Punjab

Ludhiana

CC/20/153

Arvind Verma - Complainant(s)

Versus

Star Health and Allied Ins.Co.Ltd. - Opp.Party(s)

S.S.Chatrath

22 Feb 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:153 dated 21.08.2020.                                                        Date of decision: 22.02.2023.

Arvind Verma S/o. Vijay Kumar Verma, aged about 46 years R/o. Peer Khaana Road, Kundra Street, Near Bisham Parkash, Teh. Khanna, Distt. Ludhiana.                                                                                                ..…Complainant

                                                Versus

1. Star Health & Allied Insurance Company Ltd., registered office at New Tank Street, Valiuvar Kotam High Road, Nungambakkam, Chennai, through its Director/Authorized Representative.
2. Star Health & Allied Insurance Company Ltd., Branch Office  at First Floor, SCF No.6, GTB Market, Khanna-141401, through its Branch Manager/Authorized Signatory.
3. Jiwanjot Hospital, Peerkhana Road, The. Khanna, Distt. Ludhiana through its Authorized Representative.                                                                                                                      …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant            :         Sh. S.S. Chatrath, Advocate.

For OP1 and OP2          :         Sh. Rajeev Abhi, Advocate.

For OP3                         :         Exparte.

 

ORDER

PER JASWINDER SINGH, MEMBER

1.                Briefly stated, the facts of the case are that the complainant availed a medical insurance policy No.P/211211/01/2018/001059 from the opposite party for himself and his family and the same was got renewed for the period from 09.09.2017 to 08.09.2018. The complainant got renewed the policy from 09.09.2018 to 08.09.2019 by paying premium of Rs.15,287/-. At the time of issuance of the policy, the opposite parties assured the complainant that in case of any medical ailments, they will provide full insurance claim to him and his family members. The complainant has been paying the premium regularly to the opposite parties.  The complainant submitted that on 27.08.2018  his daughter Ishita Verma met with an accident with some unknown vehicle and she received multiple grievance injuries on her body. She was admitted in Jiwanjot Hospital, Peerkahana Road, Tehsil Khanna, District udhiana and medical treatment was provided to her. The complainant intimated the opposite parties and their surveyor visited the hospital in order to verify the matter and he took all the medical bills as well as other documents with regard to the expenses borne by the complainant from his own pocket for treatment of his daughter and the opposite parties assured the complainant that they will reimburse the same later on. The complainant many times requested opposite parties to reimburse the claim amount but they did not pay the same nor gave any satisfactory reply rather lingered on the mater on one pretext or the other. The complainant served a legal notice dated 12.09.2019 upon the opposite parties but to no avail. The act and conduct on the part of the opposite parties has caused harassment, mental pain and financial loss to the complainant. In the end, the complainant has prayed for issuing direction to the opposite parties to pay the reqeuisite claim of Rs.18,000/- along with interest @24% per annum along with compensation of Rs.50,000/- and litigation expenses.

2.                Upon notice, initially Sh. Ajmer Singh, Manager of opposite party No.3 appeared but later on none turned up for opposite party No.3 and as such, opposite party No.3 was proceeded against exparte vide order dated 02.09.2021.

3.                Opposite party No.1 and 2 appeared and filed joint written statement by taking preliminary objections that the complaint is not maintainable, there is no deficiency in service on their part, lack of jurisdiction, the complainant estopped by his act and conduct. The opposite parties alleged that on receipt of cashless authorization, it was duly registered, entertained and processed. The complainant had obtained Family Health Optima Insurance Plan bearing policy No.P/211/211/01/2018/001059 covering Mr. Arvind Verma self and Mr. Megha Verma, spouse, Ishita Verma and Mukul Verma, children  for  a sum insured of Rs.5,00,000/- valid from 09.09.2017 to 08.09.2018 and the policy was renewal of previous policy No.P/211/211/01/2016/000549 valid from 09.09.2015 to 08.09.2016 and policy No.P/211/211/01/2017/000801 valid from 09.09.2016 to 08.09.2017. The insurance policy is issued on the principles uberrimae fides. The insurance policy is contractual in nature and the parties are bound by the terms and conditions of the policy and the claims arising therein are subject to terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. 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.” The opposite parties further alleged that it is clearly stated in the policy terms and conditions that the policy covers only inpatient treatment - covers hospitalization expenses for period more than 24 hours. It is also one of the exclusion No.4 in the policy that the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by the insured persons in connection with or in respect of dental treatment or surgery unless necessitated due to accidental injuries and requiring hospitalization (dental implants are not payable). The opposite parties further alleged that it is one of the condition No.6 of the policy that “the company shall not be liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be incorrect or false or such claim is in any manner fraudulent or supported by fraudulent means or devices, mis-representation whether by the insured person or by any other person acting on his behalf.”

                   The opposite parties alleged that the claim was reported in the third year of the policy and the insured submitted claim for reimbursement of medical expenses the alleged treatment for Ishita Verma in Jivanjot Hospital, Khanna from 27.08.2018 to 29.08.2018 with diagnosis of RSA fall and dental and was admitted for medical management. It was observed from the submitted medical records that the admission is not confirmed and the insured patient i.e. Ishita Verma has taken treatment as an outpatient and not as inpatient in the hospital. After scrutinizing the documents and application of mind by officials of opposite parties, the claim of the complainant was rejected as no claim vide letter dated 08.11.2018 on the ground that as per the terms and conditions of the policy, the policy provides coverage for hospitalization expenses for the treatment taken as an inpatient only. The claim has been rightly repudiated as no claim and the grounds of repudiation are legal, valid and enforceable and are in accordance with the terms and conditions of the policy.

                   The opposite parties further alleged that after the receipt of repudiation letter dated 08.11.2018, the complainant represented his claim for review of rejection dated 08.11.2018 along with treating doctor certificate dated 30.11.2019 of Jeewan Jot Hospital, Khanna. The medical team of opposite party No.1 and 2 had perused the said letter including medical records who re-examined the claim record and observed that the declaration letter of the insured’s parent father states that the history of the fall from “bicycle” but the letter from the treating doctor states history RSA falls from “Activa”. In the prescription slip dated 28.08.2018 the quadrant is mentioned as “right quadrant” in one prescription and in other prescription as “left quadrant”. There are discrepancies in the documents submitted by the complainant in review of the claim of Ishita Verma which was repudiated vide letter dated 30.04.2019. After scrutinizing the documents placed in the claim file and after due application of mind by the officials of the opposite parties, the request of the complainant for reconsidering his claim by the review committee was rejected vide letter dated 27.05.2019 on the grounds that there is discrepancies in the referred documents which amounts to misrepresentation and as per condition No.6, the company is not liable to make any payment in respect of any claim if there is mis-representation whether by the insured person or any other person acting on his behalf. Moreover, as per the prescription dated 28.08.2018 dental caries removed and advised for RCT and the claim is not payable for dental treatment and implants as per terms and conditions of the policy as such the request of complainant to reconsider the claim has rightly been rejected as no claim and the grounds of rejection are legal, valid and enforceable and are in accordance with the terms and conditions of the policy.

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections. The opposite parties alleged that no surveyor was appointed in the mediclaim policies and only the investigators are appointed to examine and investigate the medical record if so required as epr procedure. The opposite parties alleged that there is no occasion of giving any such assurance since the claim of the complainant already stands rejected vide letter dated 08.11.2018 and his review request also stands rejected vide letter dated 27.05.2019. However, the opposite parties submitted that even if this Commission finds any liability upon them that may be limited to Rs.13,502/- In the end, opposite party No.1 and 2 prayed for dismissal of the complaint.

4.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of his Aadhar card, Ex. C2 is the copy of customer identity card of oppsotie parties in the name of Angel Verma, Ex. C3 is the copy of insurance policy w.e.f. 16.09.2019 to 15.09.2019, Ex. C4 to Ex. C9 are the copies of bills/receipts of medicines etc., Ex. C10 is the copy of prescription slip dated 28.08.2018, Ex. C11 is the legal notice dated 12.09.2019, Ex. C12 and Ex. C13 are the copies of postal receipts and closed the evidence.

5.                On the other hand, counsel for opposite party No.1 and 2 tendered affidavit Ex. RA of Sh. Rajiv Jain, Chief Manager of the opposite parties along with documents Ex. R1 is the copy of policy documents, Ex. R2 is the copy of insurance policy from 09.09.2016 to 08.09.2017, Ex. R3 is the copy of policy from 09.09.2017 to 08.09.2018, Ex. R3 is the copy of insurance policy from 09.09.2015 to 08.09.2016, Ex. R4 is the copy of letter dated 01.09.2016 for renewal of policy, Ex. R5 is the copy of claim form, Ex. R6 is the copy of IPD invoice dated 28.08.2018, Ex. R7 is the copy of letter written by complainant to the  insurance company, Ex. R8 is the copy of certificate dated 16.10.2018 issued by Jiwan Jot Hospital, Khanna, Ex. R9 and Ex. R10 are the copies of prescription slips dated 28.08.2018, Ex. R11 is the copy of repudiation letter dated 27.05.2019, Ex. R12 is the copy of hospital expenses and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.     

7.                Undisputably, the complainant, a holder of the policy in question during the subsistence of the policy coverage preferred a claim with regard to sustaining of injuries by his daughter on 27.08.2018 in an accident. The complainant further claimed that his daughter Ishita Verma remained under treatment in Jiwan Jot Hospital, Khanna from 27.08.2018 to 29.08.2018. The complainant submitted the claim for reimbursement of medical expenses on the treatment of his daughter on 08.11.2018, after perusing the documents and after referring to the policy documents Ex. R1, the claim of the complainant was rejected as ‘No Claim’ on the ground that the policy provides coverage for the hospital expenses for the treatment taken as inpatient only and Ishita Verma has taken treatment as an outpatient.  Perusal of certificate Ex. R8 issued by Jiwan Jot Hospital, Khanna shows that on its letter pad, the hospital has enlisted various specialties available in their hospital but surprisingly, no doctor has been shown as dentist on rolls for dental treatment. Rather Ex. R10 shows that Ishita Verma remained under treatment of Ghai Dental Care and Implant Centre, Khanna.

8.                    The complainant again filed a review against the rejection dated 08.11.2018 with treating doctor’s certificate. The medical team of opposite party No.1 and 2 also found discrepancy with regard to the manner of accident. There was a contradiction in the statement of the complainant who started that her daughter fell from “bicycle” while treating doctor recorded the history of fall from “Activa” scooter. Further the prescription slip dated 28.08.2018 mentioned that ‘right quadrant’ while the other medical record shows it to be ‘left quadrant’. So accordingly, it was treated to be misrepresentation and the claim was again rejected. The opposite parties invoked the exclusion clause No.4 and condition No.6 of the policy and the repudiated the claim on 27.05.2019 vide letter Ex. R11. In the given set of circumstances, it can be borne from the record that the daughter of the complainant took dental treatment without hospitalization and therefore, the claim of the complainant was rightly revoked by the opposite parties.

9.                As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

10.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                       President         

 

Announced in Open Commission.

Dated:22.02.2023.

Gobind Ram.

 

 

Arvind Verma Vs Star Heath                               CC/20/153

Present:       Sh. S.S. Chatrath, Advocate for complainant.

                   Sh. Rajeev Abhi, Advocate for OP1 and OP2.

                   OP3 exparte.       

 

                   Arguments heard. Vide separate detailed order of today, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                       Member                     Member                                       President         

 

Announced in Open Commission.

Dated:22.02.2023.

Gobind Ram.