Order by:
Sh.Amrinder Singh Sidhu, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that complainant is policy holder of Health Insurance i.e. Family Health Optima Insurance Plan having policy no. P/211222/01/2021/004625 valid for the period 10.10.2020 to 09.10.2021 duly issued by the opposite party no.1, through opposite party no.2, vide this policy complainant and his wife alongwith their one minor child are covered/insured for the sum of Rs.5 Lac with a further recharge benefit of Rs.1,50,000/- i.e. for the total amount of Rs.6,50,000/-regarding their medical treatment expenses whatever incurred during the policy period, which includes the threat of Covid-19 also as per the policy in question and the same was purchased during the period of Pandemic Covid-19 on the assurance of concerned Branch Manager of Bank of Baroda as well as agent of the opposite party no.2. Further alleges that the plan of the policy in question was introduced by the officials of the Branch of Bank of Baroda where the complainant is having an account and the premium of the above said policy to the tune of Rs.9750/- alongwith the CGST @9% plus SGST/UTGST @ 9% total Rs.11,506//- was also deducted from the account of the complainant and was duly credited in the account of the opposite parties and the policy in question was issued. At the time of issuance of above mentioned policy the agent of opposite party no. 2 disclosed that in this policy the complainant, his wife and their minor child is covered regarding the medical treatment/health sufferings of any type which also includes the threat of Covid-19 for a total amount of Rs.6,50,000/- as fully mentioned in the policy cover. In the month of May 2021 wife of complainant, namely Smt.Shifali Garg who is also insured/covered under the said policy and also nominee in the said policy got some problem of fever, cough, cold etc. due to which the complainant took her to Garg Nursing Home, G.T. Road Moga where the concerned checkup revealed to complainant that these are the symptoms of Covid-19 and in this regard gave medicine for five days to the wife of complainant by saying that firstly she has to manager at home and if thereafter any complication/seriousness is arises she will be admitted in their hospital. At that time the concerned doctor also disclosed to the complainant that these are the symptoms of Covid-19 but as per the per the Government instructions they are directed to firstly gave only medicine to such type of patient with the advice for home isolation. Thereafter after taking five days medicine, on 18.05.2021 wife of complainant did not cure rather suffered difficulty in breathing and also got some other problems and the complainant along-with his wife immediately arrived in the emergency ward of Garg Nursing Home as the condition of the wife of complainant was serious, who earlier gave the medicine to the wife of complainant, where the doctors after checkup diagnosed that the Saturation of complainant was 82% on room air and advised to admit the patient in hospital. So, as per the advise of concerned doctor the complainant admitted his wife in the said hospital immediately as the doctor said that wife of complainant falls under the category of severe sickness and needs care of ICU and she is confirmed patient of Covid-19 and admitted the wife of complainant in the hospital by seeing her critical condition. In the said hospital the wife of complainant remained admitted from 18.05.2021 to 27.05.2021 for the treatment of Covid-19 taken by her as an inpatient and the doctors of the said hospital charged Rs.1, 22, 910/- for the total treatment of the wife of complainant who is insured/covered under the above mentioned policy. During the treatment at Garg Nursing complainant also got conducted some blood tests of his wife on the advice of concerned doctor from the Sigma Diagnostic Labs, Aara Road, Opposite Civil Hospital Moga and paid Rs.550/- on 20.05.2021 and again Rs.550/- on 22.05.2021 from his own pocket. Thereafter, after discharge of his wife, the complainant lodged a claim before the opposite parties along-with the original documents and other formalities required by the them for the processing of claim of complainant. However, the complainant has received a letter Dt. 19.07.2021 vide which the opposite parties have repudiated the claim of complainant on flimsy grounds by saying that as per the opinion of team of their doctors the hospitalization was not warranted and the patient could have been managed under home quarantine which is totally a baseless ground only to forfeit the genuine and legal claim of the complainant, because a common person who does not know the complications/seriousness of the medical problems would always follow the advise of concerned doctor which the complainant also followed in the present case and admitted his wife in the hospital only after the advise of concerned doctor to save the life of his wife who was on the verge death of at that time. Moreover, it is mal practice on the part of opposite parties that they have repudiated the genuine claim of the flimsy grounds which also creates deficiency in service on the part of opposite parties. Complainant issued a legal notice Dt.15.09.2021by mentioning all the true and real facts in it regarding the suffering of his wife with Covid-19 and the treatment taken by her from the above mentioned hospital. The complainant also demanded the amount of Rs.1, 23, 910/- vide said legal notice from the opposite parties, but the opposite parties did not pay any heed to the requests and legal, genuine demand of complainant and even did not reply to said legal notice. Thereafter also the complainant a number of times approached the opposite and requested to pay his genuine and legal claim, but to no effect. Hence this complaint, vide instant complaint complainant has sought the following reliefs:-
a) Opposite parties may be directed to an amount of Rs.1,23,910/- which is spent by the complainant for the treatment of wife.
b) To pay Rs.1,00,000/- as compensation on account of mental tension, agony and harassment to the complainant.
c) To pay Rs.25,000/- as litigation charges.
d) And any other relief which this Commission deem fit and proper in the interest of justice and equity.
2. Opposite parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present complaint is ex-facie misconceived, vexatious, untenable and devoid of any merit. The complainant has approached this Hon'ble forum with unclean hands and has made this complaint in order to raise a premeditated, false and frivolous dispute to harass the answering opposite party/respondent. The present complaint is without any cause of action. The complainant has tried to manipulate the facts for imposing this false and frivolous complaint. The present application pertains to insurance claim under Family Health Optima Insurance Plan Policy bearing No.P/211222/01/2021/004625 valid from 10/10/2020 to 09/10/2021 covering the Complainant self and his wife Shifali Gupta and Yashav Garg dependent child, for a sum of Rs. 5,00,000/-. However, it is submitted that the aforesaid insurance policy was issued to the insured by the answering OP 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 OP, then it would be subject to the terms and conditions of the insurance policy. Further stated that the insured submitted the claim documents for the reimbursement of medical expenses towards the treatment of Covid-19 positive for hospitalization from 18.05.2021 to 27.05.2021 at Garg Nursing Home, Moga. On scrutiny of claim documents the medical team of the answering company observed from the indoor case records of the treating hospital that the insured patient was mildly symptomatic of the Covid19 disease, vital signs were stable throughout the period of hospitalization and the investigation reports were within normal limits and the medical team of the opposite party insurance company was of the opinion that the hospitalization was not warranted and the insured patient could have been managed under home quarantine only. Hence, the claim was finally rejected and it was conveyed to insured. The claim was repudiated under the ambit of specific guidelines of Ministry of Health and Family Welfare, Government of India. As such, in terms of the said provision of the insurance policy, the insurance company have repudiated the claim of applicant in a proper manner, after due application of mind. Subsequently, the insured submitted representation to reconsider the claim. On receipt of the representation, noted that
(a) As per the admission slip the SPO2 is 82%.
(b) As per the ICP,
a. 18/05/2021 - the saturation is not noted
b. On 19/05/2021 - SPO2 level is 90.
c. On 20/05/2021 - SPO2 level is 92.
d. On 21/05/2021 - SPO2 level is 92.
e. On 22/05/2021 - SPO2 level is 94.
f. On 23/05/2021 - SPO2 level is 93.
g. On 24/05/2021 - SPO2 level is 94.
h. On 25/05/2021 - SPO2 level is 93.
i. On 26/05/2021 - SPO2 level is 94.
j. On 27/05/2021 - SPO2 level is 96.
(d) There is no ICU management notings, only in the admission slip (a white paper with seal at the bottom). It is noted that the insured was admitted in ICU for further management).
(e) No course of hospitalization and vitals on admission is noted in the Discharge summary.
From the above findings, it is noted that there is a discrepancy in the claim documents, which amounts to misrepresentation of claim documents. As per condition No.6, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the Company is not liable to make any payment in respect of any claim. The instant complaint is neither maintainable in law nor on facts and the same is liable to be dismissed in limine. No deficient services have been rendered by the answering opposite parties as alleged by the complainant. The claim in question was duly entertain, inquired into and after due application of mind the alleged claim has been repudiated on the basis of terms and conditions of insurance policy. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint has been made.
3. Complainant has also filed replication to the written reply of opposite parties, vide which the objections raised by the opposite parties in their written reply have been denied by complainant.
4. In order to prove his case, complainant tendered in evidence his affidavit Ex.C1 along with copies of documents Ex.C2 to Ex.18 and affidavit of Dr.Vikas Garg, M.B.B.S, D.A. (Anesthesia), Garg Nursing Home Ex.C-19.
5. On the other hand, to rebut the evidence of complainant, ld. counsel for the opposite parties tendered in evidence affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1, 2/A along with copies of documents Ex.OP1, 2/1 to Ex.OP1, 2/15.
6. During the course of arguments, both the ld. counsel for the complainant as well as ld. counsel for the opposite parties have mainly reiterated the facts as narrated in the complaint as well as written reply respectively. We have perused the rival contentions of both the parties and have gone through the record. Ld. counsel for the complainant contended that complainant has purchased the Health Insurance i.e. Family Health Optima Insurance Plan having policy no. P/211222/01/2021/004625 valid for the period 10.10.2020 to 09.10.2021 from the opposite parties and the sum assured under the policy is Rs.5 Lac with a further recharge benefit of Rs.1,50,000/- i.e. for the total amount of Rs.6,50,000/-regarding their medical treatment expenses whatever incurred during the policy period, which includes the threat of Covid-19 also. In the month of May 2021 wife of complainant, namely Smt.Shifali Garg got some problem of fever, cough, cold etc. due to which the complainant took her to Garg Nursing Home, G.T. Road Moga where the concerned checkup revealed to complainant that these are the symptoms of Covid-19 and in this regard gave medicine for five days to the wife of complainant by saying that firstly she has to manager at home and if thereafter any complication/seriousness is arises she will be admitted in their hospital. Thereafter after taking five days medicine, on 18.05.2021 wife of complainant did not cure rather suffered difficulty in breathing and also got some other problems and the complainant along-with his wife immediately arrived in the emergency ward of Garg Nursing Home, where the doctors after checkup diagnosed that the Saturation of complainant was 82% on room air and admitted the wife of complainant in the hospital by seeing her critical condition. In the said hospital the wife of complainant remained admitted from 18.05.2021 to 27.05.2021 for the treatment of Covid-19 and the doctors of the said hospital charged Rs.1, 22, 910/- for the total treatment of the wife of complainant. During the treatment complainant also got conducted some blood tests of his wife from the Sigma Diagnostic Labs, Aara Road, Opposite Civil Hospital Moga and paid Rs.550/- on 20.05.2021 and again Rs.550/- on 22.05.2021 from his own pocket. Thereafter, after discharge of his wife, the complainant lodged a claim before the opposite parties along-with the original documents and other formalities required by the them for the processing of claim of complainant. However, the opposite parties repudiated the claim of the complainant vide letter Dt. 19.07.2021on the ground that as per the opinion of team of their doctors the hospitalization was not warranted and the patient could have been managed under home quarantine.
7. On the other hand, ld. counsel for the opposite parties has repelled the contention of the complainant on the ground that he insured submitted the claim documents for the reimbursement of medical expenses towards the treatment of Covid-19 positive for hospitalization from 18.05.2021 to 27.05.2021 at Garg Nursing Home, Moga. On scrutiny of claim documents the medical team of the company observed from the indoor case records of the treating hospital that the insured patient was mildly symptomatic of the Covid19 disease, vital signs were stable throughout the period of hospitalization and the investigation reports were within normal limits and the medical team of the opposite party insurance company was of the opinion that the hospitalization was not warranted and the insured patient could have been managed under home quarantine only. Hence, the claim was finally rejected. We do not agree with the contention of ld. counsel for the opposite parties, because ld. counsel for the complainant has placed on record prescription slip Ex.C14 of Dr.Vikas Garg, M.B.B.S. DA. (Anaesthesia), who treated the wife of the complainant, he clearly mentioned in the prescription slip that “As per guidelines from All India Institute of Medical Sciences, New Delhi and Ministry of Health and family welfare, Govt. of India regarding treatment of Covid-19 this patient falls in category of severe Sickness and need care of ICU without need of non-masive/invasive ventilation. A patient whose is obese with B.M.I 38.89 with uncontrolled diabetes (steroid) induced and spo2 cannot be sent home for management.” Complainant also produced on record duly sworn affidavit of Dr.Vikas Garg, M.B.B.S. D.A. (Anesthesia), Garg Nursing Home, in which it is mentioned that “After proper check up of Smt.Shifali Garg, the deponent found that her saturation was only 82% on room air at that time, so the deponent advised Sh.Vishal Gupta to admit her in hospital as the patient was in need of ICU care at that very time being suffering from severe sickness and being a confirmed patient of Covid-19.” On the other hand, opposite parties failed to rebut the aforesaid affidavit of Dr.Vikas Garg by any cogent and convenience evidence or by affidavit of any doctor. In this opposite parties failed to prove that hospitalization of the wife of the complainant was not warranted.
8. In such a situation the repudiation made by the Opposite Party-Insurance Company regarding genuine claim of the complainant have been made without application of mind. It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
9. Resultantly, we partly allow the complaint of the complainant and the Opposite Parties are jointly or severally directed to pay an amount of Rs.1,23,910/-(Rupees One lakh twenty three thousand nine hundred ten only) which was spent by the complainant on the treatment of his wife alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 22.11.2021 till its actual realization to complainant. The compliance of this order be made by the Opposite Parties within 60 days from the date of receipt of copy of this order, failing which the Complainants shall be at liberty to get the order enforced through the indulgence of this Commission. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Commission.
