District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.73/2023.
Date of Institution:01.02.2023.
Date of Order: 08.02.2024.
Devi Singh, resident of House No.10, near Khillu Saini Kata Tehsil Ballabgarh, District, Faridabad.
…….Complainant……..
Versus
1. M/s. Star Health and Allied Insurance co. Ltd., Shop NO.1, FF Krishna Palace, Above Decora Car Accessories, Ajronda Neelam road, Faridabad, Haryana – 121001 Through its authorized person.
2. M/s. Star Health and Allied Insurance Co. Ltd., Registered corporate office-1, New Tank Street, Valluvar Kottam High road, Nungambakkam Chennai – 600034 through its authorized person.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Deepak Sharma , counsel for the complainant.
Sh. O.P.Gaur , counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant had already taken the family health Optima Insurance plan on 28.03.2021 with his family members namely Rajni Devi, Bhawna Saini, Lokesh Saini, Akash Saini vide policy NO. P/161217/01/2022/012349. Valid from 28.03.2022 to 27.03.2022 for the insured sum of Rs.5,00,000/- While the complainant was coming from Sector-12 Faridabad towards his home ultimately the complainant met with an accident on dated 30.07.2022 near Ambedkar Chowk at about 11:30a.m. due to bike sudden a bull came in front of bike and hit with bull and fall on road and got injury and bilateral ear pain with bleeding with deep lacerated wound on chin with bleeding multiple abrasion over knee and hands and in this regard the complainant was taken the first aid in Centre Hospital, Plot NO. 204-205, Yadav Colony, Mohna road, Ballabgarh District Faridabad and lateron the complainant was admitted in Sunshine Hospital, Sector-64, Sahupura road, Faridabad on 30.07.2022 and was discharged on 02.08.2022. The hospital raised the bill of Rs.25,983/- and the said amount was paid by the complainant form his own pocket although the said amount was to be paid by the opposite parties to the hospital. The Sunshine Hospital had given the intimation of the patient namely Lokesh Saini to the opposite parties by way of sending the email on dated 31.07.2022 and in this regard the said reply was send by the opposite parties through their mail on dated 1.08.2022. The complainant had submitted the relevant documents to the hospital and the hospital submitted all the documents to the opposite parties for getting the mediclaim amount but the opposite parties intentionally and knowingly rejected the claim of the complainant on 30.08.2022.The complainant sent legal notice dated 23.12.2022 to the opposite parties but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) make the mediclaim amount of Rs.25,983/- in respect vide policy No. P/161217/01/2022/012349 w.e.f 28.03.2022 to 27.03.2023 alongwith interest at the rate of 18% p.a. to the complainant which was paid by the complainant form his own pocket.
b) pay Rs.50,000/- as compensation for causing mental agony and harassment .
c) pay Rs.22,000/- as litigation expenses to the complainant.
2. Opposite parties Nos.1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 & 2 refuted claim of the complainant and submitted that the insurance company have not undertaken to provide insurable service to the insured within the terms & conditions of the Family Health Optima Insurance Plan” No. P/161217/01/2022/011735 for the period 18.03.2022 to 17.03.2023 out of the scope of the medi insurance policy and/or exclusion clause or violation, breach and infringing of the terms and conditions of the medi insurance policy. The isrued had obtained the Family Health Optima Insurance Plan No. P/161217/01/2022/011735 for the period 18.03.2022 to 17.03.2022 for coving the family. The complainant had accepted the medi policy agreeing and being fully aware of such terms and conditions, exclusions and warranties, which were expressly and explicitly explained to the insured on behalf of the insurance company, resultantly the insured agreed thereto. Thereafter, the insured executed and signed proposal, duly issued also in this behalf to the insured. The Preamble of the policy clearly states the proposal, declaration and other documents if any given by the proposer form the basis of the policy of insurance subject to terms, conditions, exclusion and definitions contained herein or endorsed or otherwise expressed hereon, the Company undertakes if the insured person shall contract any disease or suffer from any illness or sustain any bodily injury through accident and if such disease or injury shall require the insured person, upon the advice of the duly Qualified Physician/Medical Specialist/Medical Practitioner or duly qualified surgeon to incur hospitalization expenses for medical/surgical treatment at any Nursing Home/hospital in India as herein defined as an inpatient the company will pay to the insured person the amount of such expenses as were reasonably and necessarily incurred in respect by or on behalf of the insured person upto the limits indicated”. The complainant neither had any cause of action nor locus standi to file the present complaint. It was submitted that the insurance company received claim on 29.08.2022 enclosing therewith discharge summary for the period 30.07.2022 to 02.08.2022 issued by Sunshine Hospital, Sector-64, Sahupura Unchagaon Road, Ballabgarh pertaining to hospitalization of patient – Lokesh Saini aged about 21 years old alongwith final bill to the tune of Rs.25,983/-. As a result, the insurance company carefully and thoroughly investigated into the subject claim on the basis of the available claim document lodged by the complainant. Having examined the discharge summary, the following was observed as under:
- The patient – insured got first medical aid in Central Hospital, Yadav colony, Mohana road, Ballabgarh where NCCT Head was done (dated 30.07.2022). As per noting in the discharge summary, the patient came to sunshine Hospital, Sector-64, Sahupura Unchagaon Road, Ballabgarh on 30.07.2022 at 4.40 p.m. with history of road side accident while on bike.
- the patient was diagnosed with fracture with right condyle of mandible fracture temporal bone bilateral of ear auditory.
- As per condition h. In case of emergency hospitalization information to be given within 24 hours after hospitalization however insured was hospitalized in Sunshine Hospital which was already excluded provider hospital on 20.05.2022.
- As per internal verification, patient was admitted in this hospital after taking first aid from central Hospital. So, it was clear that the patient was admitted in this hospital which was excluded provider.
In furtherance of process of the subject claim, the insurance company observed that unshine Hospita, Sector-64, Sahupura Unchagaon Road, Ballabgarh was not the “Network Provider Hospital;” of Star Health and Allied Insurance Company Ltd., falling under the Exclusion clause under Chapter-3 – Exclusion, Clause-11 of the Family health Optima Insurance Policy No. P/161217/2022/012349 for the period 28.03.2022 to 27.07.2023. Accordingly, the insurance company arrived at its decision in treating the subject claim as “Repudiated” vide its letter of repudiation dated 26.09.2022 which decision could be termed unconscionable at all. Opposite parties Nos.1 & 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. We have heard learned counsel for the parties and have gone through the record on the file.
4. In this case the complaint was filed by the complainant against opposite parties–Star health and Allied Insurance Company with the prayer to: a) make the mediclaim amount of Rs.25,983/- in respect vide policy No. P/161217/01/2022/012349 w.e.f 28.03.2022 to 27.03.2023 alongwith interest at the rate of 18% p.a. to the complainant which was paid by the complainant form his own pocket. b) pay Rs.50,000/- as compensation for causing mental agony and harassment . c) pay Rs.22,000/- as litigation expenses to the complainant.
To establish his case the complainant has led in his evidence, Ex.CW-1/A – affidavit of Shri Devi Singh, Ex.C-1 – letter, Ex.C-2 - prescription, Ex.C-3 – Discharge summary, Ex.C4 – test, Ex.C-5 to C7 – receipts,
Ex.C-8 – Final Bill,, Ex.C-9 & 10– emails, Ex.C-11 – Status of Intimation,, Ex.C-12 – legal notice,, Ex.C-13 & 14 – postal receipts.
On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties Ex.RW1/A – affidavit of Shri Suit Sharma, Senior Manager, Star Health & Allied Insurance company Ltd., 2nd floor, Dailly Tej Building, 8-B, Bahadur Shah Zaffar Marg, New Delhi,, Annx.R/1 – Family Health Optima Insurance Plan,, Annx.R-2 – Portability form, Annx.R/3 - letter dated 16.03.2022, Annx.R/4 – Master Circular on Standardization of Health Insurance Products,, Annx.R/5 – application form, Annx.R/6 –Discharge summary, Annx.R/7 – Final bill,, Annx.R/8 – repudiation letter dated 26.09.2022, Annx.R/9 – copy of details sheet regarding excluded provider, Annx.R/10 – bill assessment sheet.
5. In this Lokesh aged 21 years met with an accident while riding on his bike and hit with bull, thus, sustained multiple injuries on his body, for which the complainant has taken first aid in Centre Hospital, Yadav Colony, Mohna road, Ballabgarh and later on got himself admitted in Sunshine Hospital, Sector-64, Sahpura Road, Faridabad and was discharged on 02.08.2022. It has also been contended that the hospital raised the bill of Rs.25,983/- which was paid by the complainant. It has further been averred that the said hospital had given intimation to the opposite parties by way of sending e-mail on 31.07.2022 and the opposite parties send reply through their mail on 01.08.2022. Sunshine Hospital. Sector-64, Sahupura Unchagaon Road, Ballabgarh was not the “Network Provider Hospital” of Star Health and Allied Insurance company Ltd. Falling under the Exclusion clause under Chapter-3 - Exclusions Clause-11 of the Family Health Optima Insurance policy NO. P/161217/01/2022/012349 for the period 28.03.2022 to 27.07.2023. Accordingly, the insurance company arrived at its decision in treating the subject claim as “Repudiated” vide its letter of repudiation dated 26.09.2022 vide Annx.R/7 which decision cannot be termed unconscionable at all.
On the other hand, counsel for the complainant has exhibited email dated 01.08.2022 vide Ex.C-10 by Customer care of Star health and Allied Insurance Co. Ltd. in which it has been mentioned that “ The hospital is listed under Excluded Providers – Any expenses incurred towards treatment in this hospital is not admissible for claim. However, in case of life threatening situations of following an accident, expenses upto the stage of stabilization are payable but not the complete claim. This is for your kind information.”
6. Keeping in view of the above submissions as well the evidence led by the parties, the Commission is of the opinion that the repudiation done by the opposite parties are not justified. Resultantly, the complaint is allowed.
7. Opposite parties Nos.1 & 2, jointly & severally, are directed to process the claim of the complainant and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing complaint till its realization The opposite parties Nos.1 & 2 are directed to pay Rs.5500/- as compensation on account of mental tension, agony and harassment alongwith Rs.5500/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. File be consigned to the record room.
Announced on: 08.02.2024. (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
