District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 210/2022.
Date of Institution: 18.4.2022.
Date of Order:24.05.2023.
Mahesh Kumar son of Shri Balram R/o H.No.1001, Behind Chouhan Dharam Kanta, Krishna Colony, Palwal, at present village Badka, Tehsil & Distt. Palwal, Haryana.
…….Complainant……..
Versus
M/s. Star Health & Allied Insurance Company Limited, Service through Branch Office: Shop No.1, First floor, Krishna Palace, near Azronda Chowk, NIT, Faridabad – 121001 Haryana through its principal officer/Auth. Signatory.
Service may also be effect:
M/s. Star Health & Allied Insurance Company Limited, Reg. Office at No. 15, Sri Balaji Complex, Ist floor, White Lane, Roy Apettah, Chennai – 600 014 through its principal officer/Auth.Signatory.
…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: Sh. OmParkash Saini , 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 taken a mediclaim insurance policy bearing No. P/161124/01/2022/000769 from the opposite party valid from 26.4.2021 to 25.4.2022 for basic floater sum insured of Rs.5,00,000/-. During the validity of said policy, the complainant as well as his wife namely Sushma and daughter i.e Avika Mathil suffered from Viral Fever and were admitted with M/s. Raghav Hospital Main Kheri Road, Karnel Vihar, Sector-87, Grater Faridabad on 23.09.2021 and remained admitted upto 28.09.2021. The total expenditure on the treatment of complainant as well his wife and daughter had coasted Rs.1,08,723/- (Rs.38080/-, Rs.38,653/- and Rs.31,990/-) approximately except the expenditure on special diets and transportation. As per the terms and condition f the above said insurance policy, the said expenditure of Rs.1,08,723/- were to be borne by the insurance company i.e the opposite party. The complainant applied for the re-imbursement of said amount of Rs.1,08,723/- with the branch office of the opposite party at Delhi dated 30.09.2021 through Trackon Courier Service within time. The complainant had also sent again the necessary documents through insurance agent Mr. Brij Mohan. On 16.10.2021, the opposite party transferred an amount of Rs.29,958/- in the account of complainant and balance amount had not sent by the opposite party till date. There was no reason or legal aspect for which re-imbursement of the balance amount of Rs.78,765/- could be denied but for the utter shock and surprised to the complainant, the opposite party refused to re-imburse the said amount without any reason or cause. 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) release or pass the balance claim of complainant of Rs.78,765/- being the losses suffered by the complainant due to deficiency of services provided by the opposite parties..
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 5100 /-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 insurance company had already reimbursed and paid the admissible & payable medical expenses to the insured viz. Ms. Avika within the scope of the terms & conditions of the Family Health Optima Insurance Policy as well as the insurance Regulatory Development Authority Guidelines. Apart that, the claim intimation qua the insured viz. Mahesh Kumar stand closed for want of original final bill with break up and receipts thereto by the insurance company vide its letter dated 19.03.2022, whereas, the mediclaim qua the insured viz. Smt. Sushma stand “Repudiated” by the insurance company vide its letter dated 20.03.2022 being based on fraudulent statement and procuring of claim documents in collusion with the hospital. The insured had obtained the Family Health Optima Insurance Plan covering Mr. Mahesh Kumar – Self, Mrs. Sushma Devi (spouse), Avika Mathil and Ansh Mathil – (Dependent children) for sum insured Rs.5,00,000/- vide policy No. P/161124/01/2022/000769 for the period 26.04.2021 to 25.4.2022 for covering the family. 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 vital and material facts and information in lodging the present complaint to the effect that:-
i. The present complaint was premature qua the claim of insured:-
Mahesh Kumar since closed by the insurance company vide its letter dated 18.4.2022, pursuant to its letter dated 04.03.2022 folowed with reminder letter dated 19.03.2022 and 03.04.2022 for want of original final bill with break up and receipts thereto.
ii. The mediclaim had already been reimbursed and released in full and final settlement on 20.10.2021 qua the insured viz. Ms. Avika.
iii. So far as the claim of the insured viz. Smt. Sushma allegedly hospitalized for the period 23.09.2021 to 28.09.2021 was concerned, the same was based on fraudulent statements and procuring of claim documents in collusion with the hospital. Hence, the insurance company had repudiated the claim vide its letter dated 20.03.2022. 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 and Allied Insurance Company Ltd. with the prayer to: a) release or pass the balance claim of complainant of Rs.78,765/- being the losses suffered by the complainant due to deficiency of services provided by the opposite parties.. b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 5100 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Mahesh Kumar, Ex.C-1 – legal notice, Ex.C2 & 3 – postal receipts, Ex.C-4 – Family Health Optima Insurance Plan, Ex.C-5 – receipt, Ex.C-6 – prescription, Ex. C-7 – Discharge summary, Ex.C-8 – invoice in the name of Mahesh, Ex.C-9 – lab breakup, Ex.C-10 – ward medicine breakup, Ex.C-11 – USG abdomen USG, Ex.C-12 – receipt,, Ex.C-13 – X-ray Chesta PA, Ex.C-14 – receipt, Ex.C-15 Discharge summary, Ex.C-16 – prescription, Ex.C-17 – lab breakup,, Ex.C-18 Invoice in the name of Sushma, Ex.C-19- X-ray – Chesta PA, Ex.C-20 – Ward medicine breakup, Ex.C-21 – receipt, Ex.C-22 – Full abdomen USG.
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 Sumit Sharma, Senior Manager, Star Health & Allied Insurance Company Ltd., Ist floor, Himalaya House, 23, Kasturba Gandhi Marg, New Delhi,, Annx.R-1 – letter dated 20.04.2021, Annx.R-2 – Claim form, Annx.R-3 – discharge summary, Annx.R-4 – requirement of additional documents/information, Annx.R/5 – letter dated 19.03.2022 regarding the required documents, Annx.R-6 - reminder letter dated 03.04.2022, Annx.R-7 – letter dated18.04.2022, Annx.R-8 – claim form, Annx.R-9 – Discharge summary, Annx.R-10 – invoice, Annx. R-11 – Bill assessment sheet, Annx.R-12 – Field Visit report, Annx.R-13 – TPA/Reimbursement/Cash payment, Annd. R-14 – Claim Form of Mahesh Kumar, Annx.R-15 – Discharge summary, Annx.R-16 – invoice, Annx.R-17 – repudiation letter dated 20.03.2022,
6. In this case, the claim was filed for the three persons namely Mahesh Kumar – complainant, Sushma –wife, Avika – daughter with the bill of Rs.38080/-, 38,653/- and 31,990/-. The total bills comes to Rs. 1,08,723/- in which the claim of Avika was settled by the opposite party. Rest two persons Mahesh and Sushma was not settled.
7. After going through the evidence led by the parties the bill of Mahesh Kumar of Rs.38,080/- vide Ex. C-8, bill in the name of Sushma of Rs.38,653/- vide Ex.C-18 and opposite party sent so many letters to the complainant for submission of documents which was not submitted by the complainant like original final bill with breakup alongwith seal and sign & cash paid receipts in original alongwith seal and sign towards the final bill.
8. Keeping in view of the above submissions, the complaint is allowed. The opposite party is directed to process the claim of Mahesh & Sushma as per terms and conditions of the policy within 30 days from the date of receipt of the copy of order , subject to submission of original final bill and cash paid receipts as required by the opposite party 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.1100/- as compensation for causing mental agony & harassment alognwith Rs.1100/- 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: 24.05.2023 (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.
