Haryana

Bhiwani

CC/85/2022

Atul Kumar - Complainant(s)

Versus

Satar Health Jic - Opp.Party(s)

Deepanshu Tuteja

22 Jul 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                            Consumer Complaint No. :  85 of 2022

                                                       Date of Institution            : 02.05.2022

                                                                 Date of order                   : 22.07.2024

 

Atul Kumar son of Sh. Bishan Sarup R/o H.No.398 Bagh Kothi, Gali No.3, Bhiwani, Tehsil and District Bhiwani.

  

           ……Complainant.

 

Versus

 

1. Star Health and Allied Insurance Co. Ltd., Reg. and Corporate Office 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai -600034 through its Director/Chairman.

 

2. Star Health and Allied Insurance Co. Ltd., Branch Office at SCF No.47, Panchayat Bhawan Pocket, Bhiwani-127021 through its Branch Manager.

 

…… Opposite Parties.

 

COMPLAINT U/S 35 OF CONSUMER PROECTION ACT, 2019.

 

BEFORE:       Mrs. Saroj Bala Bohra, Presiding Member.

  Ms. Shashi Kiran Panwar, Member.

 

Present:-        Sh. Deepanshu Tuteja, Advocate for complainant.

                     Sh. Avinash Sardana, Advocate for OPs.

 

ORDER:

 

Saroj Bala Bohra, Presiding Member:

 

1.                 In brief, facts of this case are that complainant taken a family Health Optima Insurance Plan from OP No.2 on 06.05.2019 and it was renewed from time to time. Complainant paid Rs.26001/- for the second renewal of the policy having insured value of Rs.10.00 lacs and was covering scheme description 2A + 2C. The policy was for a period from 06.05.2021 to 05.05.2022.  It is alleged that complainant fell ill and was admitted in Nitesh Goel Heart & Poison Hospital, Meham Chowk, Bhiwani on 08.05.2021. He was diagnosed as Acute Colitis with TCP and remained admitted there upto 15.05.2021. A sum of Rs.1,62,987/- was incurred on the treatment, however, the OP No.1 approved bill of Rs.1,25,206/- on 15.07.2021. Complainant has submitted that OP made deductions of Rs.38,781/- without any sufficient reason and cause for which they are bound to make the payment of the remaining amount. It has submitted that complainant again fell ill and was admitted in this said hospital on 14.06.2021 and was diagnosed as Allergic Bronchitis with Accelerated HTN. Complainant submitted to OP bill of Rs.26,788/- but the claim was repudiated by OPs vide letters dated 20.07.2021 & 16.09.2021. Hence, the present complaint has been preferred by complainant alleging deficiency in service on the part of Ops resulting into monetary loss besides mental and physical harassment. In the end, prayer has been made to direct the OPs to pay Rs.65,569/- alongwith interest @ 18% per annum from the date of submission of respective claim bills till payment, further to pay Rs.50,000/- towards compensation for harassment besides Rs.22,000/- as litigation expenses. Any other relief, to which this Commission deems fit, has also been sought.

2.                 Upon notice, OPs appeared through counsel and tendered reply raising preliminary objections qua maintainability of complaint, deficiency in service, locus standi & cause of action and suppression of material facts. On merits, it is submitted that on the basis of available documents, claim was processed and settled at Rs.1,25,206/- after applying exclusion ‘Other Excluded Items’ under the policy and the amount was paid to complainant on 20.07.2021. The second claim of complainant for the period from 14.06.2021 to 16.06.2021 was repudiated vide letter dated 20.07.2021 as the insured could have been treated as an outpatient and hospitalization was not warranted. Complainant requested review of such repudiation but repudiation was again confirmed on finding various irregularities in the hospital record during investigation. In the end, it is submitted that if liability of OPs are fixed to pay the claim amount then it may be maximum of Rs.23,160/-. In the end, denied for any deficiency in service and prayed for dismissal of the complaint with costs.

3.                 In evidence of complainant, his affidavit Ex.CW1/A alongwith documents Ex. C-1 to Ex.C-6 were tendered and then closed the evidence.

4.                 In evidence of OPs, affidavit of Mr. Sumit Kumar Sharma, Senior Manager of OP company as Ex. RW1/A alongwith documents Annexure R-1 to Annexure R-16 were filed and then closed the evidence.

5.                 We have heard learned counsels for the parties and perused the record carefully.

6.                 Undisputedly, complainant was under insurance cover during the period of treatment. Pleadings of OPs are that the first claim was

submitted by complainant for Rs.1,62,317/-, out of which, Rs.1,25,206/- was paid to him and rest of Rs.37,111/- was not payable because of several exclusions under the policy. The second claim was denied to the complainant on the ground that he could have taken treatment as outdoor patient and thus the treatment taken as indoor patient was not justified as well as there were some other irregularities in the treating hospital records viz. the indoor case records were devoid of IP number, UHID number, room category and ward number and there was no pathologist. However, the OP still admits their liability  to the tune of Rs.23,160/-.

7.                 After hearing learned counsels for the parties and going through the entire record, we have observed that the OP insurance company has  arbitrarily and unnecessarily deducted Rs.37,111/- from the claimed amount of Rs.1,62,317/-. Further the second claim for Rs.26,788/- has also been denied to complainant in a casual manner. It is worthwhile to mention here that whether  a person is required indoor treatment or outdoor depends on situation of the illness and upon the wisdom of a doctor whereas patient has only follow the instructions of the treating doctor. From Ex. C-4, Emergency certificate and Discharge Certificate Ex. C-3, complainant was admitted in the hospital from 14.06.2021 to 16.06.2021 and incurred Rs.26,788/- on his treatment. On the contrary, OPs in support of their contentions have not examined any medical expert who suggested such deductions/denial of claim nor his affidavit has been placed on record. In such a situation, the treatment taken by complainant and amount incurred thereof is proved. 

8.                 In view of the above discussion, we are of the view that OP insurance company has wrongly and illegally repudiated the claim of complainant just to cheat and harass the complainant which amounts to deficiency in service and mal-trade practice on their part resulting into monetary loss as well as mental and physical harassment. Accordingly, the complaint is allowed and the OPs, jointly and severally, are directed to comply with the following directions within 40 days from the date of order:-

 

 (i)      To pay a sum of Rs.63,899/- (Rs. Sixty three thousand eight hundred ninety nine) to the complainant so incurred by him on his treatment alongwith simple interest @ 9% per annum from the date of filing of complaint till actual realization.

(ii)      To pay Rs.5,000/- (Rs. Five thousand) as compensation   for  harassment. 

3. To pay Rs.5500/- (Rs. Five thousand five hundred) as litigation expenses.

                    In case of non-compliance, all the awarded amounts shall attract simple interest @ 12% per annum for the period of default. 

                    The complainant shall be entitled to the execution petition under section 71 of Consumer Protection Act, 2019 and in that eventuality, the opposite parties may also be liable for prosecution under Section 72 of the said Act which envisages punishment of imprisonment, which may extend to three years or fine upto rupees one lac or with both.  Copies of this order be sent to the parties concerned, free of costs.  File be consigned to the record room, after due compliance. 

Announced.

Dated: 22.07.2024