Delhi

New Delhi

CC/154/2022

Mahender - Complainant(s)

Versus

M/S. Star Health & Allied Insurance Company Ltd. - Opp.Party(s)

01 Jun 2023

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-VI

(NEW DELHI), ‘M’ BLOCK, 1STFLOOR, VIKAS BHAWAN,

I.P.ESTATE, NEW DELHI-110002.

Case No.154/2022

IN THE MATTER OF:

 

Mr. Mahender S/o Amar Nath

A-481, J.J. Colony, Sector-15, Bharat Vihar,

Kakrola, New Delhi-110078.                                                ....Complainant

 

 

VERSUS

 

Star Health and Allied Insurance Company Limited.

1^st Floor, Himalaya House, 23, Kasturba Gandhi Marg,

New Delhi-110001                                                               ....Opposite Party

 

Quorum:

 

Ms. Poonam Chaudhry, President

Sh. Bariq Ahmad, Member

Sh. Shekhar Chandra, Member

 

 

                                                                                                        Date of Institution:-05.07.2022                                                                                                                                                                                Date of Order: -      01.06.2023

 

ORDER

 

POONAM CHAUDHRY, PRESIDENT

 

 

1. The present complaint has been filed under Section 12 and 35 of the Consumer Protection Act, 1986 (in short CP Act) against Opposite Party (in short OP) alleging deficiency of services.
2. Briefly stated the facts of the case are that the complainant had taken a online health Insurance policy bearing no. P/160000/01/2022/008037 on 23.10.2021 from the opposite party. The said policy was valid from 23.10.2021 to 22.10.2022 for the sum insured of Rs.3,00,000/- (Rupees Three Lakh).
3. That the complainant got admitted in the Mahavir Multispecialty Hospital, (New Delhi) for treatment on 06.05.2022 and remained hospitalized till 18.05.2022. The said hospital generated the final bill of Rs.2,02,030/- (Rupees Two Lakh Two Thousand Thirty) which was paid by the complainant to the Mahavir Multispecialty Hospital, (New Delhi).
4. It is further alleged that complainant claimed the aforesaid bill amount from the opposite party, but the same was rejected by the opposite party on 01.06.2022 Claim no. CIR/2023/160000/0227304 with the reason “Excluded Provider (Hospital). Complainant thereafter sent a legal notice dated 02.06.2022 to the OP/Insurance company but no response was received.
5. It is further alleged that complainant having been left with no option approached this Court, hence the present complaint. It is also alleged the present case is being filed within the period of limitation. The cause of action to file the complaint arose when the claim of the complainant was rejected by opposite party on 01.06.2022. It is also stated the residence of the complainant is situated at ‘Kakrola’ New Delhi, hence, this Court has jurisdiction to entertain the present complaint.
6. It is prayed that OP be directed to pay a sum of Rs.2,02,030/- (Rupees Two Lakh Two Thousand Thirty) to the complainant with pendentelite and future interest @ 18% p.a. from the date of repudiation of claim till its realization. OP be also directed to verify and produce the medical treatment record and bills of treatment of complainant from 06.05.2022 to 18.05.2022. Cost of litigation be also awarded.
7. Notice of the complaint was issued to OP, upon which OP entered appearance and filed written statement contesting the case on various grounds inter alia that that complaint is not maintainable, as no cause of action ever arose in favour of the complainant and the same is hit by Section VII Rule 11 of CPC. It was further alleged that the present complaint has been filed on false and frivolous facts and has suppressed the material facts. It was also alleged that the present complaint has been filed on false and frivolous facts and complainant has suppressed the material facts.
8. It was further stated respondent denies each and every allegation, averments and statement made in the complaint which is contrary to and/or inconsistent with what has been stated in the reply and nothing stated in the complaint be deemed to have been admitted until the same is expressly admitted hereinafter.
9. It was further stated that the complainant had obtained the policy i.e. Young Star Insurance Policy for self and the sum insured was Rs.3,00,000/- (Rupees Three Lakh) on dated 23.10.2021 for a period of 23.10.2021 to 22.10.2022 vide policy No. P/160000/01/2022/008037 from the answering respondent/OP and at the time off inception of the policy, the terms and conditions were explained to the complainant. 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 and also upon issuance of an insurance policy.
10. It was further alleged that on 06.05.2022 the complainant was hospitalized at Mahaveer Multispecialty Hospital, Delhi for a period 06.05.2022 to 18.05.2022 for the treatment of UTI with sepsis and the complainant has submitted the documents for reimbursement of the claim i.e. Rs.2,02,030/- (Rupees Two Lakh Two Thousand Thirty). It was alleged that perusal of the documents of complaint revealed,

• As per Discharge summary dated 18.05.2022 at the time of admission the insured patient’s spo2 is 98% and Temperature  is 98F. Hence it is not a emergency situation or life threatening situation therefore the patient could have admitted in a network hospital.
• The hospital has designated as excluded provider on 11.01.2022 and the patient was admitted on 06.05.2022.

• The insured patient has taken the treatment in the above mentioned hospital, which is an excluded provider hospital as per the Exclusion No.11 in the terms of the policy which states that “Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website/notified to the policy holder are not admissible. However, in case of life threatening situations or following an accident expenses up to the stage of stabiliazation are payable but not the complete claim.”
• It is further submitted that the complainant has intimated the answering respondent about his hospitalization on 25.05.2022, whereas the condition 2(d) of the above policy states that “Upon the happening of the event, notice with full particular shall be sent to the company within 24 hours from the date of occurrence of the event irrespective of whether the event is likely to give rise to a claim under the policy or not.”
• The insured patient had also another policy with the respondent company for the period of 02.03.2019 to 01.03.2020 where insured patient had reported two claims which are pending in DCDRC,

Dwarka. The insured instead of getting the policy renewed purchased a fresh policy. The OP cannot link the two policies. Respondent rejected the claim of the complainant vide letter dated 01.06.2022 as the complainant violated the terms and conditions of the above policy.

11. It was further stated that parties were bound by the terms and conditions of contract and it is presumed that when the parties have entered into a contract  with their eyes wide open, they have to rely on the terms and contract. It was also alleged that respondent has complied with the terms and conditions, but it is the complainant failed to comply with the terms and conditions of the above policy. It was also stated that without prejudice to the contentions of OP, OP is liable to pay Rs.1,91,050/- (Rupees One Lakh Ninety One Thousand Fifty) which is the maximum quantum of liability under the policy. It was prayed that the complaint be dismissed.
12. Complainant filed rejoinder reiterating therein the averments made in the complaint and denying all the allegation made in the written statement. Both parties thereafter filed their evidence by way of affidavits.
13. Complainant relied upon the policy, the prescription of doctor who examined the complainant in Emergency advising hospitalization, the treatment record and bills, discharge summary issued by Mahavir Multispecialty hospital. It was contended by complainant OP had to failed to show whether the exclusion of said Hospital was mentioned in the terms and conditions of the policy.
14. We have heard the AR of complainant and Ld. Counsel for  OP and perused the evidence and material on record as well as their written arguments. It is admitted case that complainant had obtained the policy in question from OP which was valid with effect from 06.05.2022 to 18.05.2022. and complainant was hospitalized during the tenure of coverage of the insurance policy.  It is the case of OP the claim of complainant was repudiated for violation of the terms and conditions of the policy.
15. It is to be noted that complainant filed all medical bills, purchase vouchers, laboratory reports issued and attested by the Mahaveer Multispecialty Hospital. The repudiation letter states that the claim was repudiated as insured was admitted and treated in an Excluded provider Hospital, which was violation of the terms and conditions of the policy.
16. It is pertinent to note that OP has not filed any document to show that the terms and conditions of the policy which included the exclusion clause were communicated or served on the insured/complainant.                                                                                                                                                                                                                                                            Thus the OP could rely on the terms and conditions of the policy only if it supplied the copy thereof to insured, either at the time of inception of policy or thereafter. Thus OP cannot take recourse to the terms and conditions of the policy.
17. As regard the liability of Insurance Company in case the terms and conditions of the policy which included the Exclusion clause were not communicated or served on the insured, it has been held by the Hon’ble Supreme Court in M/s Modern Insulators  Ltd. Vs. The Oriental Insurance Company 2000 (2) SCC 734 as under :

“It is the fundamental principle of insurance law that utmost good faith must be observed by the contracting parties and good faith forbids either party from non-disclosure of the lads which the parties known. The insured has a duty to disclose and similarly it is the duty of the insurance company and its agents to disclose ill material facts in their knowledge since obligation of good faith applies to both equally.

In view of the settled position of law we are of the opinion that the view expressed by the National Commission is not correct. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant respondent cannot claim the benefit of the said exclusion clause.Therefore, the finding of the National Commission is untenable in law.”

 

18. It is to be noted that OP stated that the maximum quantum of liability under the terms of policy shall be Rs.1,91,050/- (Rupees One Lakh Ninety One Thousand Fifty). We accordingly hold that OP guilty of deficiency of services and direct OP i.e. Star Health and Allied Insurance Company Limited to pay Rs.1,91,050/- (Rupees One Lakh Ninety One Thousand Fifty) to the complainant with interest @ 9% per annum from date of filing of claim within four weeks of date of receipt of order, failing which OP will be liable to pay interest @ 12% per annum till realization. We also direct OP to pay compensation of Rs.50,000/- (Rupees Fifty Thousand only) for mental agony and Rs.10,000/- (Rupees Ten Thousand only) toward litigation expenses to the complainant.

A copy of order be sent to all the parties free of cost. The order be also uploaded on the website of the Commission (www.confonet.nic.in).

File be consigned to the record room along with a copy of the order.

 

Poonam Chaudhry

(President)

 Bariq Ahmad                                                                                                                               Shekhar Chandra

  (Member)                                                                                                                                            (Member)