DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT
C.C. No. : 10 of 2018
Date of Institution: 23.01.2018
Date of Decision : 23.07.2019
Narinder Kumar Garg aged about 47 years s/o Jagdish Lal r/o House No. B-IV/126, Ward No.08, Mohalla Baba Farid, Faridkot, Tehsil and District Faridkot.
...Complainant
Versus
- Star Health Allied Insurance Company Ltd, through its Managing Director.
- Star Health Allied Insurance Company Ltd, through its authorized signatory;
Both having registered in Corporate Office at New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034.
- Star Health Allied Insurance Company Ltd, through its Advisor Balwinder Bansal resident of Near Tower, Adarsh Nagar, Faridkot.
.....OPs
Complaint under Section 12 of the
Consumer Protection Act, 1986.
Quorum: Sh. Ajit Aggarwal, President,
Smt Param Pal Kaur, Member.
cc no.-10 of 2018
Present: Sh Atul Gupta, Ld Counsel for complainant,
Sh H S Sandhu, Ld Counsel for OP-1 and OP-2,
OP-3 Exparte.
ORDER
(Ajit Aggarwal, President)
Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to them to make payment of insurance claim of Rs.4,47,565/-and for further directing OPs to pay Rs.2,00,000/- as compensation for harassment, inconvenience, mental agony besides litigation expenses of Rs.22,000/-.
2 Briefly stated, the case of the complainant is that at the instance of OP-3 complainant purchased a Family Health Optima Insurance Policy from OPs on 12.02.2016 and paid Rs.18,159/- to them. OPs issued Policy bearing no. P/211218/01/2017/002280 and got renewed the same in February, 2017. Policy in question covered complainant, his wife Neelam Garg, his children Kunal Garg, Sonu Garg and Neha Garg and at the time of purchase, none of their family member was suffering from any ailment. It is submitted that wife of complainant got health problem and all of sudden had problem in breathing. She was immediately taken to Dr Naveen Kumar, M D Medicine, who referred her to Higher Centre for further investigation and thereafter, complainant took his wife to Fortis Hospital, Ludhiana and after admission in said hospital, complainant sought pre authorization request to Opposite
cc no.-10 of 2018
parties treatment under cashless treatment, but Ops denied the same without any reason through e-mail dated 10.04.2017 though at the time of purchasing said insurance policy, Ops assured him for cashless treatment. Wife of complainant underwent treatment at Fortis Hospital and she remained admitted there in Department of Cardiovascular and Thoracic Surgery from 10.04.2017 to 19.04.2017. She was operated upon and vide bill dated 19.04.2017, complainant paid Rs.4,47,565/-to hospital authorities and after discharge therefrom, complainant lodged claim with Ops and submitted all the relevant documents regarding treatment of his wife to OPs, but vide letter dated 28.07.2017, they repudiated the claim of complainant. Even legal notice dated 6.12.2017 issued by complainant to OPs through his counsel, served no purpose. Act of OPs in repudiating the genuine claim of complainant amounts to deficiency in service and trade mal practice and it has caused harassment and mental agony to him for which he has prayed for directions to OPs to pay Rs.2,00,000/-as compensation alongwith Rs.22,000/- as cost of litigation besides the medical insurance claim. Hence, the present complaint.
3 The counsel for complainant was heard with regard to admission of the complaint and vide order dated 30.01.2018, complaint was admitted and notice was ordered to be issued to the opposite parties.
cc no.-10 of 2018
4 On receipt of the notice, OP-1 and 2 filed written statement taking preliminary objections that this Forum has no jurisdiction to hear and try the present complaint. It is asserted that there is no deficiency in service on the part of OPs. Complainant purchased the policy in dispute after fully understanding its terms and conditions and no cause of action arises in favour of complainant. Complainant has violated the terms and conditions of Policy and he has not come to the Forum with clean hands. Complainant has concealed the material facts from this Forum and thus, he is not entitled for relief sought by him. Complainant has no locus standi to file the present complaint. However, on merits, OP-1 and 2 have denied all the allegations of complainant and reiterated that there is no deficiency on their part. It is asserted that complainant purchased the policy in question for sum of Rs.5 lacs after going through all the terms and conditions of the policy and policy in question was issued to him on the basis of proposal form submitted by complainant himself.It is admitted that complainant submitted his preauthorization request for cashless treatment and same was denied vide letter dated 12.04.2017 stating that disease is of long standing natures and same has not been disclosed by him in proposal form. From the careful perusal of claim record for reimbursement of medical expenses submitted by complainant, it is observed that patient was under treatment of Dr. Naveen and Dr Sandhu prior to admission and therefore, they called for some documents which were mandatory for processing the claim under policy in questions vide
cc no.-10 of 2018
letters dated 3.06.2017, 18.06.2017, 3.07.2017 and 18.07.2017, but he has not submitted the documents sought from him and therefore due to non submission of requisite mandatory documents, claim of complainant was repudiated vide letter dated 29.07.2017. It is further averred that complainant came for reimbursement of amount of Rs.4,47,565/- on receipt of his claim, they asked him to provide detail of treatment taken prior to his admission alongwith investigation reports from Dr Naveen and Dr Sandhu, their prescription and reports of ECGs and Echo. Original discharge summary, complete set of hospital bill, payment receipt in original towards hospital final bill, bank account of primary insured including IFSC code alongwith cancelled cheque leaf and pan card of insured person, but repeated reminders, complainant has failed to provide the same and submitted only discharge summary, final bill with break ups and cancelled cheque and never submitted other documents required by them for processing claim and therefore, complaint filed by him in not maintainable as no cause of action arises against them. All the other allegations are denied being wrong and incorrect and prayer for dismissal of complaint with costs is made.
5 Notice containing copy of complaint and other relevant documents was duly served to OP-3, but despite having sufficient knowledge about the complaint against them, nobody appeared in the Forum on date fixed on behalf of OP-3 either in person or through counsel. It was presumed that OP-3 was not interested in
cc no.-10 of 2018
contesting the complaint and therefore, vide order dated 12.06.2018, OP-3 was proceeded against exparte.
6 Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to C-15 and then, closed his evidence.
7 In order to rebut the evidence of the complainant, counsel for OP-1 and OP-2 tendered in evidence affidavit of P S Tripathy Ex OP-1, 2/1 and documents Ex Op-1, 2/2 to Ex OP-1, 2/24 and closed the same on behalf of OP-1 and OP-2.
8 We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.
9 Ld Counsel for complainant vehementally argued that at the instance of OP-3 agent of OP-1 and OP-2, complainant purchased a Health Insurance Policy for a sum of Rs. 5 lacs and paid Rs.18,159/- as premium. Policy was valid from 12.02.2017 to 11.02.2018 and it covered complainant, his wife and his two daughters and one son and at the time of purchase, none of their family member was suffering from any ailment. Wife of complainant got problem in breathing suddenly and she was immediately taken to Dr Naveen Kumar, M D Medicine, who referred her to Higher Centre for further investigation and thereafter, she was taken to Fortis Hospital,
cc no.-10 of 2018
Ludhiana and there complainant requested for pre authorization for cashless treatment, but Ops denied the same. His wife underwent treatment at Fortis Hospital and remained admitted there in Department of Cardiovascular and Thoracic Surgery from 10.04.2017 to 19.04.2017 and was operated upon. Vide bill dated 19.04.2017, complainant paid Rs.4,47,565/-to hospital authorities and after discharge therefrom, he lodged claim with Ops and submitted all the relevant documents regarding treatment of his wife to OPs, but vide letter dated 28.07.2017, they repudiated the claim of complainant. Even legal notice also served no purpose. Repudiation of genuine claim of complainant by OPs amounts to deficiency in service on their part and it has caused harassment to him. He has prayed for accepting the present complaint and stressed on documents produced by him.
10 To controvert the allegations of complainant, ld counsel for OP-1 and OP-2 argued that there is no deficiency in service on their part. it is admitted that complainant purchased the policy in question for sum of Rs.5 lacs after going through all the terms and conditions of the policy. It is also admitted that he submitted his preauthorization request for cashless treatment, which was disapproved on the ground that disease is of long standing natures and complainant did not disclose about same earlier in proposal form. Moreover, she was under treatment of Dr. Naveen and Dr Sandhu prior to admission and therefore, they demanded documents mandatory for processing the claim vide letters dated 3.06.2017, 18.06.2017, 3.07.2017
cc no.-10 of 2018
and 18.07.2017, but he failed to supply the same and therefore, claim of complainant was repudiated vide letter dated 29.07.2017. As per OPs, they asked him to provide detail of treatment taken prior to his admission alongwith investigation reports given by Dr Naveen and Dr Sandhu, their prescription and reports of ECGs and Echo. Original discharge summary, complete set of hospital bill, payment receipt in original towards hospital final bill, bank account of primary insured including IFSC code alongwith cancelled cheque leaf and pan card of insured person, but despite repeated reminders, he submitted only discharge summary, final bill with break ups and cancelled cheque and never submitted documents required by them for processing claim. There is no deficiency in service on their part and prayer for dismissal of complaint is made.
11 From the careful perusal of the record and after going through the evidence and documents available, it is observed that case of the complainant is that he was insured under the policy in question and as per policy, he was entitled for cashless treatment for himself and other insured family members. His wife suddenly suffered from breathing problem and on recommendations of Dr Naveeen, complainant got conducted the treatment of his wife from Fortis Hospital, Ludhiana. She remained admitted there in Department of Cardiovascular and Thoracic Surgery from 10.04.2017 to 19.04.2017 where she was operated upon and complainant paid Rs.4,47,565/-to hospital authorities for her treatment. Grievance of the complainant is
cc no.-10 of 2018
that as per terms and conditions of the policy, complainant was entitled for cashless treatment and all expenses on account of treatment of wife of complainant were to be borne by the Insurance Company/OP-1 and OP-2, but despite repeated requests, they have not made reimbursement of this amount, which amounts to deficiency in service. He has prayed for accepting the complaint. In reply, OP-1and 2 have stressed mainly on the point that despite issuance of letters and repeated reminders, complainant did not submit the documents required for processing the claim and thus, he is not entitled for relief of claim amount as sought by him. There is no deficiency in service on their part and prayed for dismissal of complaint with costs.
12 There is no dispute regarding insurance of complainant and his family members with OPs. Ops have themselves admitted that his wife was insured with them as per Family Medicare Policy. There is no denial that complainant spent Rs.4,47,565/- from his own pocket though he was entitled for cashless treatment. However, only plea taken by OPs is that complainant did not provide them documents regarding treatment of his wife with Dr Naveen and Dr Sandhu. From the careful perusal of document Ex OP-13 which is placed on record by Ops themselves, the copy of prescription slip given by Dr Naveen, it is clear that said doctor has only referred the patient to approach higher institution for better treatment and has not advised any medicine or test for her. This prescription slip issued by Dr Naveen, MD (Medicine) Non Invasive Cardiologist and Medical
cc no.-10 of 2018
Specialist, Faridkot is self explanatory and clearly shows that no medicine or test find mention in this slip, rather it recommends the patient to approach higher institution for better treatment. Thus, when said doctor has not prescribed any medicine for complainant, then question of detail discharge summary, admission in his hospital and treatment taken from said doctor does not arise at all. Ops are insisting for those documents in respect of treatment, which do not occur. Therefore, repudiation of genuine claim by OPs on the ground of non submission of those documents, which do not exist at all, amounts to deficiency in service and trade mal practice on the part of OPs. OPs cannot deny the amount in dispute to complainant on the ground of non submission of those document, which do not exist at all.
13 From the above discussion, we are of considered opinion that OPs have wrongly and illegally repudiated the claim of complainant on false grounds, which amounts to deficiency in service on their part. From the documents produced by the complainant it is proved that he spent Rs.4,47,565/-for treatment of his wife from his own pocket which is not paid by OPs though she was entitled for cashless treatment under policy in question being insured. The OPs have failed to place on record any documentary evidence to contradict the pleadings of complainant. Hence, present complaint is hereby accepted and OPs are directed to pay Rs.4,47,565/-to complainant alongwith interest at the rate of 9% from the date of filing the present complaint till final realization. OPs are further directed to pay Rs.5,000/- to
cc no.-10 of 2018
complainant as consolidated compensation for harassment and mental agony suffered by him and for litigation expenses. Compliance of this order be made within prescribed period of 30 days of receipt of the copy of this order, failing which complainant shall be entitled to proceed under Section 25 and 27 of the Consumer Protection Act. Copy of the order be supplied to parties free of cost. File be consigned to record room.
Announced in Open Forum
Dated : 23.07.2019
(Param Pal Kaur) (Ajit Aggarwal)
Member President
