DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/12/2023
Date of Institution: 23.01.2023
Date of Decision: 20.09.2024
Darshan Kumar son of Nohar Chand resident of H.No. B-XIII/1636, Lakhi Colony, Barnala Tehsil and District Barnala-148101.
…Complainant
Versus
- Star Health and Allied Insurance Company Limited, Regd. & Corporate Office-1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034.
- Star Health and Allied Insurance Company Limited, Branch office, 1st Floor, Sunami Gate, Sangrur 148001 through its authorized signatory.
- Rajan Mehra authorized representative of Star Health and Allied Insurance Company Limited, Near Mittal Jewellers, Sadar Bazar, Barnala District Barnala-148101.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Varinder Kumar Goyal counsel for complainant.
Sh. Rohit Jain counsel for opposite parties No. 1 & 2.
None for opposite party No. 3.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Smt. Urmila Kumari : Member
3. Sh. Navdeep Kumar Garg : Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Star Health and allied Insurance Company Limited & others (in short the opposite parties).
2. The facts leading to the present complaint are that complainant purchased one Health Insurance Policy of Star Health and Allied Insurance Company Ltd. It is further alleged that under Family Health Optima Insurance Plant SHAHLIP21211V042021 for sum of Rs. 5,00,000/- which including himself and wife named Sheela Devi and pay Rs. 24,142/- being premium of the above said Insurance policy with Star Health and Allied Insurance Company Ltd. Branch Sangrur and Ops issued certificate/policy No. P/211223/01/2021/000036 valid from 30.04.2021 to 29.04.2022. It is further alleged that complainant's wife namely Sheela Devi admitted in Delhi Heart Institute & Multispecialty Hospital, G.T. Road, Bathinda on 16.05.2021 for her treatment vide UHID No. 126413 IPD No. 30521/21 and deposited Rs. 50,000/- on 16.05.2021 vide Receipt No. IR3059/21-22 and further deposited Rs. 50,000/- on 18.05.2021 vide Receipt No. IR3248/21-22 and further deposited an amount of Rs. 21,000/- on 20.05.2021 vide Receipt No. IR3413 /21-22.3. It is alleged that Delhi Heart Institute & Multispecialty Hospital, G.T. Road, Bathinda discharged to complainant's wife on 20.05.2021 at 6:23:55 PM and prepared the final Bill for an amount of Rs. 1,21,000/- and delivered to complainant. It is further alleged that complainant submitted the above said claim to the Ops for an amount of Rs. 1,21,000/- alongwith the Hospital Bills including Diagnostic, Pharmacy Bill alongwith the other required documents as per the guidelines of Insurance Regulatory and Development Authority of India. It is further alleged that Ops have paid only an amount of Rs. 46,694/- and Rs. 15,000/-Total Rs. 61,694/- instead of Rs. 1,21,000/- and Ops have deducted the remaining amount against the law and facts without any legal right. However, complainant is entitled to get the remaining amount of Rs. 59,306/- and Ops are also bound to pay the above said amount to complainant without any further delay. It is further alleged that the complainant served a legal notice to the Ops on 09.05.2022 vide registered Post receipt No. RP 873529215IN, RP 873529440IN AND RP 873529334IN dated 10.05.2022 which were received by the Ops but of no use. Thus, the above said act and conduct of the opposite parties falls under the deficiency in service and unfair trade practice on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.-
- To pay the remaining amount of Rs. 59,306/- alongwith interest @ 18% per annum from the date of discharge.
- To pay Rs. 3,00,000/- for mental shock, pain, agony and Rs. 11,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties No. 1 & 2 appeared and filed written version taking preliminary objections interalia on the grounds that the complainant has got no locus-standi or cause of action to file the present complaint, the present complaint is not maintainable, the complainant dragged the opposite parties in false litigation, not come with clean hands etc.
4. On merits, it is admitted to the extent that the complainant purchased family Health Optima Insurance plan vide policy No. P/211223/01/2021/000036 30.04.2021 to 29.04.2022 covering Darshan Kumar - SELF and Sheela Devi SPOUSE, for the sum insured Rs. 5,00,000/- and paid Rs.24, 142/- towards premium. It is further alleged that as per documents relating to the claim submitted by the complainant, Sheela Devi was admitted in Delhi Heart Institute & Hospital, G.T. Road, Bathinda on 16.5.2021 for her treatment and the complainant deposited Rs.1,21,000/- in the Hospital on various dates. It is further admitted to the extent that the complainant submitted claim of Rs.1,21,000/- with the answering opposite parties. It is further admitted to the extent that the answering opposite parties paid Rs. 61,694/- against the claim amount of Rs. 1,21,000/-. It is further alleged that the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. Moreover it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED". It is further alleged that the insured preferred claims in the 3rd year of FHO and 06th year of continuation of policy. The insured’s wife (Sheela Devi) was hospitalized at Delhi Heart Institute & Multispecialty Hospital on 16.5.2021 to 20.5.2021 for treatment of BLACK FUNGS. Based on submitted reimbursement documents, the claim was processed and an amount of Rs. 49,744/- was approved and paid to insured through NEFT-N221211595547663 dated 9.8.2021. On further review of claim, the claim was again evaluated and a further of Rs. 15,000/- was approved and paid to insured through NEFT-N320211715639850 dated 16.11.2021. The reasons for the deductions during hospitalization period are “The Insured availed Deluxe Room for which the charge per day was Rs.12000 for 5 days (room rent and Nursing). However, as per the policy terms and Conditions, charges for SINGLE STANDARD AC ROOM was payable. Hence, charges over and above the eligibility has been disallowed. Hence, Rs. 31,500/-are deducted towards the room rent in excess of eligibility. As per the Other Excluded Expenses of the Policy, the charges pertaining to THERMOMETER, GLOVES, CANNULA, MVI, ZANDU BALM, AUGMETIN, ANOLIP totaling to Rs.16,850/-is not payable. As per the Other Excluded Expenses of the Policy, the charges pertaining to GLOVES, CANNULA FIXATOR totaling to Rs. 306/- is not payable. As regards the Other Excluded Expenses of the ADMISSION, NASAL Policy, the charges pertaining to CANNULA for an amount of Rs.10,560/- is not payable. Further, no reports relating to the bill dated 10/5/2021, hence Rs.4,220/- have been submitted and is therefore deducted. As per the other excluded expenses of the policy, the charge towards Rs.750/- FOR D-DIMER, Rs.100/- MAX FOR CRP an amount of Rs.910/- are deducted. Hence, Maximum payable amount of Rs. 64,744/-has been already paid to insured. The balance amount of Rs. 59,306 /- is not payable as explained above in detail. All other allegations of the complainant are denied. Therefore, there is no deficiency in service on the part of opposite parties No. 1 & 2 and prayed for the dismissal of complaint.
5. The opposite party No. 3 also filed written version. It is admitted to the extent that complainant Mr. Darshan Kumar get a Health Insurance Policy of Star Health and allied Insurance Company Ltd. under Family Heath Optima Insurance Plan for a sum of Rs. 5,00,000/. It is further submitted that the Op No. 3 introduce the above said policy and explained the terms and conditions of the above said insurance and also explain that after issuance of policy the Op. No. 1 and 2 shall provide all the facilities/claims from time to time as per the policy conditions and after confirmation and satisfaction of the complainant, the complainant issued a cheque of premium in favour of Star Health and Allied Insurance Company Ltd. Op. No. 1 and 2 which was sent to the Op. No. 1 and 2, who issued the policy against the above said premium with the terms and conditions of the above said Health Insurance Policy. It is alleged that the Op No. 3 is only representative of the Op No. 1 and 2 after issuance of policy Op No. 3 have no responsibility for the settlement of claim beyond the terms and conditions of the policy. All other allegations of the complainant are denied. Therefore, there is no deficiency in service on the part of opposite party No. 3 and prayed for the dismissal of complaint.
6. Ld. Counsel for complainant on 19.10.2023 has suffered the statement that I do not want to file any rejoinder against the version of opposite parties.
7. To prove his case the complainant tendered into evidence copy of policy as Ex.C-1 (containing 5 pages), copy of hospital receipt dated 16.05.2021 as Ex.C-2, copy of receipt dated 18.05.2021 as Ex.C-3, copy of receipt dated 20.05.2021 as Ex.C-4, copy of hospital bill as Ex.C-5 (containing 7 pages), copy of letter dated 29.09.2021 as Ex.C-6, copy of adhaar card of complainant as Ex.C-7, copy of adhaar card of Sheela Devi as Ex.C-8, copy of legal notice as Ex.C-9, postal receipts are Ex.C-10 to C-12, copy of reply of legal notice as Ex.C-13, copy of bill assessment sheet as Ex.C-14, copy of track consignment as Ex.C-15 (containing 2 pages), affidavit of Darshan Kumar as Ex.C- 16 and closed the evidence.
8. The opposite parties No. 1 & 2 tendered into evidence affidavit of Sumit Kumar Sharma as Ex.OP1.2/1, copy of proposal form as Ex.OP1.2/2 (containing 8 pages), copy of probability form as Ex.OP1.2/3 (containing 2 pages), copy of policy schedule as Ex.OP1.2/4 (containing 5 pages), copy of terms and conditions as Ex.OP1.2/5 (containing 6 pages), copy of IRDA Guidelines as Ex.OP1.2/6 (containing 10 pages), copy of claim form as Ex.OP1.2/7 (containing 5 pages), copy of discharge summary as Ex.OP1.2/8 (containing 3 pages), copy of final bill as Ex.OP1.2/9, copy of lab bill as Ex.OP1.2/10, copy of lab report as Ex.OP1.2/11, copy of bill assessment sheet as Ex.OP1.2/12 (containing 5 pages) and closed the evidence.
9. The opposite party No. 3 has not produced any evidence and the evidence of the opposite party No. 3 was closed by order of this Commission dated 8.5.2024.
10. We have heard the learned counsel for the parties and have gone through the record on file.
11. It is admitted case of the opposite parties that the complainant purchased family Health Optima Insurance plan vide policy No. P/211223/01/2021/000036 30.04.2021 to 29.04.2022 covering Darshan Kumar - SELF and Sheela Devi SPOUSE, for the sum insured Rs. 5,00,000/- and paid Rs. 24,142/- towards premium (as per Ex.C-1 & Ex.O.P1.2/4). It is also not disputed that as per documents relating to the claim submitted by the complainant, Sheela Devi was admitted in Delhi Heart Institute & Hospital, G.T. Road, Bathinda on 16.5.2021 for her treatment and the complainant deposited Rs.1,21,000/- in the Hospital on various dates (as per Ex.C-5). It is further admitted case of the opposite parties that the complainant submitted claim of Rs.1,21,000/- with the opposite parties and the opposite parties paid Rs. 61,694/- against the claim amount of Rs. 1,21,000/- and out of which the opposite parties have deducted an amount of Rs. 59,306/-.
12. Ld. Counsel for the complainant argued that opposite parties have paid only an amount of Rs. 46,694/- and Rs. 15,000/- in total Rs. 61,694/- instead of Rs. 1,21,000/- and opposite parties have deducted the remaining amount against the law and facts without any legal right, however the complainant is entitled to get the remaining amount of Rs. 59,306/- and the opposite parties are also bound to pay the above said amount to complainant without any further delay. It is further argued that the complainant served a legal notice to the opposite parties dated 09.05.2022 Ex.C-9 which was received by them but of no use. Ld. Counsel for the complainant further argued that the opposite parties No. 1 & 2 have not supplied the terms and conditions of the policy. Ld. Counsel for the complainant further argued that the opposite parties No. 1 & 2 assured the complainant at the time of taking the policy that the entire claim amount will be disbursed to the complainant if any medical issue arises.
13. On the other hand, Ld. Counsel for the opposite parties No. 1 & 2 argued that the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. It is further argued that the insured preferred claims in the 3rd year of FHO and 06th year of continuation of policy and the insured’s wife (Sheela Devi) was hospitalized at Delhi Heart Institute & Multispecialty Hospital on 16.5.2021 to 20.5.2021 for treatment of BLACK FUNGS and on the basis of submitted reimbursement documents the claim was processed and an amount of Rs. 49,744/- was approved and paid to insured through NEFT-N221211595547663 dated 9.8.2021. It is further argued that on further review the claim was again evaluated and an further amount of Rs. 15,000/- was approved and paid to insured through NEFT-N320211715639850 dated 16.11.2021 and the reasons for the deductions during hospitalization period are as under; “The Insured availed Deluxe Room for which the charge per day was Rs.12000 for 5 days (room rent and Nursing). However, as per the policy terms and Conditions, charges for SINGLE STANDARD AC ROOM was payable hence, charges over and above the eligibility has been disallowed. Further, Rs. 31,500/-are deducted towards the room rent in excess of eligibility and as per the other Excluded Expenses of the Policy, the charges pertaining to THERMOMETER, GLOVES, CANNULA, MVI, ZANDU BALM, AUGMETIN, ANOLIP totaling to Rs.16,850/-is not payable. As per the Other Excluded Expenses of the Policy, the charges pertaining to GLOVES, CANNULA FIXATOR totaling to Rs. 306/- is not payable. As regards the Other Excluded Expenses of the ADMISSION, NASAL Policy, the charges pertaining to CANNULA for an amount of Rs.10,560/- is not payable. Further, no reports relating to the bill dated 10/5/2021, hence Rs.4,220/- have been submitted and is therefore deducted. As per the other excluded expenses of the policy, the charge towards Rs.750/- FOR D-DIMER, Rs.100/- MAX FOR CRP an amount of Rs.910/- are deducted”. Hence, Maximum payable amount of Rs. 64,744/-has been already paid to insured and the balance amount of Rs. 59,306 /- is not payable as explained above in detail.
14. We have perused the copy of bill assessment sheet Ex.C-14 & Ex.O.P1.2/12 which shows the total bill amount of Rs. 1,21,000/- and the deduction amount shown as Rs. 59,306/- and the total authorized amount shown as Rs. 61,694/-. The allegation of the complainant is that the opposite parties illegally and unreasonably deducted the amount of Rs. 59,306/- from the total bill amount of Rs. 1,21,000/-. We have perused the record minutely and are of the view that the opposite parties No. 1 & 2 are not justified in deducting the amount of Rs. 59,306/-. Since these charges such as room rent & nursing charges, investigation & Diagnostics, Medicines-within Hospital and miscellaneous charges were part of treatment of the insured and the deducted amount was deposited by the insured. We are of the view that there is nothing on record from the side of opposite parties No. 1 & 2 that the insured was explained specifically at the time of subscribing the policy in question with regard to the expenses which were payable or not payable. Moreover, the opposite parties No. 1 & 2 have failed to place on record any cogent, reliable and trustworthy evidence in order to rebut the allegations of the complainant. Ld. Counsel for complainant placed reliance on citation 2001(1) CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, It is usual with the insurance company to show all types of green pastures 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. Ld. Counsel for the complainant also relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims.
The Hon’ble Supreme Court of India 2020 (2) Civil Court Cases 082 (SC) in case titled New India Assurance Co. Ltd. & Ors. Vs Paresh Mohanlal Parmar held that “Non-communication of terms and conditions of insurance policy to insured, not open to insurer to rely upon exclusionary clause of policy”. The similar view has been taken by the Hon’ble Supreme Court of India (2019) 6 Supreme Court Cases 212 in case titled Bharat Watch Company Through Its Partner Vs National Insurance Company Limited.
15. So, from the above discussion, it is established that the claim of the complainant was repudiated by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service on the part of opposite parties No. 1 & 2. Therefore, the present complaint is partly allowed against the opposite parties No. 1 & 2 and the opposite parties No. 1 & 2 are directed to pay the deducted amount of Rs. 59,306/- alongwith interest @ 7% per annum to the complainant from the date of filing the present complaint till its actual realization. The opposite parties No. 1 & 2 are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
20th Day of September, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
(Navdeep Kumar Garg)
Member
