Delhi

New Delhi

CC/263/2014

Devi - Complainant(s)

Versus

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

24 Nov 2015

ORDER

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI), ‘M’ BLOCK, 1^STFLOOR,

VIKAS BHAWAN, I.P.ESTATE,

NEW DELHI-110002.

 

Case No.CC/263/14                                                                                                                                                                           Dated:

In the matter of:

Smt. Devi,

R/o B-57, Defence Colony, Ground Floor,

New Delhi                                            

 

……..COMPLAINANT

       

VERSUS

 

Star Health & Allied Insurance Co. Ltd.,

Through its M.D/Principal Office,

C-11, Vista House,

1^st Floor, SDA Commercial Complex,

Near IIT Gate, Behind Canara Bank, Delhi-110016

 

                                         ……. OPPOSITE PARTY

 

 

 

ORDER

President: C.K Chaturvedi

               

The Complainant Mrs. Devi is in consumer dispute with the OP Star Health & Allied Insurance Co. Ltd., over denial of her treatment expenses of Rs.48,000/- by it to complainant, under the medic classic insurance policy.

The facts are that she took a medi claim policy for self effective from 30.05.13 to 29.05.14, for a sum assured of Rs.2 lakh. It is alleged that on 25.10.13, she was admitted in B.L Kapoor Hospital, with complaint of fever, generalized body ache, recurring vomiting and right upper abdominal pain for lost 7 days and jaundice of 2 days.  She reported with no history of any major illness, as is found recorded in the discharge summary of the hospital. She remained in hospital till 29.10.13, where her ailments were investigated, tests done. She was treated conservatively. Her nausea & abdominal pain were found better. The hospital planned to consider her for anti-viral therapy for HBV after all pending reports were available, and need for HAART was clarified. She was diagnosed with Acute Hepatitis B, Antiretroviral serology positive.

It is stated that as per policy terms, she had to inform the OP, within 24 hours of such hospitalization, which she did. The OP demanded certain documents and queries, which were provided to it. The OP on 28.10.13 rejected the request of cashless at pre-authorization stage as stated below:

‘Hospitalization is for the management of ailment which is related to a pre-existing condition clause.’

The Complainant, being a poor and illiterate was shocked as she could not afford the treatment cost any further without cashless authorization., She, in the circumstances, sought discharge to save from further treatment expenses though she was still not out of her full course of treatment for which reports were pending. She was faced with a bill of Rs.48,209/- which she somehow arranged by borrowing. It is informed during arguments that she being a maid had taken this policy for such unforeseen events and huge expenditure.

She has filed this complaint, claiming reimbursement of expenses and compensation, as she had to terminate her treatment.

The OP in its reply has staed that it received the claim of the complainant from BLK Memorial Hospital, Pusa Road, and that cashless authorization was rejected vide letter dated 28.10.13 on the ground of pre-existing disease with the available documents. It is seen from the reply that having already rejected the claim on pre-existing disease basis clause of policy, the OP is still seeking certain medical paper, in the custody to hospital to evaluate the claim, and stating that on receiving these documents it will process the claim as per terms and conditions of policy. It is blaming complainant for not giving papers, which admittedly can be obtained by OP direct from the hospital.

We have considered the entire material on record, perused the evidence and heard the submissions. It is admitted case that OP has rejected the cashless; on the basis of some of its own medical opinion that she was suffering from vehicle pr-existing disease. The discharge summary and diagnose with hospital at the time of admission clearly stated that she was admitted in hospital on complaint of fever, generalized body ache, recurring vomiting and right upper abdominal pain only for last 7 days and jaundice of 2 days. These are only symptoms, and investigations for identifying the cause of disease were still on and test reports were pending. On the simply medically poor condition of patient on admission, no inference of any pre-existing disease arises. The opinion of doctor who gave such finding without clinical examination of patient is not placed on record. It is strange that when the hospital itself is writing for pre-authorization for cashless seeing the condition of patient admitted, OP Company is inventing ways to defeat it unjustly.

In our considered opinion, OP has displayed only mala fide, in further demanding treatment papers having already rejected the claim based on exclusion clause. We have also seen the exclusion clause, which does not in any way cover the simple illness of complainant.

It has been repeatedly observed by us in numerous cases that OP insurance companies turn their face away at the time when consumer needs it most, and sell the policies on the promises of cashless facilities, just to get more and more business on false promises, which they do not intend to fulfill.

In this particular case, we find that complainant was badly ill, she was found suffering from Hepatitis B and HIV +ve and many report were still pending. She has secured the insurance upto Rs.2 lakh only for such a rainy day. Being poor lady, she decided to rather endanger her life by terminating treatment half way, due to totally insensitive and mercenary attitude of OP Insurance Company. There can be no greater disservice to the consumer than this kind of casual approach, just to deflect every cashless authorization on false pleas.

 In the given circumstances, we hold OP grossly deficient and direct OP to pay Rs.48,209/- with interest of 9% from date of bill paid in hospital. We also award punitive damages of Rs.1,00,000/- inclusive of litigation expenses for gross deficiency in service to a poor lady, which led her to get discharge from hospital in condition dangerous to her life.

The order shall be complied with within 30 days of the receipt of the copy of the order; otherwise action can be taken against OP under Section 25 / 27 of the Consumer Protection Act.

File be consigned to record room.

Copy of the order be sent to the parties free of cost.

 

        Pronounced in open Court on 24.11.2015.

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 (Ritu Garodia)

MEMBER