5.                After hearing the learned counsels for both the parties and having gone through the material available on the records, we are of the considered view that the complaint in hand deserves acceptance, as there is deficiency in service on the part of the OPs.  The complainant has fully proved his case by placing on record certain documents.  On the other hand, the OPs has failed in proving its stand taken in its written statement by not submitting cogent and convincing documentary evidence.  The case produced by the OPs i.e. Satwant Kaur Sandhu Vs New India Assurance Company, Civil Appeal No. 2776 of 2002, decided by the Hon’ble Supreme Court of Inida, is not applicable to the facts of the present case.

6.                The only plea taken by the OPs is that the complainant is not eligible for the claim as it does not fall under the purview of the policy terms & conditions No. 6, as the insured/patient during the treatment of chronic diarrhea and immune deficiency disorder, it was observed from consultation report dated nil of Dr. Randhir Sud submitted during cashless proceedings that the insured had history of abdominal tuberculosis in the year 2013, which amounts to misrepresentation/non-disclosure of material facts.  This plea of the OPs is not tenable at all, because they have not placed on record any documentary evidence in support of their plea.  On the other hand, the complainant has placed on record a certificate dated 23.5.2018 issued by the Dr. Randhir Sud Ex. C-4, wherein it has been mentioned that: -

“The medical history of abdominal TB in 2013 has been given by the patient’s attendant during OPD consultation and the patient denies any such history”.

          From the certificate given by Dr. Randhir Sud, it has no where establish on record that the complainant was suffering from abdominal TB in 2013.  Moreover, the complainant has not taken the treatment of abdominal TB during the period of hospitalization and he was treated for chronic diarrhea and immune deficiency disorder.  In this regard, the OPs have also stated in their written statement that the complainant had chronic diarrhea for the past one year.  This plea of the OPs is also not tenable at all, because they have not placed any treatment papers of the same on record.  The OPs have placed on record treatment papers, claim form, bills etc. on record and from the perusal of claim form Ex. R11, it is clear that the complainant had submitted his claim for Rs. 1,47,581/- (1,46,481/- + 1100/-).  The OPs in its written statement has stated that even assuming without conceding that the company is liable to pay the claim in terms of contract of insurance issued to the claimant, the maximum quantum of liability under the terms of the policy shall be Rs.1,20,615/-, as per bill Ex. R15.  But from the perusal of bill Ex. R15, it is clear that an amount of Rs.1,46,481/- has been charged and paid by the complainant.  Thus, it is clearly proved that the OPs have wrongly repudiated the genuine claim of the complainant on flimsy grounds.  

7.                Now question of law arises as to whether the insurance company was justified in repudiating the claim of the complainant.  The sought answer is “No”.  The claim of the complainant was repudiated on the allegations that the complainant has violated the terms & conditions of the policy.  This policy is not a policy at all, as it is just a contract entered only for the purpose of accepting the premium without the bonafide intention of giving any benefit to insured by raising unnecessary objections.  So, it cannot be said that he had violated any terms & conditions of the policy.  Moreover, violation of terms & conditions of the policy, if any, was not of such an important significance.

8.                Moreover, the Insurance Companies adopt very unethical and wrong procedures just grab the money from the people and harass them when they are in need of the money.  It is also moral & social duty of the insurance companies to conduct proper enquiry of buyers of the insurance policies before they accept the hard earned money on account of premium from policy buyers, as lateron they are on giving hand and they cannot escape from their liability and also cannot harass the people on unnecessary excuses especially at the time of giving the claim to the insured.  Generally it is routine practice that as and when a common person searches on internet about insurance/mediclaim policies, then he receives many unwanted telephone calls from the different insurance companies and these companies try to induce the people through their agents without disclosing the entire terms & conditions and at that time the only purpose of their agents is to extort money from public and to get the commission on that amount and they complete all the formalities by themselves including filling of proposal form and they also obtained the signature of assured on some blank forms and for this they always adopt the unethical, unsocial and un-genuine procedure to issue the insurance policy.  As and when the assured needs claim and apply for the same, then agents of the insurance companies some-times unethically bargains for settling the claim.  So after considering all above mentioned important issues, we come to the conclusion that the insurance companies should have held liable for their errors & negligence committed on their part and to protect the interest of genuine buyers of the insurance policies.  The Insurance Companies and their agents are also duty bound to disclose all hidden terms & conditions of the insurance policy to protect the interest of consumers and these companies are also duty bound to get investigate the assured with their entire satisfaction before issuing the insurance/mediclaim policies.  It cannot be said that insured has violated the terms & conditions of the policy at the time of processing the claims, because everything was within the approachable hand of the OPs and they must investigate all the facts pertaining to the insured before issuing the policy to provide proper justice to the needy claimants.  Thus, there is clear cut deficiency in service and unfair trade practice on the part of the OPs.  In our view, The insurance companies, are not acting fairly in all such matters after charging huge premium intention is always to repudiate the claim on one ground or the other.  The conditions of the insurance agreements are so minutely printed that per-son gets hardly any time to go through such conditions to make it legally binding in any appropriate manner and at the times of issuance of policy persons are not allowed to read or fill forms at their own and same are filled in lateron by the agents or officials of the insurance companies”.

9.                From the above facts, it is clearly proved on record that the claim has been wrongly repudiated by the OPs on the ground that complainant has violated the terms & conditions of the policy.  The OPs have failed to provide satisfactory services to the complainant i.e. settling the genuine claim of the complainant, for which they have charged the premium and they are bound to settle the genuine claims of their consumers.  So, OPs have defeated the very purpose for which the complainant has taken the mediclaim policy.  Thus, there is gross negligence and deficiency in service on the part of OPs and they cannot be allowed to run away from their responsibility.

10.              Moreover, the Insurance Companies deliberately with malafide intention do not settle the claim of its consumers in time and harassed them without any reason.  So in our view the complainant is also entitled for compensation on account of mental and physical harassment for deficiency in service & mal trade practice on the part of the Insurance Company. Therefore, in view of the facts and circumstances mentioned above, complaint of the complainant is partly allowed and the OPs are directed:-

i.        To pay Rs.1,46,481/- (One lac forty six thousand four hundred eighty one only) together with interest @ 9% per annum from the date of repudiation of claim i.e. 29.8.2018 till its realization.

2.  

iii.      To pay Rs.10,000/- (Ten thousand only) as litigation charges. 

The OPs shall make the compliance of the order within 45 days from the date of receipt of copy of this order.  Non compliance of this order on the part of OPs will lead to action in terms of Section 71 and 72 of the Consumer Protection Act, 2019.  The copy of order be supplied to the parties free of cost as per rules.  Order be promptly uploaded on the website. File be consigned to the record room, after due compliance.