District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.73/2020.
Date of Institution: 04.02.2020.
Date of Order: 31.10.2022.
Mittar Sain R/o Shop No. 36, 2nd part, Anaz Mndi, Ballabgarh, District Faridabad.
…….Complainant……..
Versus
1. M/s. Star Health and Allied Insurance Co. Ltd., Himalaya House 23, Kasturba Gandhi Marg, New Delhi – 110 013 through its MD/Director/manager.
2. M/s. Star Health & Allied Insurance company Limited, service through: A-18 Neelam Bata Road, Nehru Ground NIT, Faridabad through its Branch Manager/Authorised Signatory.
…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: Ms. Neena Sharma, counsel for the complainant.
Sh. Chahat Gaur, counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant, his son namely Ghanshyam, his wife Smt. Seema Mittal and daughter namely Vaishali obtained the mediclaim insurance policy “Family Health Optima Health Plan” bearing its policy No. P-161116/01/2019/006075 and the same was further renewed for further period of one year vide Renewal Endorsement No. P/161217/01/2019/002029 valid 15.01.2019 to midnight of 14.01.2020 for the total basic floater sum insured of Rs.5,00,000/-. Scheme description 2A + 3C in the name of the complainant and his family members. The complainant had already paid the amount of yearly premium to the opposite parties. The complainant’s son namely Shri Ghanshyam became sick due the problem of rashes in face region itching & headache so Shri Ghanshyam was admitted in metro Health Institute with Multispecialty, sEcator-16A, Faridabad on 07.07.2019 and the complainant’s son remained under treatment in the said hospital upto 09.07.2019 as indoor patient. The complainant informed the opposite parties regarding the hospitalization of his son in the said hospital. The said hospital authorities raised the bill dated 9.7.2019 amounting to Rs.20,760/- and accordingly the complainant paid total amount of Rs.20,760/- to metro heart Institute with Multispecialty, Sector-16A, Faridabad on 09.07.2019 out of his own pocket. Besides this the complainant also spent an amount of Rs.5000/- on the medicines extra. As per the instructions and directions of the opposite parties the complainant to deposit the concerned treatment records i.e. original bills of the hospital, cash receipts, investigation reports etc. with the opposite parties and the opposite parties allotted the claim NO. 032808 to the complainant. Thereafter the complainant requested the opposite parties to reimburse the amount of Rs.20,760/- to the complainant but the opposite parties avoided to the legitimate request of the complainant. Ultimately the complainant sent the letter dated 12.07.2019 to the opposite parties thereby requesting the opposite parties to reimburse the amount of Rs.20,760/-. The said letter as duly received by the opposite parties but neither the opposite parties had sent any reply of the said letter nor reimbursed the amount of Rs.20,760/- to the complainant. The complainant sent legal notice dated 03.09.2019 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 payment of treatment amount of Rs.20,760/- alognwith interest @ 24% p.a. from the date of due till upto date.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the insured had availed the Family Health Optima Insurance Plan vide policy No. P/161217/01/2019/002029 valid from 15.01.2019 to 14.01.2020 for covering the family for the sum insured of Rs.5,00,000/-. The complainant had accepted the medi policy agreeing and being fully aware of such terms and conditions, pursuant to execution, signing and furnishing the proposal form in this behalf. The complainant neither had any cause of action nor locus standi in lodging the present complaint before this Forum. It was submitted that the complainant had suppressed the true, vital and material facts & information from this Forum in lodging the complaint. As a sequel of brief history of the matter and for the purposes of facilitation of the true, vital and material facts & information by this Forum, it was submitted that the insurance company received a “Request for cashless hospitalization dated 07.07.2019 from Metro heart Institute with Multi Specialty, Faridabad in respect of hospitalization of the patient – Ghanshyam. As per the initial medical papers, the patient – Ghanshyam was diagnosed as a case of “Acute Allergice”. Accordingly, the insurance company sought the requisite medical documents and information from the hospital vide its query letter dated 08.07.2019 as under:-
i. Certification form the Trating doctor stating the cause of aCute Alelrgic.
ii. Previous history of similar episodes/hospitalization.
iii. Provide indoor case paper sheets and progress sheets.
It was further submitted that on arranging the initial treatment papers by the hospital, the insurance company again examined the same and observed that vitals were stable, all investigations were also normal and there was no evidence of shock. Hence, the patient could be managed on OPD basis instead of hospitalization. Accordingly, the insurance company declined the cashless request vide its letter dated 09.07.2019 addressed to the insured. However, at the same time, the insurance company notified in its letter dated 09.07.2019 by enclosing claim form with advise to lodge regular claim alongwith the original discharge summary and related medical documents and final bill. At later date, the mediclaim was lodged in the name of the patient – Ghanshyam without tendering claim form, however, arranging the discharge summary, lab tests and final bill only to the tune of Rs.19,800/-. In consideration of the medical treatment record and the attending facts, the hospitalization of patient for investigation and test purposes was unwarranted without any active disease and thereafter follow up thereto. As a matter of medical instances and protocol, since there was no active disease and diagnosis, so there was no follow up treatment after discharge on 09.07.2019. In nutshell, the hospitalization merely meant for investigations and test purposes was unwarranted and unjustified, which investigations and tests could even on OPD basis. It was further submitted that since the mediclaim insurance policy provides cover for hospitalization expenses incurred by the insured for the purposes of medical and/or surgical treatment on account of disease only, hence the insurance company had repudiated the subject claim vide its letter dated 18.07.2019. As such, the decision arrived at by the insurance company in treating the subject claim as repudiated could not be termed unconscionable at all. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Shri Chahat Gaur, counsel for opposite parties Nos.1 & 2 has made a statement that reply already filed on behalf of opposite party No.1 be read as reply of opposite party No.2.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties–Star Health and Allied Insurance Co. Ltd. with the prayer to: a) make the payment of treatment amount of Rs.20,760/- alognwith interest @ 24% p.a. from the date of due till upto date. b)pay Rs. 50,000/- as compensation for causing mental agony and harassment . c) pay Rs. 11,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Mittar Sain,, Ex.C-1 – policy, Ex.C-2 – Final Bill break up, Ex.C-3 – Admission Advance Receipt, Ex.C-4 – letter regarding request for reimbursement amounting to Rs.20,760/- only treatment expenses, Ex.C-5 – legal notice,, ex.C-6 – 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 Sumit Sharma, senior Manager Star Health & Allied Insurance company Ltd., Ist floor, Himalaya House, 123 Kasturba Gandhi Marg, New Delhi,, Annexure R-1- Common Proposal Form, Annx.R-2 – Insurance policy, Annx.R-3 - letter, Annx.R-4 – Request for Cashless hospitalization for medical insurance policy, Annx.R-5 – Star Medical Officer FVR (Pan India) – Revised,, Annx.R-6 – Query on Authorization for cashless treatment,, Annx.R-7 – Denial of preauthorization request for cashless treatment,, Annx.R-8 – Discharge summary, Annx.R-9 – Test, Annx.R-10 – Daily plan of care for doctor,, Annx.R-11 – Final bill, Annx.R-12 – Repudiation letter, Annx.R-13 – Bill assessment sheet – hospital payment.
7. After going through the evidence led by the complainant there are medical bills and the investigations report on the file and this is the actual fact the patient was admitted in the Metro Hospital. On the other hand, opposite parties have failed to establish their case. They can not deny the mediclaim when the complainant has the valid insurance policy.
8. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 31.10.2022 (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.
