Punjab

Ludhiana

CC/15/10

Amritpal Singh - Complainant(s)

Versus

Star Healh & Allied Ins.Co.Ltd - Opp.Party(s)

A.S.Arora

30 May 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

Consumer Complaint No. 10 of 02.01.2015

Date of Decision            :   30.05.2016

 

Amritpal Singh son of Shri Kartar Singh, resident of 13140, Vijay Nagar, Grewal Market, Tajpur Road, Ludhiana and presently resident of 172-A, Block-B, Ahluwalia Colony, Kuliawal, Jamalpur, Ludhiana.

….. Complainant

Versus

1.Star Health and Allied Insurance Company Limited, Registered and Corporate Office No.I, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai 600034 through its Manager/authorized representative.

2.Star Health and Allied Insurance Company Limited, Branch Office at 2716, Ist Floor, Gagan Complex, Backside Majestic Park Plaza Hotel, Gurdev Nagar, Pakhowal Road, Ludhiana through its Branch Manager.

…Opposite parties

 

                             (Complaint U/s 12 of the Consumer Protection Act, 1986)

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

MS.BABITA, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant                      :           Sh.Amandeep Singh Arora, Advocate.

For OPs                          :           Sh.Akash Bhalla, Advocate

 

PER G.K DHIR, PRESIDENT

 

1.                          Sh.Amritpal Singh filed complaint under Section 12 of the Consumer Protection Act, 1986(hereinafter referred to as ‘Act”) against OPs, by claiming that in the year 2011, he purchased a family health optima insurance policy from OPs on payment Rs.6530/- as premium for the period from 14.3.2011 to 13.3.2012. That policy covered the health risk of the complainant and his wife for assured sum of Rs.5 lac. That policy was got continued on year to year basis by the complainant. Premium of Rs.5877/- was paid for continuing that policy for the year 2013 and 2014 and said policy was again got issued by the complainant for self as well as for family vide new policies on payment of premiums of Rs.5955/- and 7736/- respectively with validity upto 27.2.2015. On 21.9.2014, during night at about 11:00 PM, complainant was not feeling well because his left eye was unable to close. Complainant tried to drink water but the same itself came out from his mouth. Complainant was unable to close his mouth and thereafter, wife of the complainant took him to S.P.S.Apollo Hospital, Sherpur Chowk, Ludhiana in emergency. Complainant was admitted in that hospital. Intimation regarding cashless treatment policy was given to the hospital authorities. Policy card was also given by the wife of the complainant. That necessary intimation was given to the OPs in the morning. Wife of the complainant was asked to deposit a sum of Rs.5000/- immediately by disclosing that on such deposit alone, the doctor will start the treatment. That amount was deposited under compulsion through credit card. On the next date i.e.on 22.9.2014 in the morning, OPs were informed about the admission of the complainant in the above said hospital qua the above said problem. Ops lodged the claim No.0138870 in their record and acknowledgment of the same was conveyed to the complainant via SMS on cell phone. MRI of brain/head of the complainant was performed by the doctors and even medical investigations/tests/scans were conducted. Dr.Rupinder Singh Bhatia, Senior Consultant (Neurology) gave treatment accordingly. Complainant remained admitted for treatment upto 25.9.2014. During admission period, family of the complainant was called upon to deposit a sum of Rs.28,497/- immediately, which was deposited through credit card. Rs.670/- separately was deposited as Bank Commission/charges. In this way, complainant was compelled to pay total sum of Rs.34,167/-. Complainant approached OPs for getting knowledge as if his medical claim is rejected. That rejection is without cogent reasons. Complainant was called upon to submit the documents again and he did so. Despite that Ops kept on procrastinating the matter and complainant reported the matter to the Grievance Redressal Department of OPs, but nothing happened and that is why, by pleading deficiency in service and unfair trade practice on the part of OPs, compensation of Rs.1 lac for mental pain, agony and physical harassment sought along with reimbursement of Rs.34,167/-.

2.                          In written reply submitted by OPs, it is claimed that the complainant submitted duly signed proposal form after understanding the terms and conditions of the policy. Those terms and conditions are strictly in accordance with IRDA guidelines. OPs took all the necessary precautions for informing the complainant about the terms and obligations under the policy. This complaint alleged to be pre-mature because the complainant had not submitted the requisite documents for the purpose of claim despite repeated requests sent by the OPs. Complaint alleged to be filed with malafide intention for grabbing public money. Besides, it is claimed that complainant does not fall under the definition of the consumer as laid under the Consumer Protection Act. It is also claimed that complainant has not approached this Forum with clean hands because he has filed a false, frivolous, misconceived and vexatious complaint by concealing the true and material facts. It is claimed that complainant has no locus standi and cause of action. Admittedly, complainant purchased Family Health Optima Insurance Policy covering self and his wife for assured sum of Rs.5 lac with validity period from 28.2.2014 to 27.2.2015. From the documents available with OPs, they scrutinized the claim records and observed that the complainant was admitted for treatment of Lower Motor Neuron Lesion. However, complainant had not submitted the sufficient documents despite sending of letters dated 23.9.2014 and 25.9.2014. Original discharge summary, final bill and payment receipts, indoor case papers and investigation reports performed during the admission are alleged to be not submitted by the complainant. In view of non submission of these documents, complaint of the complainant alleged to be premature. Each and every other averment of the complaint denied.

3.                Counsel for the complainant tendered in evidence affidavit Ex.CA  of complainant along with documents Ex.C1 to Ex.C37 and thereafter, he closed the evidence.

4.                On the other hand, counsel for OPs tendered in evidence affidavit Ex.RW1/A of Sh.Rajnish Kohli, Assistant Vice President of Claims, Star Health and Allied Insurance along with documents Ex.R1 to Ex.R11 and thereafter, closed the evidence.

5.                          Written arguments submitted by the OPs, but oral arguments addressed by counsel for the parties. Records gone through minutely. 

6.                Undisputedly, Star Health and Allied Insurance Policy was purchased by the complainant and terms of the said insurance policy produced on record as Ex.R9 by the OPs. Copies of insurance cover notes Ex.C1 to Ex.C4 are produced by the complainant and those are also produced on record as Ex.R1 to Ex.R3 by the Ops. So, certainly the complainant was covered under the policy for the period from 22.9.2014 to 21.9.2015, during which period, he got treatment from S.P.S.Apollo Hospital, Sherpur Chowk, Ludhiana. Records of retail invoice Ex.C5, copy of advance receipt Ex.C6, copy of another receipt Ex.C7 and all other records of treatment are produced on record are Ex.C8 to Ex.C17, Ex.C21 to Ex.C35.

7.                Denial of pre-authorization for cashless treatment done through letter Ex.C37. That denial was done on the grounds that there is lack of clarity of case; documents are not sufficient; cause for facial nerve plasy is not clear; there is no risk factor  presented  with  only  deviation  of m outh;  details  and  degree of palsy is not clear. That denial is inappropriate, particularly  when the above referred hospital records establishes that case of the complainant was diagnosed as a case of ‘Left 7^th LMN palsy’ as disclosed by the discharge summary Ex.C17. Admission of the complainant during night took place for that treatment on 23.9.2014 is also a fact borne from certificate Ex.C9 of doctor concerned. Report Ex.C8 of Dr.R.S.Bhatia shows that the electrophysiological findings are suggestive of left facial involvement. That LMN palsy is disclosed in Ex.R7 (discharge summary produced by the OPs) as Lower Motor Neuron Lesion. Lower Motor Neuron Facial Palsy means idiopathic facial paralysis (IFP) as per search on internet. So, the treatment for which, the complainant admitted in S.P.S.Apollo Hospital, Ludhiana was idiopathic facial paralysis. In an LMN lesion, the patient can’t wrinkle their forehead, the final common pathway to the muscle is destroyed. The lesion must be either in the pons, or outside the brainstem (posterior fossa, bony canal, middle ear or outside skull). The most common system used for describing the degree of paralysis is the House-Brackmann scale, where 1 is normal power and 6 is total paralysis. Amplitude of left facial measured as 2.12 MV, but of right facial as 4.24 MV in page no.2 of report Ex.C8. So, report Ex.C8 itself reflect as if the degree of paralysis in this case was abnormal because it was more than 1. In view of this report Ex.C8 read with report Ex.C17, it is made out that due to diagnosis of LMN palsy, complainant complained of deviation of mouth; heaviness over left ear, difficulty in swallowing since midnight. These chief complaints specifically mentioned in Ex.C17. Complainant was managed conservatively with IV antibiotics, steroids and other supportive treatment and thereafter, he was discharged in stable condition is a fact borne from page no.2 of Ex.C17. Physiotherapy treatment even was advised and the complainant was called upon to approach emergency services, in case of need. Complainant was advised to visit Neurology OPD after 5 days. All this records of discharge summary or of treatment or of Neurophysiological findings contained in Ex.C8 leads to the inference as if there was involvement of left facial of the complainant, due to paralysis of some of low amplitude. In view of this, rejection of claim is improper, particularly when record of Ex.R5 discloses that the complainant was having no previous history of similar complaints. Even in Ex.R5, the chief complaints referred above are mentioned qua deviation of mouth etc. Complainant authorized M/s Star Health and Allied Insurance Company to collect his medical information/records from the hospital, where he got treatment and as such, complainant has not denied the assess to the Ops to the hospital record at all. Rather, whatever documents available with the complainant, the same have been supplied by the complainant and he has not concealed the facts qua previous ailments and as such, the complainant being purchaser of the health insurance policy in question, entitled for the due insurance claim amount.

8.                 It is vehemently contended by the counsel for the OPs that terms and conditions of the insurance policy are binding and that there is no dispute in this regard. Even if terms and conditions of the insurance policy are binding, despite that in case complainant has not submitted the original discharge summary or final bill and payment receipts or indoor case papers etc., despite that Ops themselves can collect these documents from the hospital authority. Repudiation of claim for not providing the available medical record is not justified at all because in case titled as Avneet G.Singh vs. ICICI Lombard General Insurance Company Limited and others-2014(2)CLT-374(CHD), it has been held that when a cashless health insurance policy purchased by complainant and he lodged claim by providing the available medical record with him, then claim of insurance cannot be repudiated merely because of non supply of some more record because the insurance company itself can collect medical record from hospital concerned.  In view of this legal position, in case some of the documents not provided by the complainant, then Ops themselves can collect the medical records from the  hospital concerned. Rather, plea taken by the OPs is that complaint is premature and     as such virtually Ops have not finally denied the claim of the complainant. However, complainant has to face mental agony and harassment because of denial of cashless facility and as such, complainant is entitled for compensation for mental agony and harassment as well as for litigation expenses.

9.                As a sequel of above discussion, complaint allowed in terms that Ops will finalize the claim of the complainant within 90 days from the date of receipt of copy of this order by collecting the necessary documents from S.P.S.Apollo Hospital, Sherpur Chowk, Ludhiana or by verifying the required documents from the records of that hospital. In case, Ops require any documents from the complainant, then they will serve written notice upon the complainant for producing that records. After receipt of that notice in writing, complainant will respond within 10 days there from. In case, the complainant is not in possession of the sought documents, then complainant will submit the affidavit with Ops qua non possession of the concerned required documents. If any records from the complainant to be sought by the OPs, then notice in writing must be served within 10 days from the receipt of copy of this order. Compensation of Rs.5000/- for mental harassment and agony and litigation expenses of Rs.5000/- more allowed in favour of the complainant and against OPs. Payment of compensation and litigation amounts be made within 30 days from the date of receipt of copy of this order. Copies of order be supplied to parties free of costs as per rules.

10.              File be indexed and consigned to record room.

 

                             (Babita)                                        (G.K. Dhir)

                             Member                                           President

Announced in Open Forum.

Dated:30.05.2016. 

GurpreetSharma