District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.442/2020.
Date of Institution: 26.11.2020.
Date of Order: 29.09.2022.
Diwan Singh s/o Sh. Daryab Singh, R/o HNO.39, Rao Colony, Ahirwada, Ballabgarh, Faridabad (Haryana) – 121004. Aged: 48years Mobile NO. 09810678093 Aadhar card No. 3645 9637 9683.
…….Complainant……..
Versus
1. M/s. star Health and Allied Insurance Company Limited Sri Balaji Complex, 15, Whites Road, Chennai – 600 014.
2. M/s. star Health and Allied Insurance Company Limited Corporate Grievance Department, No.1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai – 600 034.
3. Branch Manager, M/s. Star Health and Allied Insurance company Limited Branch office: Shop No.1, FF, Krishna Palace, Above Decora Car Assessories, Ajronda-Neelam Road, Faridabad – 121001.
…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. V.P.Singh, counsel for the complainant.
Sh. Chahat Gaur and O.P.Gaur, counsel for opposite parties.
ORDER:
The facts in brief of the complaint are that the complainant had obtained the mediclaim policy Family Health Optima Insurance -2017-MED-PRD-051 bearing NO. P/161217/01/2020/006384 read with policy NO. P/161217/01/2019/002655 under product namely Family Health Optima Insurance Co, Ltd. Through Intermediary Code/Name: BA0000281145/Mr. Abhinav Goyal, SM code/Name: SH55655/Mr. Lakhan Lal by paying/depositing the premium for the period of insurance from 17.03.2020 to midnight of 16.03.2021 in his name. All of sudden on account of illness complainant namely Diwan Singh admitted in the panel/approved hospital i.e. Metro Heart Institute with Multi-specialty Hospital, Sector-16A, Faridabad on 18.03.2020 at 09:19 AM under IPD No. 20/07427 as indoor patient and diagnosed the patient of AFI. It was pointed out that despite submission of mediclaim policy for cashless treatment at the time of admission in the hospital as asked by the hospital, but the opposite parties denied the cashless facility to the complainant vide letter dated 18.03.2020 by giving wrong and false excuse, further the complainant gone through required tests and medical treatment of his disease as a indoor patient form 18.03.2020 ato20.03.2020 and discharged at 15:55pM on dated 20.03.2020 but at the time of his discharged from this panel hospital no amount against this mediclaim policy bearing NO. P/161217/01/2020/006384 was sent to this panel hospital and as a result of this prolonged transferring of the amount complainant had to be paid/deposited in cash total amounting to Rs.54,310/- (including final bi8ll) and the hospital told to the complainant and in case amount against the mediclaim policy received through transfer or received by deposit form the insurer herein opposite parties, then the said amount should be released/refunded to him. The mediclaim policy in question was not arrived at to its purpose and destination and it reveals that the opposite parties appears in the nature to defeat the justice and correct claim of the rightful holder of the mediclaim policy. The opposite parties vide letter dated 1803.2020 and dated 19.03.2020 rejected the authorization for cashless treatment alleging that “It was observed from pre-authorization form that the onset of the above disease was during the break period of insurance and this was not disclosed at the time of renewal of this policy. Hence the claim was not admissible.” Further vide letter dated 04.07.2022 the claim of the complainant was repudiated stating that “As per condition No. 7 of the above policy, the company was not liable to protect the insured person for disease contract between the policy expiry date and the date of payment of premium for renewal”. The above Family health Optima Insurance Plan Policy bearing NO. P/16/1217/01/2020/006384 after renewal of the said policy on 17.03.2020 the proposed policy stands regularized and it should be treated as continued policy for all intents and purposes and no break should be taken into account as a broken period with the intent to deny the admissible relief under the said Family health Optima Insurance Plan policy in question and the proposed denial/rejection that the above said policy was renewed after break period of one day 15.03.2020 to 16.03.2020 and further attempted wrongful observation that the on set of the above disease was during the break period of insurance and under the abuse of powers in a discriminatory manner the claim of the complainant was denied vide Repudiation of claim letter dated 04.07.2020 had no sanctity in eye of law and it deserves to be set aside/quashed. It was worth mentioning that ant might contracted the disease HINI on any day between 08.03.2020 to 18.03.2020, then on what reason/ground opposite parties concluded that complainant only contracted the disease HINI during the break period of insurance between 15.03.2020 to 16.03.2020. The complainant sent legal notice dated 10.08.2018 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 mediclaim amount of Rs.54,310/- alongwith interest @ 18% p.a. from the date of submitting the mediclaim till its actual realization.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite parties put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that the insured had availed, the “Family Health Optima Insurance Plan” vide policy No. P/161217/01/2020/006384 for the period 17.03.2020 to 16.03.2021 for covering the family for the sum insured of Rs.10,00,000/-. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form, The complainant neither had any cause of action nor locus standi in lodging the present complaint before this Commission. It was submitted that the complainant had suppressed and concealed the true material and vital facts and information from this Hon’ble Commission, in lodging the present complaint before the Hon’ble Commission. As a sequel of brief history of the matter in hand and for the purposes of facilitation of the true, vital and material facts and information of this Commission, it was submitted that the insurance company received a “Request for cashless hospitalization” of the insured – Diwan Singh and enclosing there with certification of the treating doctor in Metro Heart Institute with Multi Speciality Hospital, Sector-16A, Faridabad on 18.3.2020 with the complaint “Patient presented on 18.03.2020 with complaint of Chills headache, sore throat and cough for last 2 days. Whereas, as per the “request for cashless hospitalization” duly signed by the treating doctor as well as the patient, duration of the complaint present 3 days. On perusal of the available documents, it was observed by the medical team of the insurance company that the “onset of the disease” was during the break period of insurance and the patient was symptomatic when n o policy was in force” (Medi insurance NO. 3/161217/01/2020/006384 for the period 17.03.2020 to 16.03.2021). As a result, the insurance company declined the request for cashless treatment vide its letter dated 18.03.2020 duly communicated to the hospital inter-alia notifying therein that the ailment was onset from 15.03.2020, whereas the medi insurance policy was got renewed form 17.03.2020, which ailment was not disclosed at the time of renewal of the policy, hence the claim was not admissible. In furtherance of communicated dated 18.03.2020, the insured was also duly communicated vide its letter dated 19.3.2020 by requesting the hospital to hand over the same to the patient, in declining the reimbursement of medical expenses. It was further submitted that consequently, the complainant lodged regular claim for reimbursement of medical expenses to the tune of Rs.54,310/- received by the insurance company o9n 30.06.2020. In furtherance of lodging the claim annexing “Discharge summary dated 20.03.2020, the complainant was diagnosed as a case of “LRT1 (H1N1 positive) and hypertension. As per the hospital course, the complainant was known case of “HTN” (Hypertension) admitted with the complaint of High Grade Fever with Chills, cough with sputum headache and sore-throat. As per the available medical documents the same confirmed that onset of the ailment was for the past 3 days, which ailment was during the break period of insurance (i.e the ailment was from 15,03.2020, whereas the insurance risk was got renewed from 17.03.2020 which ailment was not disclosed on 17.3.2020 while the hospitalization was dated 18.03.2020). Opposite parties 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 as well as written arguments submitted by counsel for the parties have been perused.
5. In this case the complaint was filed by the complainant against opposite parties– M/s. Star Health & allied Insurance Company Ltd. & Ors. with the prayer to: a) make the payment of mediclaim amount of Rs.54,310/- alongwith interest @ 18% p.a. from the date of submitting the mediclaim till its actual realization. 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 Diwan Singh, Eax.C1 – letter dated 18.03.2020, Ex.C-2 – Request for cashless hospitalization for medical insurance policy, Ex.C-3 – Rejection of authorization for cashless treatment dated 18.03.2020, Ex.C4 – letter dated 19.03.2020 regarding rejection of authorization for cashless treatment , Ex.C-5 – discharge summary, Eax.C-6 – Claim form, Ex.C-7 – repudiation letter dated 04.07.2020,, Ex.C-8 – legal notice, ex.C-9 to C-13 – 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 Smit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Company Ltd., Ist floor, Himalaya House, 23, Kasturba Gandhi Marg, New Delhi, Ex.R/1 – letter dated 17.03.2020, Ex,R-2 – letter dated 18.03.2020, Ex.R-3 - Portability Form, Ex.R-4 – insurance policy with terms and conditions, Ex.R-5 – Request for cashless hospitalization for medical insurance policy, Ex.R-6 - treated doctor certification- metro heat Institute, Ex.R-7 – Rejection of authorization for cashless treatment letter dated 19.03.2020, Ex.R-8 – Claim form, Ex.R-9 – Discharge of request, Ex.R-10 – Final bill, Ex.R-11 – Repudiation letter dated 04.07.2020, Ex.R-12 – letter dated 10.09.2020 regarding requirement of additional documents/information, Ex.R-13 – Ist reminder letter dated 25.09.2020 regarding requirement of additional documents/details, Ex.R-14 – 2nd reminder letter dated 10.10.2020 regarding requirement of additional documents/details, Ex.R-15 – letter dated 25.10.2020 regarding rejection of reimbursement claim, Ex.R-16 – legal notice, Ex.R-17 – reply to legal notice.
6. In this case, the complainant had obtained the mediclaim
policy Family Health Optima Insurance -2017-MED-PRD-051 bearing No. P/161217/01/2020/006384 read with policy NO. P/161217/01/2019/002655 under product namely Family Health Optima Insurance Co, Ltd. Through Intermediary Code/Name: BA0000281145/Mr. Abhinav Goyal, SM code/Name: SH55655/Mr. Lakhan Lal by paying/depositing the premium for the period of insurance from 17.03.2020 to midnight of 16.03.2021 in his name. All of sudden on account of illness complainant namely Diwan Singh admitted in the panel/approved hospital i.e. Metro Heart Institute with Multi-specialty Hospital, Sector-16A, Faridabad on 18.03.2020 at 09:19 AM under IPD No. 20/07427 as indoor patient and diagnosed the patient of AFI. It is evident from repudiation letter dated 04.07.2020 vide Ex.R-11 on the ground that “we have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of H1N1. You have renewed the above policy after a break of 2 days from 15.03.2020 to 16.03.2020. It is observed form the pre auth request form duly completed and signed by the doctor and with the seal of the above hospital, the insured patient had complaints of cough, cold, fever and headache for last 3 days which confirms that the onset of the above ailment is during the break period of insurance. As per condition No. 7 of the above policy, the company is not liable to protect the insured person for diseases contracted between the policy expiry date and the date of payment of premium for renewal. We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.”
7. After going through the evidence led by the parties, the Commission is of the opinion that the incubation period for H1N1 ranges form 1 to 4 days, with the average around the 2 days in most individuals, but some individuals, it may as long as 7 days. It means that it may takes upto 7 days before symptoms develops in the patient, therefore, if the complainant had symptom/complaint of cough, cold, fever, and headache for the past 3 days before admission in the hospital means complainant may contracted the disease H1N1 on any day between 08.03.2020 to 18.03.2020, then on what reason/ground opposite parties concluded that complainant only contracted the disease H1N1 during the break period of insurance between 15.03.2020 to 16.03.2020. In the interest of justice, the complaint is allowed. Opposite parties are directed to process the claim of the complainant as per the T&C of the policy 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: 29.09.2022 (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.
