DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/106/2023
Date of Institution: 23.08.2023
Date of Decision: 20.09.2024
Pankaj Goyal son of Raj Kuma Goyal resident of House No. B-XI/1946, Kartar Nagar, Near Municipal Office, Barnala Punjab 148001 Mobile Number 93175-10667.
…Complainant
Versus
- M/s Star Health and Allied Insurance Company Limited, Branch office-Sangrur 1st Floor, Sunami Gate, Sangrur above IDBI Bank, Sangrur 148001 through its Branch Manager.
- M/s Star Health and Allied Insurance Company Limited, Regd. & Corporate Office-1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034, through its Managing Director.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Varinder Kumar Goyal counsel for complainant.
Sh. Rohit Jain counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Smt. Urmila Kumari : Member
3. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Star Health and allied Insurance Company Limited & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant is having a Bank account number 12660001052001 in Punjab National Bank, Barnala and the complainant continuously purchased Raksha Health Insurance till 20.11.2021. It is alleged that the complainant purchased the said policy for himself, wife and two sons and before the issuance of said policy all of us were medically checked and fit for health insurance purpose. Thereafter, the opposite party number 1 approached the complainant and asked him to buy Star Group Health Insurance policy Gold (for Bank Customers). It is alleged that the O.P-1 further told that he should buy policy from the Op's have tie up with Punjab National Bank and there will be no break the policy of the complainant and his previous policy will continue. It is further alleged that the complainant paid a sum of Rs.12,055/- for the purchase of above said policy for his family for the period of 21.11.2022 to 20.11.2023 for floater basic sum insured Rs. 10,00,000/- and it was a cashless policy. It is further alleged that the complainant started suffering from severe pain in hip joint on 12.04.2023 and on dated 18.04.2023 the complainant went to Amar Hospital, Patiala for his treatment then in that Hospital Dr. R.S. Nagpal checked the complainant and afterwards the complainant consulted with the Doctors at Manipal Hospital on dated 28.04.2023 and again with the Doctors of DMC Ludhiana on dated 09.05.2023 and again with the Doctors of PGI Chandigarh on dated 12.05.2023. It is further alleged that on dated 09.06.2023 the complainant visited Max Healthcare to Dr. Jatinder Kumar Singla, Mohali for the treatment of the complainant and the doctor at the hospital saw his previous medical reports and the complainant told the doctor that he is suffering from severe hip pain. The doctor checked him and told that this severe pain in joint hip to you due to Covid-19 infection and gave him medicines but with no benefit to the complainant. It is further alleged that after the doctor's advice the complainant decided to undergo for Core Decompression and Stem Cell Therapy (B Mac) for treatment of his severe pain in hip joint afterwards the complainant decided to use the said insurance policy for treatment of his severe hip joint pain and the said hospital issued a duly stamped certificate for pre-authorization for cashless treatment to the complainant. It is alleged that the OP's rejected the pre-authorization of the complainant on the basis of certificate issued by Max Super Specialty Hospital, Mohali in which it was stated that the complainant drink socially but it is pertinent to mention here that the doctor in his second certificate dated 10.06.2023 clearly stated that the said severe pain in hip joint due to covid infection in 2021, but this time opposite parties also rejected the pre-authorization of the complainant. Thus, the above said act and conduct of the opposite parties falls under the deficiency in service and unfair trade practice on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.-
- To pay a sum of Rs. 31,757/- as Admission to Discharge Expenses and direction may be issued to the opposite parties to allow the pre-authorization for cashless treatment of the complainant.
- To pay Rs. 3,00,000/- for mental shock, pain, agony and Rs. 33,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version taking preliminary objections interalia on the grounds that the complainant has got no locus-standi or cause of action to file the present complaint, the present complaint is not maintainable, the complainant dragged the opposite parties in false litigation, not come with clean hands etc.
4. On merits, it is submitted that the complainant is having a bank account number 1260001052001 in Punjab National Bank, Barnala and the complainant continuously purchased Raksha Health Insurance till 20.11.2021 and the complainant purchased said policy for himself, wife and two sons and before the issuance of said policy the complainant and his family members were medically checked and fit for health insurance purpose. It is alleged that the opposite party No. 1 never approached the complainant and never asked him to buy Star Group Health Insurance policy Gold (for bank customers) and the opposite party No.1 never told that he should buy policy from the opposite parties as the opposite parties have tie up with Punjab National Bank and there will be no break in the policy of the complainant and his previous policy will continue continuously. It is further alleged that the complainant paid sum of Rs.12,055/- for purchase of above said policy for his family for the period of 21.11.2022 to 20.11.2023 for floater basic sum insured Rs. 10,00,000/- and it was a cashless policy. It is further alleged that it is matter that the complainant started suffering from severe pain in hip joint on 12.04.2023 and on 18.04.2023 the complainant went to Amar Hospital, Patiala for his checked the treatment then in that Hospital Dr. R.S. Nagpal complainant and afterwards the complainant consulted with the Doctors at Manipal Hospital on dated 28.04.2023, again with the doctors of DMC Ludhiana on dated 09.05.2023 and again with the doctors of PGI Chandigarh on dated 12.05.2023. It is further alleged that it is matter of record that on dated 09.06.2023 the complainant visited Max Healthcare to Dr. Jatinder Kumar Singla, Mohali for his treatment and the doctor at the hospital saw his previous medical reports and the complainant told the doctor that he is suffering from severe hip pain and the doctor checked him and told that this severe pain in joint hip is due to Covid 19 infection and gave him medicines but with no benefit and the doctor advised to the complainant to undergo for core Decompression and Stem Cell Therapy (B MAC). It is admitted that the insured availed the Star Group Health Insurance Policy Gold (For Bank Customers) through Area Office Covering PANKAJ GOYAL-Self, Spouse, ARUNA GOYAL- PULKIT GOYAL and RAGHAV GOYAL DEPENDANT CHILD for the sum insured Rs. 10,00,000/- vide policy No. P/211223/01/2023/002841 from 21.11.2022 to 20.11.2023 which is port policy and the terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. Moreover it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED". It is submitted that the Policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. It is alleged that the insured preferred claims in the 1st year of policy and the insured has requested for cashless for treatment of AVASCULAR NECROSIS B/L HIP for hospitalization from 09.06.2023 at MAX SUPER SPECIALITY HOSPITAL MOHALI. It is observed from the medical records that the insured-patient has undergone treatment for the AVN which is due to use of alcohol/drug/ intoxication or substance abuse and expense incurred at hospital for treatment of alcoholism, drug or substance abuse and consequences is not admissible as per exclusion- Excl 12. As per 3.Exclusions - Code Excl 12 of the above policy, the Company is not liable to make any payment in respect of expense incurred at hospital for treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof. Hence cashless claim was rejected and conveyed to insured vide letter dated 10.06.2023 of the opposite parties. All other allegations of the complainant are denied. Therefore, there is no deficiency in service on the part of opposite parties and prayed for the dismissal of complaint.
5. Ld. Counsel for complainant on 17.7.2024 has suffered the statement that I do not want to file any rejoinder against the version.
6. To prove his case the complainant tendered into evidence affidavit of complainant as Ex.C-1, copy of certificate for the period 21.11.2022 to 20.11.2023 as Ex.C-2 (11 pages), copy of medical bills as Ex.C-3 (11 pages), copy of rejection letter as Ex.C-4 (4 pages), copy of certificate dated 10.06.2023 as Ex.C-5, copy of treatment as Ex.C-6 and closed the evidence.
7. To rebut the case of the complainant the opposite parties tendered into evidence affidavit of Sumit Kumar as Ex.OPs-1, copy of proposal form as Ex.OPs-2 (2 Pages), copy of policy as Ex.OPs-3 (10 Pages), copy of term and conditions as Ex.OPs-4 (12 Pages), copy of request of cashless as Ex.OPs-5 (4 Pages), copy of certificate of doctor as Ex.OPs-6, copy of prescription slip as Ex.Ops-7, copy of rejection pre-authorization as Ex.OPs-8 (2 Pages), copy of guide lines of IRDA as Ex.OPs-9 (4 Pages) and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on file.
9. It is admitted case of the opposite parties that the insured availed the Star Group Health Insurance Policy Gold (For Bank Customers) through Area Office Covering PANKAJ GOYAL-Self, Spouse, ARUNA GOYAL- PULKIT GOYAL and RAGHAV GOYAL DEPENDANT CHILD for the sum insured Rs. 10,00,000/- vide policy No. P/211223/01/2023/002841 from 21.11.2022 to 20.11.2023 (as per Ex.C-2 & Ex.O.Ps-3.
10. Ld. Counsel for the complainant argued that the complainant purchased the above said policy from the opposite parties as the opposite parties have told the complainant that they have tie up with Punjab National Bank and there will be no break the policy of the complainant and his previous policy will continue. It is further argued that the complainant paid a sum of Rs.12,055/- for the purchase of above said policy for his family for the period of 21.11.2022 to 20.11.2023 for floater basic sum insured Rs. 10,00,000/- and it was a cashless policy. It is further argued that the complainant started suffering from severe pain in hip joint on 12.04.2023 and on 18.04.2023 the complainant went to Amar Hospital, Patiala for his treatment then in that Hospital Dr. R.S. Nagpal checked the complainant and afterwards the complainant consulted with the Doctors at Manipal Hospital on 28.04.2023 and again with the Doctors of DMC Ludhiana on 09.05.2023 and again with the Doctors of PGI Chandigarh on 12.05.2023. It is further argued that on 09.06.2023 the complainant visited Max Healthcare to Dr. Jatinder Kumar Singla, Mohali for the treatment and the doctor at the hospital saw his previous medical reports, the complainant told the doctor that he is suffering from severe hip pain and the doctor checked him and told that this severe pain in joint hip to you due to Covid-19 infection and gave him medicines but with no benefit to the complainant. It is further argued that after the doctor's advice the complainant decided to undergo for Core Decompression and Stem Cell Therapy (B Mac) for treatment of his severe pain in hip joint (as per Ex.C-6) and the complainant decided to use the said insurance policy for treatment of his severe hip joint pain and the said hospital issued a duly stamped certificate for pre-authorization for cashless treatment to the complainant. It is argued that the opposite parties rejected the pre-authorization of the complainant on the basis of certificate issued by Max Super Specialty Hospital, Mohali in which it was stated that the complainant drink socially but it is pertinent to mention here that the doctor in his second certificate dated 10.06.2023 clearly stated that the said severe pain in hip joint due to covid infection in 2021, but this time opposite parties also rejected the pre-authorization of the complainant. Ld. Counsel for the complainant further argued that the opposite parties may be also directed to issue direction to allow the preauthorization for cashless treatment of complainant. The Ld. Counsel for the complainant further argued that the complainant is very poor person and he is unable to take treatment by paying the huge amount claimed by the hospital for his treatment.
11. On the other hand, Ld. Counsel for the opposite parties argued that the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. Moreover it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED". It is further argued that the insured preferred claims in the 1st year of policy and the insured has requested for cashless for treatment of AVASCULAR NECROSIS B/L HIP for hospitalization from 09.06.2023 at MAX SUPER SPECIALITY HOSPITAL MOHALI. It is further argued that it is observed from the medical records that the insured-patient has undergone treatment for the AVN which is due to use of alcohol/drug/ intoxication or substance abuse and expense incurred at hospital for treatment of alcoholism, drug or substance abuse and consequences is not admissible as per exclusion- Excl 12 and as per 3.Exclusions - Code Excl 12 of the above policy the Company is not liable to make any payment in respect of expense incurred at hospital for treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof, hence cashless claim was rejected and conveyed to insured vide letter dated 10.06.2023 of the opposite parties.
12. We have carefully gone through the facts and evidence produced by both the parties. The specific plea in the present case of the opposite parties for the rejection of claim of the complainant is that it is observed from the medical records that the insured-patient has undergone treatment for the AVN which is due to use of alcohol/drug/ intoxication or substance abuse and expense incurred at hospital for treatment of alcoholism, drug or substance abuse and consequences is not admissible as per exclusion- Excl 12. On the other hand, the complainant to rebut the allegation of the opposite parties has placed on record copy of certificate of Dr. Jatinder Kumar Singla Ex.C-6 vide which it is mentioned that “THIS IS TO CERTIFY THAT PATIENT PANKAJ GOYAL PRESENTED TO ME WITH PAIN B/L HIP SINCE 12TH APRIL 2023. HE WAS DIAGNOSED WITH AVN STAGE IIIA RIGHT HIP AND IC LEFT HIP.1ST CONSULTATION WAS DONE AT AMAR HOSPITAL WITH DR.R.S NAGPAL ON 18TH APRIL 2023. FURTHER CONSULTATIONS WERE DONE ON 28TH APRIL 2023 AT MANIPAL HOSPITAL, DMC LUDHIANA ON 9TH MAY 2023 AND PGI CHANDIGARH ON 12TH MAY 2023. PREVIOUS CONSULATION RECORDS, INVESTIGATIONS SUPPORTING DI|AGNOSIS AND TREATMENT ARE ATTACHED. ETIOLOGY OF AVN IS IDIOPATHIC IN MOST PATIENTS. PATIENT IS NON SMOKER AND DRINKS SOCIALLY. PATIENT PLANNED FOR CORE DECOMPRESSION AND STEM CELL THERAPY (B MAC)”. So, from the above said certificate of treating doctor it is not established that the insured has undergone for the treatment of AVN which is due to use of alcohol/drug/ intoxication or substance abuse. The same certificate has also placed on record by the opposite parties i.e. Ex.O.Ps-6. Moreover, there is nothing on record from the side of opposite parties that they have verified the above said medical records of the insured from the doctors/hospital. The opposite parties have also failed to place on record any cogent evidence to rebut the claim of the complainant. Therefore, it is established that the opposite parties have rejected the claim of the complainant on such unreasonable and flimsy grounds.
13. Further, the Ld. Counsel for the complainant argued that the terms and conditions were not supplied to the complainant alongwith policy, therefore the same are not part of contract. We have carefully gone through the policy placed on record by the complainant Ex.C-2 which are not containing the terms and conditions of the policy in question. On the other hand, the opposite parties have failed to place on record any postal receipt or any document to prove that they have supplied the terms and conditions of the policy to the insured/complainant alongwith policy in question. Moreover, the opposite parties have also placed on record the insurance policy Ex.O.Ps-3 which are also not containing the terms and conditions of the insurance policy in question. Therefore, the terms and conditions on which the opposite parties have relied upon are not part of the contract. The Hon'ble Supreme Court of India titled Modern Insulators Limited Versus Oriental Insurance Company Limited reported in 2000(1) CPC-596 in which Hon'ble Supreme Court held that “As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclose to the appellant, respondent cannot claim the benefit of the said exclusion clause.” The Hon’ble Supreme Court of India (2019) 6 SCC 212 in case titled Bharat Watch Company Through its Partner Vs National Insurance Company Limited held that “Conditions of exclusion under policy document not handed over to insured by insurer and in absence of insured being made aware of terms of exclusion, held, it is not open to insurer to rely upon exclusionary clauses”. Ld. Counsel for the complainant also relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims.
The relief sought by the complainant in his complaint regarding directed the opposite parties to allow the preauthorization for further treatment cashless, the Insurance Companies indemnify the losses the preauthorization has been rejected by the opposite parties then it very much difficult to determine the loss without taking the treatment. The complainant can approach the opposite parties for reimbursement of claim by submitting the medical record, bills and receipts etc. The complainant can take the treatment and submit the claim form alongwith required documents with the opposite parties for reimbursement.
14. From the above discussion, it is proved that the claim of the complainant/insured was rejected by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties.
15. The complainant to prove his claim has placed on record copy of bill as Ex.C-3 (containing 11 pages) which shows that Rs. 33,756/- has been spent on the treatment of the complainant in the above said hospital. However, the complainant in the present complaint has claimed Rs. 31,757/-.
16. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 33,756/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. If the complainant will take the further treatment which is denied by the opposite parties for cashless then the opposite parties are directed to consider the reimbursement claim of complainant under policy in question. The opposite parties are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
20th Day of September, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
(Navdeep Kumar Garg)
Member
