District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 218/2022.
Date of Institution:21.04.2022.
Date of Order:.26.07.2023.
Alka Mehra aged about 42 years W/o Shri Kuldeep Mehra, R/o House No. 540, Sector-18, Faridabad – 121002.
…….Complainant……..
Versus
M/s. Star Health and Allied Insurance Company Limited, Branch Office: Shop NO.1, Ist floor, Krishna Palace, Near Ajronda Chowk, Faridabad through its Branch Manager/Authorized signatory.
…Opposite party
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
PRESENT: Sh. Nishant Nagar, counsel for the complainant.
Sh. O.P.Gaur, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant had availed the medical policy of the opposite arty vide policy No. P/161100/01/2021/022162 valid from 12.10.2020 to 11.10.2021 for herself and for her husband. On 19.07.2021, the complainant suffered from high fever and vomiting and approached Chawla Nursing Home, J-150, Rajouri Garden, New Delhi where the doctor of said hospital examined the complainant and advice for admission. Acceding to the advice of the said doctor the complainant admitted
vide admission No. 2710/21 on 19.07.2021 and tests were done and found that the complainant was suffering from typhoid. The doctors of said hospital managed the complainant and discharged on 23.07.2021. However, the said hospital administration duly informed the opposite party for providing cashless facility but the opposite party declined the same. The said hospital issued a bill No.. 2557 dated 23.07.2021 for Rs.36,360/- and the complainant had to pay the said billing amount to the said hospital. Thereafter the complainant submitted all requisite documents i.e. final bill, discharge summary etc. with the opposite party and claim was lodged vide No. 3016495. Thereafter the complainant contacted the concerned officers/officials of the office of the opposite party and requested several times telephonically, but there was no satisfactory response from the opposite party and the concerned officer/official avoided to accede to the legitimate request of the complainant. The complainant sent legal notice dated 14.03.2022 to the opposite party through registered post but all in vain. 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) pay the amount of Rs.36,360/- spent on treatment alongwith interest @ Rs.18% p.a. to the complainant..
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 31,000 /-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 insured had availed the Family Health Optima Insurance Plan vide policy No. P/161100/01/2021/022162 for the period 12.10.2020 to 11.10.2021 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 before this Commission. It was submitted that the complainant had suppressed and concealed the true vital and material facts and information in lodging the present complaint inter alia that the complainant viz, Smt. Alka Mehravital signs and general condition were stable throughout hospitalization period i.e.19.07.2021 to 23.07.2021. The complainant – patient was “Hemodynamically stable and the investigation reports were within the normal limit”. Therefore, the insured patient could have been managed as an “Outpatient” and no hospitalization was warranted. Hence, the hospitalization falls under Exclusion Clause No.4. The repudiation and/or denial of the claim in accordance with terms and conditions of contract can, by no stretch, be termed as “deficiency in service” as envisage din Consumer Protection Act. 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–M/s. Star Health and Allied Insurance Company Ltd. with the prayer to: a) pay the amount of Rs.36,360/- spent on treatment alongwith interest @ Rs.18% p.a. to the complainant. b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .c) pay Rs. 31,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW-1/A – affidavit of Alka Mehra, Marck-C-1 - insurance policy,, MarkC-2 &
3 – Identity cards, Mark C-4 – Discharge file, Ex/C-5 (P1 to P8) – receipt, bill book , tests, Ex.C-6 – legal notice,, Ex.C7 & 8 – postal receipts. Ex.C-9 – letter dated 13.12.2021.
On the other hand, counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Shri Sumit Sharma, Senior Manager, Star Health & Allied Insurance Company Ltd., 2nd floor, Daily Tej Building, 8-B, Bahadur Shah Zaffar Marg, New Delhi, Annexure R/1 – Proposal form, Annexure R/2 – insurance policy containing terms & conditions,, Annexure R/3 – Declaration letter, Annexure R/4 –Claim Form, Annexure R/5- Discharge summary, Annexure R/6 – Prescription by Dr, Preet Singh Chawla, Annexure R/7 – Test report, Annexure R/8 (colly) – bill book, Annexure R/9 – Repudiation letter dated 31.08.0221,Annexure R/10 – Repudiation letter dated 22.09.2021, Annexure R/11 – Bill Assessment Sheet.
6. In this case, the date of admission of patient is 19.07.2021 and date of discharge is 23.07.2021. The complainant suffered from high fever and vomiting and approached Chawla Nursing Home, J-150, Rajouri Garden, New Delhi, where the doctor of said hospital examined the complainant and advice for admission. Acceding to the advice of said doctor the complainant admitted vide admission No. 2710/21 on 19.07.2021 and tests were done and found and found that the complainant was suffering from typhoid vide Ex.C4. 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 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.2200/- 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. File be consigned to the record room.
Announced on: 26.07.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
