BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.196 of 2020
Date of Instt. 20.07.2020
Date of Decision: 28.04.2023
Bhupinder Singh aged about 43 years son of Sewa Singh resident of 20/21, Ganga Road, Jalandhar Cantt.
..........Complainant
Versus
1. M/s. Star Health & Allied Insurance Co. Ltd., Regd. & Corporate Office: 1 New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai, through its M. D./Chairman, also at No.15, Sri Balaji Complex, First Floor, Whites Lane, Roya, Pettah, Chennai 600014.
2. M/s Star Health & Allied Insurance Co. Ltd. EH 198, 2nd Floor, Nirmal Complex, G. T. Road, Jalandhar (PB.) through its Branch Manager.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Neeraj Kaushik, Adv. Counsel for Complainant.
Sh. Nitish Arora, Adv. Counsel for OPs No.1 & 2.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the complainant purchased one policy namely Family Health Optima Insurance 2017, bearing policy no.P/211215/01/2020/001860, of Star Health Insurance Policy valid from 21.08.2019 to 30.08.2020 from the OPs and the said policy include the coverage of all kinds of risks of medical expenses including transportation, evacuation and repatriation during the above said period. The said policy was cashless policy and the complainant has paid the premium of Rs.17,005/- for the purchase of the said policy. During the validity of said policy, the complainant suffered with accidental injury of Acid Poisoning with severe corrosive oesophagitis, gastritis and duodenitis and was admitted in New Ruby Hospital, Jalandhar twice. On the first time he was treated from 29.10.2019 to 07.11.2019 and the injuries to the complainant mentioned above were diagnosed by the doctors. The complainant was given medical treatment by the hospital authority and remained admitted in New Ruby Hospital for the above said period for the first time and during this period, the complainant had to pay Rs.1,18.250/- as hospital expenses, Rs.83,336/- for medicines and Rs.2,000/- as Lab charges. Then he was again readmitted in the said hospital for surgery and remained admitted from 10.11.2019 to 29.11.2019 and the hospital expenses for the said period were Rs.2,37,950/-, expenses on medicine were Rs.1.69,796/- and lab (pathology etc.) expenses were Rs.23,800/-, while scanning expenses were Rs.10,000/-. After that the complainant submitted the claim to the OPs and completed all the necessary formalities as required by OPs which was about Rs.15 Lacs and details too were given. Even after the earlier treatment, the complainant is still undergoing medical expenses and has another operation to undergo which is to take place in the PGI and the insurance company is bound to cover the medical expenses as per the policy for the same also but all the requests to the OPs have fallen to deaf ears and they have already rejected the claim regarding the treatment at New Ruby Hospital, Pvt. Ltd. and are also indicating that they will not provide the insurance service for the future treatment also. In spite of completion of all the necessary formalities, OPs repudiated the claim of the complainant vide its letter dated 09.12.2019, by which the OPs declined the claim of the complainant on the ground that the injury is self intentional injury and the OP in its repudiation of the claim letter dated 19.12.2019 wrongly relied upon exclusion clause no.4 (7) alleging that the company is not liable to make the payment because of a condition arising out of an act of intentional self injury/self intentional injury. The said repudiation is prima facie false and unlawful because there is a clear report of the doctors as well as the General Diary Details that the injury was accidental. The said general diary details clearly mention that in the night of 28.10.2019 mistakenly instead of drinking lemon, complainant accidentally drank chemical meant for cleaning washroom. After mixing soda in the same, and because of which reason he started vomiting and therefore, immediately he was admitted to New Ruby Hospital and was treated therein. The complainant has already incurred huge medical expenses due to the operation conducted upon him and subsequent treatment and the medical bills including lab bills expenses of medicines and hospital charges are on record. At the time of purchase of the policy, OPs assured that the complainant needs not to bother anything as the said policy is cashless policy and if required, the entire amount of the treatment will be directly paid by the OPs to the hospital authority. In spite of the fact that the complainant had completed all the formalities, OPs have deliberately repudiated the claim which has resulted into deficiency in service on part of OPs and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay Rs.15,00,000/- as hospital expenses alongwith Rs.3,00,000/- as compensation for causing mental tension and harassment to the complainant alongwith litigation expenses.
2. Notice of the complaint was given to the OPs, who filed reply and contested the complaint by taking preliminary objections that the complaint filed by the complainant is false, frivolous, vague, baseless and misconceived because there was/ is no deficiency in service on the part of the OPs. The true facts of the case are that it is submitted that complainant availed the Family Health Optima Insurance plan Covering himself (covering all treatment related to varicose veins & their complications), Mrs. Riya - Spouse and Hrideyraj Singh dependent child for the sum insured Rs.15,00,000/- vide policy No.P/211215/01/2020/001860 for the period from 31.08.2019 to 30.08.2020. The terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. Moreover it is clearly stated in the policy schedule ‘the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc., attached’. It is further averred that the complainant was hospitalized on 29.10.2019 and was discharge on 07.11.2019 From New Ruby Hospital, Jalandhar towards the treatment of Acid Poisoning with Severe Corrosive Oesophagitis, Gastritis and Duiosdeniti and submitted claim for reimbursement of medical expenses amounting to Rs.1,67,322. On scrutiny of the claim documents submitted by the complainant for reimbursement of medical claim of the complainant from 29.10.2019 to 07.11.2019 at New Ruby Hospital Jalandhar, it was observed from the discharge summary that the insured patient has history of Acid Poisoning. Based on these findings the medical team of the opposite parties opined that complainant has undergone treatment for above ailment i.e. self intentional injury and as per exclusion no.4 (7) of the terms & conditions of the insurance policy ‘the company is not liable to
make any payment in respect of any expenses for treatment of a condition arising out of an act of intentional self injury self intentional injury’. Hence, the claim was repudiated vide letter dated 09/12/2019 and the same was communicated to the insured. Thereafter, complainant request to reconsider and review the case vide letter dated 17.12.2019, which was considered. The team of the OPs, which re-examined the claim record has observed that as per medical record, the insured patient has alleged history of taking Acid Poisoning. Hence the repudiation of claim invoking exclusion no.4(7) of the policy of insurance was found to be in order. Thus the claim was rejected vide letter dated 03.01.2020. It is further averred that the complainant has only intimated his date of admission for the treatment taken by him on 10.11.2019. Thereafter repeated requests & reminders, the complainant has not submitted the medical record as well as claim form, bills and other necessary documents, thus the said claim was rejected due to non-submission of documents. It is further averred that no cause of action has arisen in favor of the Complainant to file the present case. It is submitted that the Respondent/ OP's has acted strictly on the basis of the terms and conditions contained in the policy. The present case is premature as the complainant had not submitted the required documents for the purpose of the claim despite of repeated requests by the answering respondents/OP's. The complaint has been filed by the complainant with the mala-fide intention, and further to grab the public money. Hence, the present complaint is liable to be dismissed. It is further averred that the relief sought in the present complaint is in violation of the terms and conditions contained in the policy. Therefore, the complaint is liable to be dismissed with exemplary costs. It is further averred that the complaint is bound by the terms and conditions as applicable and which were expressly made known to the complainant at the time of his taking the policy in question. The OP had at the time of issuing the policy explained to the complainant the exclusion clauses and the payment plan. The complainant has approached this Forum with unclean hands by not disclosing and misrepresenting material facts. The present complaint is false, frivolous, misconceived and vexatious in nature and has been filed with the sole intention of harassing the OPs. The complainant has knowingly and intentionally concealed the true and material facts from this Forum. The present complaint is a gross abuse of the process of law and is liable to be dismissed with costs. It is further averred that the present complaint is the misuse of the legal process. The present complaint was filed only with the motive to harass the OPs. The complainant has no locus-standi and cause of action to file the present complaint. On merits, the factum with regard to taking insurance policy by the complainant is admitted and it is also admitted that the complainant was admitted in New Ruby Hospital, Jalandhar from 29.10.2019 to 07.11.2019 and it is also admitted that the claim was rejected vide letter dated 25.12.2019, but the other allegations as made in the complaint are categorically denied and lastly prayed that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file as well as written arguments submitted by counsel for the complainant very minutely.
6. It is admitted that the complainant had availed the Family Health Optima Insurance Plan Policy for the sum insured of Rs.15,00,000/- for the period from 31.08.2019 to 30.08.2020. The complainant has proved on record the insurance policy Ex.C-1 and Ex.C-2. The complainant has alleged that during the validity of the said policy, he suffered with accidental injury of Acid Poisoning with severe corrosive Oesophagitis, gastritis and duodenitis and was admitted in New Ruby Hospital, Jalandhar twice. Firstly, he was treated from 29.10.2019 to 07.11.2019. The record of the New Ruby Hospital, which include the bills, admission record, the investigation reports, bills of Pharmacy and Ultrasound report from Ex.C-7 to Ex.C-112 has been proved by the complainant. He has proved on record the discharge summary Ex.C-6. Claim was admittedly filed before the OPs. Vide Ex.C-3 the insurance company was authorized to seek any medical information from New Ruby Hospital, Jalandhar. He has proved on record the letter of repudiation of the claim Ex.C4 and the DDR Ex.C5. Perusal of Ex.C-4 shows that the claim of the complainant was repudiated on the opinion of the medical team to the effect that the insured patient has under gone treatment for the Acid Poisoning with severe corrosive Oesophagitis, gastritis and duodenitis i.e. self intentional injury. They had applied the exclusion clause 4 (7) of the policy and have stated that the company is not liable to make any payment in respect of any expenses for the treatment of a condition arising out of an act of intentional self injury/self intentional injury.
7. Now the point in controversy is as to whether the complainant has got intentional self injury or it was an accidental. The alleged incident took place on 29.10.2019 when he was admitted in New Ruby Hospital, Jalandhar. The matter was reported to the police and the DDR was registered vide Ex.C-5. Perusal of Ex.C-5 shows that the complainant gave the statement to the police that on 28.10.2019 in the night while he was about to drink lemon, but by mistake he drank the chemical mint for cleaning the wash room which was lying near to him in his side after mixing in soda as a result of which he started vomiting. Ex.C-7 is the ultrasound requisition form and as per this document also, the physical finding and clinical history shows that it was accidental acid ingestion. As per discharge summary Ex.C-6, the complainant was diagnosed with Corrosive injury GI tract with Massive haematemesis with Gastric perforation with Hypovolemic shock. He was admitted on 29.10.2019 with acute onset blood vomiting since night. He complained of abdominal pain and fever since one week. No complaint of loose stools. From the documents produced on record by the complainant, it is not proved nor it is clear from anywhere that the injury was self created or intentional injury. It is admitted and proved that, he suffered with accidental injury of Acid Poisoning with severe corrosive oesophagitis, gastritis and duodenitis. It is also not disputed that he was admitted to the hospital. The OPs have relied upon the opinion of the medical team that it is self intentional injury. From where they have got this opinion is not proved on record. The complainant has authorized the OP’s team vide Ex.C-3 to seek any medical information or record from the hospital. The OP could have taken the medical opinion or record from the New Ruby Hospital, Jalandhar to come to the conclusion as to whether the injury suffered by the complainant was self inflicted injury or it was an accidental injury. It is also proved and admitted that the complainant had insurance plan earlier also and the same have been proved by the OP Ex.OP-1 from 31.08.2016 to 30.08.2017, Ex.OP-2 from 31.08.2017 to 30.08.2018, Ex.OP-3 from 31.08.2018 to 30.08.2019 and the present insurance policy from 31.08.2019 to 30.08.2020. Clause 4 (7) of the insurance policy shows that the company is not liable to make any payment, if it is intentional self injury. If the OPs is to bring the present injury in this column, then it was incumbent upon the OP to prove that the injury suffered by the complainant was intentional self injury. The proposal form has been proved by the OP, which is Ex.OP6, Claim form Ex.OP7. Ex.OP8 Claim Form Part-B shows Acid Poisoning. From the word mentioned Acid Poisoning does not prove that it was intentional self injury rather it was poisoning from Acid. The detail has been mentioned in this document about the problem suffered by the complainant which was severe corrosive oesophagitis, gastritis and duodenitis. From these wordings, it cannot be inferred that the injury suffered by the complainant was self intentional injury. Similarly, from the document Ex.OP9 also, it is not clear that the complainant has anywhere stated that he had suffered intentional injury. Even the discharge summary proved by the complainant as well as the OPs nowhere shows that it is self intentional injury. The OP has relied upon the Colour Doppler Study of Right Leg Ex.OP11, but it nowhere relates with the present problem suffered by the complainant. He suffered corrosive gastritis due to acid poisoning and this document Ex.OP-11 deals with the Varicoase Veins in right lower limb with incompetent sphenofemoral junction and perforators. The image reports filed by the OPs also nowhere show that it was self inflicted injury. The OPs have relied upon the letters written to the complainant Ex.OP15, Ex.OP16 and Ex.OP17. Ex.OP15 show that the OPs have demanded the documents i.e. discharge summary etc. which are regarding the record of the New Ruby Hospital, Jalandhar, similar is the document Ex.OP16. Document Ex.OP17 shows that the claim of the complainant was rejected as he had not produced on record the document sought for, whereas the contention of the complainant is that he has produced all the documents alongwith claim form to the OP. More so, the OP was authorized to get any medical record or information from the New Ruby Hospital, Jalandhar as per the letter Ex.C-3 written by the complainant. Merely on this ground the OP cannot repudiate the claim as they were duly authorized and they could have got the documents from the hospital. In Ex.OP6, the complainant has mentioned the fact that he took the treatment for Varicoase Veins in right leg on 20.11.2015. So, it cannot be said that there was any concealment of the fact on the part of the complainant. The OP has not produced on record the opinion of any medical team who have opined that the complainant had suffered act of intentional self injury/self intentional injury. So, merely on the presumptions that the fact is written on the discharge summary Acid Poisoning, they have come to conclusion that it was self intentional injury. This act of the OP is wrong and illegal. There is clear cut deficiency in service and unfair trade practice on the part of the OPs. The repudiation letter Ex.OP-14 is accordingly set-aside. Therefore, the complainant is entitled for the relief.
8. In view of the above detailed discussion, the complaint of the complainant is partly allowed and the OPs are directed to pay hospital expenses, medicine expenses and lab charges etc. as per bills submitted in the Court Ex.C-8 to Ex.C-112 to the complainant. Further, OPs are directed to pay a compensation of Rs.15,000/- for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
9. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
28.04.2023 Member Member President
