DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

BATHINDA

C.C. No. 21 of 17-1-2018.

Decided on : 8-02-2022

Ashwani Kumar aged about 49 years S/o Sh. Dharam Chand, Prop. of Hotel President, Backside New Bus Stand, Bathinda. ........Complainant

Versus

1. Star Health & Allied Insurance Co. Ltd., # 2716, 1^st Floor, Gagan Complex, Gurdev Nagar, Pakhowal Road, Ludhiana, through its Managing Director

2. Asha Sachdeva, Assistant Manager, Start Health & Alied Insurance Co. Ltd., SCO No. 133, 2^nd Floor, Above Tata Motors Finance Near Hotel Sweet Milan, G.T. Road, Bathinda.

3. Star Health & Allied Insurance Co. Ltd., No. 2-A, Ganga Nagar, 4^th Cross Street Opposite TP BSNL Customer Service Centre, Kodamabakka, Chennai through its Authorized Representative/Signatory

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986

QUORUM

Kanwar Sandeep Singh, President

Sh. Shivdev Singh, Member.

Smt. Paramjeet Kaur, Member

Present

For the complainant : Sh. Parveen Kumar Sharma, Advocate

For opposite parties : Sh. Naresh Garg, Advocate.

ORDER

Kanwar Sandeep Singh, President

1. The complainant Ashwani Kumar (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against Star Health & Allied Insurance Company Limited & others (here-in-after referred to as opposite parties).

2. Briefly stated, the case of the complainant is that he purchased "Family Health Optima Insurance Revised policy" vide policy No. P/211200/01/2015/001195 on payment of requisite premium from the opposite parties and the customer ID of the complainant is 2950658-1.

3. It is alleged that at the time of issuance of the policy, the opposite party No. 2 assured the complainant that in case of any health disorder or any minor or major operation, opposite parties shall indemnify the insured for the total expenses incurred thereon by the complainant/insured. It is also alleged that opposite party No. 2 obtained the signatures of complainant on various blank papers/blank printed forms, without disclosing the contents thereof and complainant put his signatures on the same in good faith while reposing confidence on the opposite party No.2. The opposite party No.2 asked some personal information of the complainant like name, name of father, age proof, residence proof etc., and asked some questions about the habits like smoking and drinking etc., and also about any pre existing disease and the complainant cleared all the quarries put by the opposite party No 2, which the opposite party No.2 noted down on a simple plain paper with the pretext that they shall fill the proposal form at their own by filling the personal data and habits etc. It is further made clear that at the time of obtaining the policy, the complainant was not suffering from any pre existing disease nor he was aware about the same.

4. It is further alleged that unfortunately, the complainant fell ill due to severe abdominal pain, yellowish discoloration of eyes and fever for which he approached the doctor of Chitkara Hospital, Bathinda, who referred the complainant to PGI but the complainant was taken to Dayanand Medical College & Hospital, Ludhiana (here-in-after referred to as 'DMC') by his relatives where he remained admitted vide CR No. 2015-232450 on 11.11.2015 upto 7.12.2015 and was diagnosed for the ailment and was operated on 21.11.2015. The complainant was discharged as cured on 7.12.2015.

5. It is also alleged that intimation regarding admission of the complainant in the said hospital was given to the opposite parties for pre authorization for cashless treatment of PERIAMPULLARY CARCINOMA which was approved for a sum of Rs.3,25,200/- after deducting the non payable, non consumables and the opposite parties deposited an amount of 2,90,000/- with DMC, for the treatment of the complainant but the complainant also purchased the medicines prescribed by the doctors of DMC during the said period of his treatment from outside and spent Rs. 82,053/-.

6. It is also alleged that the complainant after discharge from the hospital, applied for the reimbursement of the said amount of Rs.82,053/- spent by him for the purchase of the medicines vide claim no. CLI/ 2016/211200/0236788 and furnished the medical claim along with all original bills regarding purchase of medicines and the same was duly received by the opposite party No.2. under signature in token of receipt on 8.3.2016 with an assurance to do the needful at the earliest but the opposite parties have failed to reimburse the said amount of Rs. 82,053/- to the complainant without assigning any cogent reason.

7. The complainant also alleged that he personally visited the opposite party No.2 and requested to make the payment but opposite party No.2 kept on putting the matter off under one or the other false pretext. The complainant also got issued a legal notice dated 27.6.2016 to the opposite parties No.1 and 2 and requested them to make payment of insurance claim amount, but to no effect rather the opposite party No. 3 gave a false and frivolous reply vide letter dated 14.7.2016 even though the complainant had already furnished all the original bills and the other relevant documents. The complainant also replied the said letter.

8. It is further alleged that due to act and conduct of the opposite parties, as they failed to comply with its own terms and conditions, the complainant suffered mental tension for which he claims compensation to the tune of Rs. 1,00,000/-.

9. On this backdrop of facts, the complainant has prayed for directions to the opposite parties to make payment of Rs. 82,053/- as per terms and conditions of the policy and pay compensation to the tune of Rs. 1,00,000/- besides litigation expenses.

10. The opposite parties put an appearance through their counsel and contested the complaint by filing written reply. In joint written reply, the opposite parties raised preliminary objections that no cause of action has arisen in favour of complainant to file the present case and the complaint is pre-mature; that the relief sought by complainant is in violation of terms and conditions contained in the policy; that the complainant is bound by the terms and conditions of the insurance contract which were expressly made known to the complainant/policy holder; that the complainant has not approached this Commission with clean hands and that the complaint is misuse of legal process.

11. On merits, the opposite parties admitted that complainant purchased the Family Health Optima Insurance Revised Policy, which includes himself, his spouse Anju Rani and Dorthi Shree and Hemant dependent child. Under said policy, the total sum assured was Rs. 5.00 Lacs and policy was valid from 16-12-2014 to 15-12-2015 vide Policy No. P/211200/01/2015/001195. It is pleaded that said policy was purchased by the complainant with his own sweet will and without any pressure. All the benefits, tenure, terms and conditions were well explained to the complainant before inception of the policy and after being fully satisfied, the complainant purchased the said policy. The benefits under the policy are subject to certain terms and conditions of the insurance contract, upon which both the parties become agreed at the time of inception of the policy. No objection or complaint was ever raised by the complainant after issuance of the policy and as such the above policy was accepted by the complainant as it is.

12. It is pleaded that complainant got admitted on 14-11-2015 in DMC and raised a pre-authorization for cashless treatment of PERIAMPULLARY CARCINOMA and the same was approved for Rs. 3,26,200/- after deducting non-payable non-consumable and opposite parties deposited an amount of Rs. 2,90,000/- with DMC. Subsequently, the complainant came for reimbursement of the amount of Rs. 36,990/- and on the receipt of claim, query was raised to submit the following documents for further process and the same was informed to the insured/complainant vide letter dated 30-5-2016 :

    'Doctor prescription for medical bill submitted alongwith all the investigation reports.'

13. The opposite parties have further pleaded that despite repeated reminders, the insured did not submit the above said requisite claim documents to enable the opposite parties to process the claim. The complainant never submitted the said documents as required by the opposite parties, as such, the complaint of the complainant is pre-mature and the same is not maintinable. The opposite parties denied that complainant applied for reimbursement of amount of Rs. 82,053/- and opposite party No. 2 kept on putting the matter off under one or the other false pretext. After controverting all other averments, the opposite parties prayed for dismissal of complaint.

14. In support of his complaint, the complainant has tendered into evidence photocopy of Health Insurance Card (Ex. C-1), photocopy of legal notice and postal receiapts (Ex. C-2 to Ex. C-4), reply of notice (Ex. C-5), copy of letter (Ex. C-6) postal receipt (Ex. C-7), photocopy of detail of bills (Ex. C-8), photocopy of retail invoices (Ex. C-9 to Ex. C-20), photocopies of payment receipts, prescriptions, bills, lab reports, cash memos, CT scan report (Ex. C-21 to Ex. C-106) and photocopy of policy schedule (Ex. C-107).

15. In order to rebut the evidence of complainant, the opposite parties have tendered into evidence affidavit dated 15-3-2018 of N Gopalan (Ex. OP-1/1), photocopy of proposal form (Ex. OP-1/2), photocopy of insurance plan (Ex. OP-1/3), photocopy of policy schedule (Ex. OP-1/4), photocopy of pre-authorization request Form (Ex. OP-1/5), photocopy of query on pre-authorization (Ex. OP-1/6), photocopy of authorization dated 18-11-2015 (Ex. OP-1/9), photocopy of authorization for enchancement of amount (Ex. OP-1/8), photocopy of claim form (Ex. OP-1/9), photocopy of letter (Ex. OP-1/10), photocopy of reminders (Ex. OP-1/11 & Ex. OP-1/12) and photocopy of letter (Ex, OP-1/13 to Ex. OP-1/16).

16. Learned counsel for the parties reiterated their stand as taken in their respective pleadings.

17. We have heard learned counsel for the parties and gone through the record.

18. These are undisputed facts between the parties that complainant and his family members were insured vide Family Health Optima Insurance Revised Policy No. P/211200/01/2015/001195 for sum assured of Rs. 5.00 Lacs for the period from 16-12-2014 to 15-12-2015. The complainant suffered from Periampuliary Carcinoma and remained admitted in DMC for the period from 11-11-2017 to 7-12-2015. The said hospital applied for pre-authorization for cashless treatment and opposite parties approved the same for a sum of Rs. 2,90,000/-. After discharge from hospital, complainant filed claim with the opposite parties claiming reimbursement of medical expenses for the medicines which he purchased from outside (other than DMC) during the period of treatment.

19. The version of the complainant is that as per details of bills/reports/cash memo/receipts amounting to Rs. 82,053/-(Ex. C-8), he filed claim with opposite party No. 2 for reimbursement of said medical expenses and these documents were duly received by Ms. Asha Sachdeva on 8-3-2016 and she put her signature on Ex. C-8 in token of receipt of documents. The learned counsel for the complainant submitted that, if need be, complainant is ready to submit the photocopy of these documents/bills again.

20. On the other hand, the version of the opposite parties is that opposite parties issued repeated reminders to complainant to submit doctor's prescription for the medicine bills submitted alongwith all investigation reports for the charged amount, but he failed to send the same. The learned counsel for the opposite parties submitted that opposite parties are still ready to pay the claim as per policy terms and conditions if complainant submits the required documents.

21. Thus, keeping in view the evidence placed on file by the parties, this Commission is of the considered opinion that at this stage, no direction can be given for reimbursement of medical expenses in question to opposite parties as complainant has not produced any document on file to show that he has submitted the documents demanded by the opposite parties vide letter dated 14-5-2016 (Ex. OP-1/12) i.e. after submission of documents by complainant on 8-3-2016. A perusal of record reveals that opposite parties also issued subsequent reminders Ex.OP-1/13 to Ex. OP-1/16 to complainant in this regard.

22. In view of what has been discussed above, this complaint stands disposed off with direction to complainant to submit photostat copies of bills and prescription slips of doctor for the medicine bills/amount claimed (Rs. 82,053), within 30 days from the date of receipt of copy of this order and opposite parties are directed to settle the claim of the complainant within 45 days of receipt of documents from complainant.

23. The complaint could not be decided within the statutory period due to heavy pendency of cases.

24. Copy of order be sent to the parties concerned free of cost and file be consigned to the record.

    Announced :

    8-2-2022

    (Kanwar Sandeep Singh)

    President

     

     

    (Shivdev Singh)

    Member

     

    (Paramjeet Kaur)

    Member