Order by:

Smt.Priti Malhotra, President

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that complainant obtained a ‘Family Health Optima Insurance Plan’ from the Opposite Party vide policy no.P/211222/01/2022/010965 valid from 11.03.2022 to 10.03.2022 having limit of coverage of Rs.5,50,000/- covering complainant himself, Seema Kansal, Pankaj Kansal and Kamal Kansal having third year renewal, as the policy was incepted on 11.03.2019. Unfortunately, son of the complainant namely Kamal Kansal got ill on 20.04.2022 and he got treatment from Guru Nanak Dev University Health Centre, Amritsar, but his body temperature did not come normal due to which he again took medicine from said health centre on 21.04.2022. Even after taking such medicines the body temperature of son of the complainant did not come normal, the complainant got his son treated from Dr.Vijay Pahuja, M.D. c/o Pahuja Multispeciality Clinic, Main Bazaar, Moga on 23.04.2022, but even then his son had no recovery of any kind and body temperature was still rising day by day, thus complainant got his son treated from Dr.Seemant Garg c/o Sharm Nursing Home, Moga on 27.04.2022 and took medicine on 01.05.2022. Even then the son of the complainant did not get well, due to which complainant took him to another doctor namely Dr. Suresh Singal c/o Suresh Nursing Home, Moga on 02.05.2022. His son remained admitted in Suresh Nursing Home from 02.05.2022 to 07.05.2022. As such, the complainant incurred medical expenses of Rs.22,529/- at Suresh Nursing Home plus Rs.1700/- qua blood tests etc. totaling Rs.24,229/-.The complainant lodged the claim with Opposite Party for the reimbursement of the medical expenses, but the opposite party vide letter dated 04.06.2022 repudiated the claim of the complainant on false and illegal ground that “the hospitalization of the insured patient is not warranted and medicine bill numbers are in consecutive for consecutive days and there is discrepancy in the record, which amounts to misrepresentation of facts and thus repudiated the claim.”.Further alleged that at the instance of Opposite Party, the complainant got issued certificate dated 10.06.2022 from Dr.Suresh Singal, vide which the doctor mentioned the detailed reason of getting the patient admitted and also proved the fact that the bill issued by them are genuine, but to no effect. The complainant made several requests to the Opposite Party to admit his rightful claim and served a legal notice dated 21.09.2022 upon the Opposite Party, but all in vain. Hence this complaint Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite party may be directed to pay the amount of Rs.24,229/- alongwith interest @ 18 % p.a.

 b)     To pay an amount of R.3,00,000/- as compensation on account of damages for physical as well as mental pain and agony suffered by the complainant.

c)       To pay an amount of Rs.50,000/- as litigation expenses.

d)      And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite Party appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present complaint is filed without any cause of the action. The present complaint pertains to insurance claim under Family Health Optima Insurance Policy bearing no.P/211222/01/2022/010965 valid from 11.03.2022 to 10.03.2023 covering the Complainant himself and his spouse Seema Kansal, dependent children namely Pankaj Kansal and Kamal Kansal for a sum of Rs.5,00,000/-. However the aforesaid insurance policy was issued to the insured by the answering Opposite Party subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of the contract. Moreover the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same were served to the complainant along with policy schedule. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Therefore it is submitted that in case if any liability would arise against the answering Opposite Party, then it would be subject to the terms and conditions of the insurance policy. Further alleged that the insured submitted the claim documents for the reimbursement of medical expense towards the treatment of Entric Fever for hospitalization at Suresh Nursing Home, Moga, from 02.05.2022 to 07.05.2022. On scrutiny of the claim documents the medical team of the answering Opposite Party observed that the hospitalization of the insured patient was not warranted. Further the indoor case records and vital charts have been found in stereotyped manner and the medicine bill numbers are in consecutive for consecutive days and thus there is discrepancy in the records  which amounts to misrepresentation of the facts. Based on these findings, the claim was repudiated vide letter dated 04.06.2022 as according to the condition no.1 of the policy the claim for the alleged medical expenses is based upon the basis of misrepresentation and the deliberate manufactured record. Hence, the claim was finally rejected and it was conveyed to insured. The claim was repudiated under the ambit of specific condition no.1 as mentioned under the policy terms and conditions. The instant complaint is neither maintainable in law nor on facts. No deficient services has been rendered by answering Opposite Party. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       Complainant also filed replication to the written reply of Opposite Party, vide which, all the objections raised by the Opposite Party in the written reply are denied.

4.       In order to prove his case, complainant tendered in evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C16 and Ex.C9/A.

5.       To rebut the evidence of the complainant, Opposite party tendered in evidence affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1/A alongwith copies of documents Ex.OP1/1 to Ex.OP1/11.

6.       We have heard the counsel for the parties and also gone through the documents placed on record.

7.       It is well proved on record that the complainant obtained the mediclaim policy namely ‘Family Health Optima Insurance plan’ covering his wife Seema Kansal and two dependent children namely Pankaj Kansal and Kamal Kansal for the period 11.03.2022 to 10.02.2022 (Ex.C2) from the Opposite party. Further it is also evident on record that during the policy coverage son of the complainant namely Kamal Kansal, duly insured under the policy fell ill and for his treatment, the complainant visited different doctors/clinics, which is duly proved on record vide Ex.C3 to Ex.C7 and finally he got admitted his son in Suresh Nursing Home, where complainant’s son remained admitted for the period w.e.f 02.05.2022 to 07.05.2022.

8.       The main dispute arises between the parties when the claim lodged by the complainant for the expenses incurred on the treatment of his son was repudiated by the Opposite party on the ground that “hospitalization of the insured patient is not warranted and further the indoor case records and vital charges are in stereotyped manner; the medicine bill numbers are in consecutive for consecutive days and there is discrepancy in the records”

9.       In our considered opinion, the pleas/defences taken by the Opposite party while repudiating the claim of the complainant on the ground that medical record seems to be in genuine and hospitalization of the insured patient is not warranted, are not justified. The officials of the Opposite party intentionally ignored the factum that son of the complainant duly insured under the policy fell ill and the complainant for getting his son treated visited number of doctors/clinics i.e. one after the other and when there was no relief from the ailment, finally the complainant visited Suresh Nursing Home, Moga, wherein after getting the required tests conducted son of the complainant got admitted on 02.05.2022 and thereafter  after due treatment he was discharged from the hospital in stable condition on 07.05.2022. We  surprise to note that how the officials concerned of the Opposite party mistook to conclude that hospitalization of the insured was not warranted and was not required. It is matter of common prudence that decision qua hospitalization is the sole prerogative of the doctor concerned to decide which is need based and not at the sweet will of the patient concerned. However, also there is no report and opinion of the doctor concerned of the Opposite party to opine that the hospitalization of the complainant’s son was not required. In the absence of any substantial evidence on record countering the genuine claim of the complainant, this complaint deserves to be allowed.  We do not find any reasonable justification in repudiating the genuine claim of the complainant by opposite party.

10.     Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant claimed the amount of Rs.24,229/-.  We found the claim of the complainant thoroughly genuine as bills for the claimed amount are duly been placed on record vide Ex.C9 and Ex.C14 and the subtotal of these two bills amounts to Rs.24,229/-, which is the claimed amount. Thus, claim of Rs.24,229/- is allowed with the following directions.

11.     From the discussion above, we partly allow the complaint of the complaint and direct the Opposite Party to pay a sum of Rs.24,229/- (Rupees Twenty Four Thousand Two Hundred Twenty Nine only) incurred by the complainant on the treatment of his son. For rejecting the genuine claim of the complainant, Opposite Party is also directed to pay compository amount of Rs.7000/- (Rupees Seven Thousand only) towards compensation and litigation costs to the complainant. The compliance of this order be made by the Opposite Party within 30 days from the date of receipt of copy of this order, failing which, the Opposite party are further burdened with additional amount of Rs.5000/- (Rupees Five Thousand only) to be paid to the complainant in addition to the awarded amount. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission