District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.228/2023.
Date of Institution: 31.03.2023.
Date of Order: 27.09.2024.
Mr. Vikas Thukral S/o Shri Chander Bhan Thukral R/o H.No. 986, Sector-17, Faridabad (Haryana).
…….Complainant……..
Versus
Star Health & Allied Insurance Company Limited having its branch office at: Shop No.1, First floor, Krishna Palace, Above Decora Car Accessories, Ajronda Neelam Road, Faridabad- 121001 through its Branch Manager.
Also at:
Star Health & Allied Insurance Company Limited having its branch office at : Plot No.A-6, Part-A, 2nd floor, Nehru Ground, Neelam Bata Road, NIT, Faridabad, Haryana – 121001 through its Branch Manager.
…Opposite party……
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: Shri Ankit Sharma, counsel for the Complainant.
Shri Abhishek Kumar, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant upon the representations and warranties of the authorized insurance agent of the opposite party regarding the genuineness and reliability of mediclaim insurance of opposite party company availed the renewal insurance of Mediclaim Policy under Family flotter Plan vide policy No. P/161217/01/2021/008987 in the year 2021 after duly paying the applicable insurance premium of the said policy to the opposite party as per their demand. The said policy of mediclaim including the complainant covered his wife and two minor sons. The said policy was valid from 13.03.2021 to 12.03.2022.On 12.06.2021, the complainant’s youngst minor son namely Master Preatham Thukral while running accidently slipped on the floor and met with a fracture of humerus condyle (fracture of left hand elbow) and was taken for day care treatment with Dr. Madhukan M.B.B.S, M.S. (Ortho) of “The Orthopaedic Clinic”, SCO-2, Sector-16A, Faridabad (Haryana). The incident of aforesaid fracture of the complainant’s minor son Master Pratham Thukral was duly notified immediately by the complainant to the opposite party vide a claim intimation No. CLI/2022/161217/2756633 and which was also duly acknowledged by the opposite party vide their SMS dated 17.06.2021 to the complainant. The complainant incurred the total expenses of Rs.8378/- which however, was erroneously totaled in the claim form as Rs.7478/- on the fracture treatment of his minor son Master Pratham Thukral, which was inclusive of professional fee and expense of Rs.6100/- paid to the Orthopaedic Clinic (Dr. Madhukant), Rs.800/- paid to Swanya Imaging Center for X-ray, Rs.478/- paid to Ramji Medicos towards the purchase of medicines and lastly Rs.1000/- paid to Metro Heart Institute for the final X-ray carried out by the complainant as per the instruction of “The Orthopaedic Clinic” for checking the proper joining of the bone of Master Pratham Thukral. It was further submitted that all the abovesaid expenses including towards X-ray and medicines were incurred by the complainant out of his pocket as per the instructions/prescription of Dr. Madhukan Orthopaedic and against all these expenditures all the concerned medical/para medical agencies/medical Stores had issued their respective original invoice(s) to the complainant. Thereafter the complainant through the authorized insurance agent of the opposite party received an intimation dated 21.09.2021 regarding submission of X-ray images alongwith duly filled claim form Part-A and claim form Part-B. The complainant for claiming the aforesaid legal expenses incurred on account of the medical treatment of his son Master Pratham Thukral, as per the requirement of the opposite party, duly filled the claim form-Part-A and claim form Part-B dated 25.09.2021 and 27.09.2021 respectively in the standard format of the opposite party and attached all the original invoices/bills of the claim totaling of Rs.8378/- alongwith original X-rays & reports (which however, was erroneously totaled in the claim form as Rs.7478/-) as per the requirement of the opposite party so that the legitimate claim of the complainant might be processed accordingly and the reimbursement of the abovesaid expenses might be made at the earliest to the complainant. All the original bills and x-ray certificates alongwith the duly filled original claim forms were into the possession of the opposite party till date and on which the opposite party had chosen not to act without any reasonable cause. However, on 27.10.2021, the complainant surprisingly received a SMS from the opposite party regarding the settlement of the aforesaid claim No. 2756633 of the complainant to the extent of Rs.2278/- without furnishing any further details of such deficit claim amount and without furnishing any further details as to on which basis the claim amount was finalized by the opposite party. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) notice of the complaint be sent to the opposite party and they be ordered and directed to collectively reimburse the amount of Rs.8378/- immediately paid by the complainant on the treatment of his minor son Master Pratham Thukral alongwith upto date interest @ 18% p.a. from the date of payment by the complainant till the date of actual realization by the complainant.
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 1,00,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the proposer/complainant Mr. Vishal Thukral availed the Star Comprehensive Insurance Plan vide policy No. P/161217/01/2021/008987 covering Mr. Vishan Thukral – Self (all complications related to the surgeries of procedures performed previously – CBE-Cicumsion), Mrs. Nisha Thukral – Spouse (Calculous disease of urinary system), Tejas Thukral and Pratham Thukral – dependent child (No. PED declared) for the basic floater sum insured of Rs.5,00,000/-. The opposite party insurance company issued the policy to the insured persons on the basis of information disclosed by the proposer in the proposal form by believing in proposer and assuming that the information disclosed by proposer in the proposal form to be true based on the principle of Utmost Good faith, without any Pre Medical Screening. It was fresh policy taken by the proposer first time form the opposite party insurance company on 13.03.2021. The complainant neither had any cause of action or locus standi to file the present complaint. It was submitted that the insured was admitted in Orthopaedic Clinic at Faridabad on 12.06.2021 to 05.07.2021 for the treatment of Sternoclavicular Joint displaced and submitted final clam for reimbursement of expenses incurred on the treatment of the insured. On scrutiny of medical documents, it was observed that:- As per the letter from 12.06.2021 from Orthopaedic Hospital, insured was having complaints of swelling and was diagnosed with Sternoclavicular joint displaced. On the basis of the submitted documents, opposite party insurance company raised a query vide letter dated 21.09.2021 and 06.10.2021 requesting insured to submit the requisite documents in order to process the claim further. The details of the documents were as follows:
- Kindly submit X-ray images.
-Submit detailed line of management.
- kindly submit part A of the claim form duly completed in all respects and signed by the insured on the second page (submitted part A of the claim form had not been signed).
-Part B of the claim form duly completed in all respects by the treating doctor and signed by him with his seal and hospital seal and also by the insured. On the basis of the submitted medical documents, it was observed by the opposite party insurance company that: as per the X-ray left elbow A.P.& LAT views, there was incomplete old to subacute fracture of humerus condyle with periosteal reaction and periarticular soft tissue swelling. Hence, the opposite party insurance company had settled the amount of Rs.2278/- vide bill assessment sheet dated 22.10.2021 after reasonable deductions as per the terms and conditions of the policy and was paid to the insured in the bank account vide UTR NO. N299211687462283 dated 26.10.2021. The opposite party insurance company had already settled the amount of Rs.2278/- as per the terms and conditions of the opposite party after deducting the non payables. Repudiation and/or denial of claim in accordance with terms and conditions of contract. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party– Star Health & Allied Insurance Company Limited with the prayer to: a) notice of the complaint be sent to the opposite party and they be ordered and directed to collectively reimburse the amount of Rs.8378/- immediately paid by the complainant on the treatment of his minor son Master Pratham Thukral alongwith upto date interest @ 18% p.a. from the date of payment by the complainant till the date of actual realization by the complainant. b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 1,00,000 /-as litigation expenses.
To establish his case, the complainant has led in his evidence Ex.CW1/A- affidavit of Vikas Thukral, Ex.CW-1/A - policy,, Ex.CW-1/B - prescription dated12.06.2021, Ex.CW-1/C – acknowledgement of opposite party, Ex.CW-1/D – intimation letter dated 21.09.2021, Ex.CW-1/E – claim form – Part A, Ex.CW-1/F – Claim form – Part B, Ex.CW-1/G & H – photos, Ex.CW-1/I - X-ray report of Metro Hospital, Ex.CW-1/J – receipt, Ex.CW-1/K – bill, Ex.CW-1/L & M– GST Invoice, Ex.CW-1/N – Receipt, Ex.CW-1/O – bill, Ex.CW-1/P – SMS, Ex.CW-1/Q 0 legal notice,, Ex.CW-1/R – postal receipts, Ex.CW-1/S – track consignment,, Ex.CW-1/T - - prescription, Ex.CW-1/U – bill,
On the other hand counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party vide Ex.RW1/A – affidavit of Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd., 2nd floor, Daily Tej Building, 8-B, Bhadur Shah Zafar Marg, New Delhi,, Ex.R-1 – Common proposal form,, Ex.R-2 - insurance policy,, Ex.R-3 – terms and conditions,, Ex.R-4 - Claim form Part-A,, Ex.R-5 & 6– prescriptions, Ex.R-7 – report of Metro Heart Institute with Multispeciality, Ex.R-8 – bill, Ex.R-9 – receipt,, Ex.R-10 – intimation letter dated 21.09.2021, Ex.R-11 – reminder letter dated 06.10.2021,, Ex.R-12 – bill assessment sheet – member payment, Ex.R/13 – Master circular on standardization of Health Insurance Products
6. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite party is directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order, subject to submission of documents vide Ex.R-10 & R-11 and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite party is also directed to pay Rs.3300/- as compensation for causing mental agony & harassment alognwith Rs.2200/- 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. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 27.09.2024 (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.
