District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 132/2020.
Date of Institution:06.03.2020.
Date of Order: 21.03.2023.
Gajender Singh aged about 37 years son of Shri Karamvir r/o House No.164, Jat Mohalla village Bhigan, District Sonepat Haryana.
…….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. O.P.Gaur , counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant, his wife Smt. Kanta, Tanisha and Kunal had obtained the mediclaim insurance policy “Family Health Optima Health Insurance Plan” bearing policy No. P-161116/01/2018/00/4989 valid form 28.11.2017 to midnight of 27.11.2018 for the total insurance amount of Rs.5,00,000/- in the name of the complainant and his family members. The wife of the complainant was suffering from chief complaint of pain in his both hips hence so the complainant was taken to Max Smart Speciality Hospital Saket, registered office Mandir Marg Press Enclave road, Saket, New Delhi where the complainant was admitted on 17.09.2018. In the said hospital the complainant was diagnosed by the doctors and Avascular necrosis of hip right and the total hip replacement right done on 18.09.2018 and the complainant remained under treatment in the said hospital upto 21.09.2018 as indoor patient. The complainant informed the opposite parties regarding his hospitalization in the said hospital. But the opposite parties had rejected the cashless authorization. The said hospital authorities raised the bill amounting to Rs.3,37,283/-. As per the instructions and directions of the opposite parties, the complainant deposited the concerned treatment records, bill and discharge summary etc. with the opposite parties. Thereafter the complainant requested the opposite parties to reimburse the treatment amount of Rs.3,37,283/- to the complainant but the opposite parties avoided to the legitimate request of the complainant on one pretext or the other. Instead of reimbursing the amount of Rs.3,37,283/- the opposite parties had repudiated the claim of the complainant on the false grounds. 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) make the payment of treatment amount of Rs.3,37,283/- interest @ 24% p.a. since the date of admission of discharge of the complainant from the hospital till upto date to the complainant.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-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 obtained the “Family Optima Insurance Plan” vide policy NO. P161116/01/2018/004989 valid from 28.11.2017 to 27.11.2018 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. It was submitted that the claim of the complainant was duly processed by the opposite party in accordance with the terms and conditions of the policy and as it was found not admissible, the same had duly been communicated to the complainant dated 21.09.2018. 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 and concealed the true, material and vital facts & information from this forum, in lodging the present complaint. It was submitted that the insurance company received a “Request for cashless Hospitalization” and enclosing therewith prescription from Saket City Hospital Press Enclave road, Mandir Marg, Saket, New Delhi pertaining to the proposed hospitalization of patient – Gajender Singh. As a result, the medical team of the insurance company examined the medical documents and sought the following documents from the hospital vide its query letter dated 13.09.2018:-
- As per consultation/prescription dated 27.08.2018 pertaining to max healthcare, Saket, New Delhi. The patient had hospitalized for ailment two years back. So provide MRI done 2 years back.
- As per consultation and MRI report dated 27.08.2018 the same present previous surgical intervention, so provide discharge summary.
- Further, the insurance company deputed its house investigator being a competent and qualified doctor to verify the proposed admission on 14.09.2018.
It was submitted that the company’s doctor visited the hospital and observed that there was no such admission of a patient with the name of Gajender Singh in Saket City Hospital. As a esult, the medical team of the insurance company examined the available medical documents and arrived at its decision in declining the request for “Cashless Hospitalization vide its “letter of rejection” dated 14.09.2018, addressed to the patient viz. Gejender Singh. The medical team of the insurance company perused and examined MRI report dated 20.07.2017 pertaining to Satya Health Care, new Delhi read with prescription dated 27.08.2018 pertaining to Max Healthcare, New Delhi and observed that the patient was diagnosed with “Avascular Necrosis” 2 (two) year back which was prior to inception of medi insurance policy No. P/161116/01/2018/004989 for the period 28.11.2017 to 27.11.2018 being the first year of insurance policy, which ailment was not disclosed at the time of inception of medi insurance policy, which constitute violation, breach and infringement of condition No.6 of the medi insurance policy as well as Regulation No. 19(2) of the IRDA .In furtherance of process of the claim intimation, the insurance company had also invoked Condition No.12 of the medi insurance policy by notifying also in the letter dated 21.09.2018, enabling the complainant to show cause within 30 days, failing thereof, the medi insurance policy should be deemed cancelled by deleting the name of the complainant – Gajender Singh. But the complainant neither contacted the insurance company nor forwarded any response to the insurance company in token of its show cause notice dated 21.09.2018, hence the insurance policy stand cancelled accordingly w.e.f 31.10.2018 by making endorsement thereto vide dated 25.10.2018. 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.
5. In this case the complaint was filed by the complainant against opposite parties–M/s. Star Health and Allied Insurance Company with the prayer to: a) make the payment of treatment amount of Rs.3,37,283/- interest @ 24% p.a. since the date of admission of discharge of the complainant from the hospital till upto date to the complainant. b) pay Rs. 1,00,000/- 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 – affidavit of Gajender Singh,, Ex.C-1 – insurance policy for the period 28.11.2017 to 27.11.2018, Ex. C-2 & 3 – Inpatient bill, Ex.C-4 – bill, Ex.C-5 OP consumable bill, Ex.C-6 & 7 – Bill of supply, Ex.C-8 – Tax invoice,, Ex.C-9 to 12– bill, Ex.C-13 & 14– duplicate invoice cum receipts, Ex.C-15 – Tax invoice, Ex.C-16 – MRI report,, Ex.C-17 – discharge summary,, Ex.C-18 – Laboratory investigation report, Ex.C-19 to 20 – Prescription of Max Healthcare, Ex.C-22 – discharge summary, Ex.C-23 – legal notice, Ex.C-24 & 25 – 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 P.C.Tripathy, Zonal Manager, Star Health & Allied Insurance Co. Ltd., Himalaya House, 23, Kasturba Gandhi Marg, New Delhi, Annx.R-1 – policy terms and condition, Annx.R-2 – insurance policy valid from 28.11.2017 to 27.11.2018, Annx.R-3 – letter dated 21.9.2018 regarding nondisclosure of pre-existing disease, Annx.R/4 – endorsement schedule, Annx.R/5 – proposal form, Annx.R/6 – Request for cashless hospitalization for medical insurance policy, Annx.R/7 – Field visit report, Annx.R/8 - letter dated 13.09.2018 regarding query on pre authorization, Annx.R/9 - letter dated 14.09.2018 regarding rejection for pre-authorization for cashless treatment, Annx.R-10 – MRI report dated 20.07.2017, Annx.R-11 – consultation reports issued by Dr. Narender Kumar Magu, Annx.R/12 – reply to legal notice, Annx.R/13 – IRDA guidelines.
6. In this complaint, the complainant has prayed to make the payment of treatment amount of Rs.3,37,283/- interest @ 24% p.a. since the date of admission of discharge of the complainant from the hospital till upto date to the complainant.
7. The complainant, his wife Smt. Kanta, Tanisha and Kunal had obtained the mediclaim insurance policy “Family Health Optima Health Insurance Plan” bearing policy No. P-161116/01/2018/00/4989 valid form 28.11.2017 to midnight of 27.11.2018 for the total insurance amount of Rs.5,00,000/- in the name of the complainant and his family members. The wife of the complainant was suffering from chief complaint of pain in his both hips hence so the complainant was taken to Max Smart Speciality Hospital Saket, registered office Mandir Marg Press Enclave road, Saket, New Delhi where the complainant was admitted on 17.09.2018. In the said hospital the complainant was diagnosed by the doctors and Avascular necrosis of hip right and the total hip replacement right done on 18.09.2018 and the complainant remained under treatment in the said hospital upto 21.09.2018 as indoor patient. Opposite party repudiated the claim of the complainant vide letter dated 14.09.2018 (vide Annx.R-9) on the ground that “As per MRI report dated July 2017 it is evident that the patient was diagnosed with avascular necrosis which is prior to policy and the same was not disclosed during policy inception. Hence, we regret to inform that the claim cannot be considered.”
8. After going through the evidence led by the parties, the Commission is of the opinion that the report of MRI is not proved by the opposite party and opposite party has not filed any affidavit and name of the authority about this by which testing authority the MRI was done . T & C of the policy has been tendered by the opposite party whether it was for 12 months and for 48 months in the exclusion clause. Annx.R10 placed by the opposite party is not visible. The patient is a young boy of 34 years. The opposite party has not cancelled the policy yet. The complainant has already paid the premium amount to the opposite party.
In the interest of justice, the complaint is allowed.
9. Opposite parties are directed to process the claim of the complainant and pay 50% of the payable amount to the complainant. Opposite parties are 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. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 21.03.2023 (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.
