Punjab

Ludhiana

CC/20/319

Ashok Aggarwal - Complainant(s)

Versus

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

A.N.Juneja Adv.

26 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:319 dated 01.12.2020.                                                         Date of decision: 26.10.2023.

 

Ashok Aggarwal, Resident of House No.1856, Sector 32-A, Chandigarh Road, Opposite Sanjay Gandhi Colony, Ludhiana.                                                                                                                                              ..…Complainant

                                                Versus

1. Star Health & Allied Insurance co. Ltd., Near Ansal Plaza, Ferozepur Road, Ludhiana, through its manager.
2.  Star Health & Allied Insurance Co. Ltd., No.15, Sri Balaji Complex, 1^st Floor, Whites lane, Roy Apettah, Chennai-600014, through its Director/M.D./G.M.
3. Dev Hospital, 1402, Sector 32-A, Chandigarh Road, Ludhiana, through its Director/M.D./Head Doctor.                                                                                                                                            …..Opposite parties 

Complaint Under section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. A.N. Juneja, Advocate.

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

For OP3                         :         Exparte.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant availed Family Floater Insurance Policy No.P/161130/01/2020/027266 from the opposite parties having validity from 12.09.2019 to 11.09.2020 having a coverage of Rs.10,00,000/- with recharge benefit of Rs.1,50,000/- for himself and his wife Asha Aggarwal and son Mohit Aggarwal. During the subsistence of the policy, son of the complainant Mohit Aggarwal fell seriously ill and was taken to Dev Hospital, Ludhiana with the complaint of viral fever and thrombocytopenia. Dr. Ritu Dhingra, M.D. Doctor of  Dev Hospital, Ludhiana after checking, admitted the son of the complainant  in the hospital considering his serious and critical situation. Mohit Aggarwal remained admitted in the hospital from 29.11.2019 to 01.12.2019 and the complainant spent a sum of Rs.25,896.70 on treatment of his son vide bill dated 3302 dated 01.12.2019 of the said hospital. The complainant further stated that since the said hospital was not empanelled on the panel of network hospital of the opposite parties as such, the complainant had to pay the entire hospital bill from his own pocket. Thereafter, the complainant lodged the reimbursement claim with opposite parties but the opposite parties repudiated the claim vide letter dated 07.01.2020, on the reason reproduced as under:-

“It is observed from the submitted medical records that the insured patient is afebrile, vital signs are stable throughout the period of hospitalization. Our medical team is of the opinion that the insured patient could have been treated as an outdoor patient and hospitalization is not warranted.”

According to the complainant, his claim has been repudiated on flimsy reason  which is illegal, arbitrary, capricious and amounts to deficiency in service and unfair trade practice due to which the complainant has suffered physical as well as mental pain, agony and harassment etc. The complainant sent a legal notice dated 20.10.2020 upon the opposite parties through his counsel but no reply was received. Hence this complaint, whereby the complainant has prayed to issue direction to the opposite parties to pay the claim amount of Rs.25,896/- along with compensation of Rs.1,00,000/- and litigation expenses of Rs.22,000/-.

2.                Notice was sent to OP3 through registered post but none turned up for OP3 despite service of notice and as such, OP3 was proceeded against exparte vide order dated 18.03.2021.

3.                Upon notice, OP1 and OP2 filed joint written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability of the complaint; lack of jurisdiction; concealment of material facts; the complainant being estopped by his own act and conduct from filing the present complaint etc. OP1 and OP2 stated that immediately on the receipt of the claim, it was duly registered, entertained and processed. Complainant had obtained Family Health Optimal Insurance Plan bearing policy No.P/161130/01/ 2020/027266 valid from 12.09.2019 to 11.09.2020 Mr. Ashok Kumar Aggarwal self, Mrs. Asha Aggarwal spouse and Mohit Aggarwal dependent children for the floater sum insured of Rs. 10,00,000/-. Insurance policy is issued on the principles uberrimae fides. Utmost good faith is a cardinal principle of insurance. This means that all the parties to an insurance contract must deal in good faith, making a full declaration of all material facts in the insurance proposal. Material facts are those that would influence underwriters as to whether he should or should not accept the risk. If a party fails to adhere to the principles of utmost good faith, the outcome of the claim may be affected. The insurance policy is issued on the basis of the proposal form. The insurance policy is a contractual in nature and the parties are bound by the terms and conditions of the policy. The claims arising therein are subject to terms and conditions forming part of the policy. The claim was reported in the first year of the policy for Rs.24,997/- as per claim form for the treatment of Mohit Aggarwal in Dev Hospital, Ludhiana from 29.11.2019 to 1.12.2019 for the treatment of viral fever with Thrombocytopenia. On scrutiny of the documents placed on the claim file the medical team of the opposite party observed that:

• The insured patient is afebrile, vital signs are stable throughout the period of hospitalization.
• Our medical team is of the opinion that the insured patient could have been treated as an outpatient and hospitalization is not warranted.

After scrutinizing the documents placed in the claim file and after due application of mind by the officials of OP1 and OP2, the claim of the complainant was rejected as no claim vide letter dated 07.01.2020 on the ground that the insured Mohit Aggarwal is a patient of afebrile, vital signs are stable throughout the period of hospitalization and as such the insured patient could have been treated as outpatient and hospitalization is not warranted. According to OP1 and OP2, the claim of the complainant has rightly been repudiated as no claim.

                   On merits, OP1 and OP2 reiterated the crux of averments made in the preliminary objections and facts of the case. OP1 and OP2 have denied that there is any deficiency of service and have also 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 insurance policy, Ex. C2 is the copy of premium receipt, Ex. C3 is the copy of welcome letter dated 11.09.2019, Ex. C4 to Ex. C6 are the copies of policy documents, Ex. C7 and Ex. C8 are the copies of bill No.3302 dated 01.12.2019 of Dev Hospital, Ex. C9 is the copy of repudiation letter dated 07.01.2020 and closed the evidence.

5.                On the other hand, counsel for OP1 and OP2 tendered affidavit Ex. RA of Sh. Rajiv Jain, Chief Manager of Star Health & Allied Insurance Co. Ltd. along with documents Ex. OP1 is  copy of policy terms and conditions, Ex. R2 is the copy of policy schedule, Ex. R3 is the copy of proposal form, Ex. R4 is the copy of field visit report, Ex. R5 is the copy of claim form, Ex. R6 is the copy of discharge summary, Ex. R7 is the copy of final bill, Ex. R8 is the copy of indoor case papers, Ex. R9 is the copy of lab reports, Ex. R10 is the copy of repudiation letter dated 07.01.2020, Ex. R11 is the copy of billing assessment sheet 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 documents produced on record by both the parties.

7.                On 29.11.2019, Mr. Mohit Aggarwal, son of the complainant  in the first year of the policy, was hospitalized in Dev Hospital, Ludhiana and was discharged on 01.12.2019. He was diagnosed of fever and thrombocytopenia, viral and an amount of Rs.25,896/-  was incurred as medical expenses. On 20.12.2019, the complainant lodged a claim Ex. R5 which was repudiated by OP1 and OP2 on 07.01.2020 vide letter Ex. C9 = Ex. R10, the operative part of which reads as under:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of viral fever with thrombocytopenia.

It is observed from the submitted medical records that the insured patient is afebrile, vital signs are stable throughout the period of hospitalization. Our medical team is of the opinion that the insured patient could have been treated as an outpatient and hospitalization is not warranted.

We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.”

OP1 and OP2 have also placed on record the complete discharge summary as Ex. R6 and tried to pick holes in the discharge summary in order to deny the claim of the complainant. The discharge summary contains the treatment record in chronicle order by the treating doctors and there is nothing to suggest that the complainant was not hospitalized or he did not suffer the ailment which has been diagnosed by the doctors. Moreover, as per discharge summary the patient was diagnosed of viral fever and thrombocytopenia. The term ‘thrombocytopenia’ signifies low number of platelets in the blood and in certain conditions it could be life threatening also, if not treated at the earliest. Ex. R9(1) and Ex. R9(2) shows the low platelet counts at the range of 127000 and 122000 respectively than of the normal range. It is not the case of OP1 and OP2 that the diagnosed ailment does fall within the purview of the exclusion clause as per terms and conditions of the policy for which the expenses on the treatment is not admissible. Moreover, OP1 and OP2 in their repudiation letter 07.01.2020 vide letter Ex. C9 = Ex. R10 made a mention of opinion of their medical team that the insured patient could have been treated as an outpatient and hospitalization is not warranted, which is the main ground to repudiate the claim of the complainant. However, no expert of the medical team was examined nor any affidavit of medical team was tendered by OP1 and OP2 to support their contentions. In the absence of any expert medical opinion or affidavit of the team member, the claim of the complainant with regard to the ailment and admission of his son Mohit Aggarwal seems to be genuine and not false or fraudulent. Even OP1 and OP2 as per bill assessment sheet Ex. R11 approved the amount of Rs.24,497/- out of Rs. Total claimed amount of Rs.24,997/- as hospitalization expenses. As such, in the given circumstances, it will be just and appropriate if OP1 and OP2 are directed to pay the amount of Rs.24,497/- approved as per bill assessment sheet Ex. R1 to the complainant along with composite compensation of Rs.10,000/-. 

8.                As a result of above discussion, the complaint is partly allowed with direction to OP1 and OP2 to pay the amount of Rs.24,497/- approved as per bill assessment sheet Ex. R1 to the complainant within 30 days from the date of receipt of copy of order failing which the complainant shall be held entitled to interest @8% per annum on the settled amount from the date of order till its actual payment.  OP1 and OP2 shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainant within 30 days from the date of receipt of copy of order.  However, the complaint as against OP3 Dev Hospital, Ludhiana is hereby dismissed. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

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

 

(Monika Bhagat)                        (Sanjeev Batra)

Member                                       President         

 

Announced in Open Commission.

Dated:26.10.2023.

Gobind Ram.