Punjab

Ludhiana

CC/22/14

Sarabjeet Kaur - Complainant(s)

Versus

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

A.K.Rana

08 Feb 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 14 dated 14.01.2022.                                                Date of decision: 08.02.2023.

Sarabjeet Kaur Aged 58 years wife of Sh. Manjit Singh, R/o. H. No.1044, Near B.C.M. School, Basant Avenue, Dugri, Ludhiana. M. 9478605000, gurminder

1. Star Health & Allied Insurance Company Limited, Registered & Corporate Office, 1, New Tank Street, Valluvar High Road, Nungambakkam, Chennai-600 034, through its Director/Managing Director/Authorized Signatory.        
2. Star Health & Allied Insurance Company Limited, Branch Office No.3369, 4^th Floor, Sandhu Tower-II, Ferozepur Road, Ludhiana, through its Branch Manager/Authorized Signatory.                                                                                                   …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act, 2020.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. A.K. Rana, Advocate.

For OPs                          :         Sh. Rajeev Abhi, Advocate.

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Tersely put, the case of the complainant is that as per proposal dated 18.09.2019, she obtained a cashless policy i.e. Family Health Optima Insurance plan bearing No.P/161114/01/2020/002943 for a sum inusred of Rs.5,00,000/- from the opposite parties on payment of premium of Rs.25,165/- for the period from 18.09.2019 to 17.09.2020. The opposite parties issued the policy cover note to the complainant, details of which is reproduced as under:-

The complainant got renewed the policy from 18.09.2020 to 17.09.2021 for a premium of Rs.25,165/- and limit of coverage insurance was enhanced to Rs.6,25,000/- by adding bonus will all old terms and conditions. The complainant further got renewed the policy for the period from 18.09.2021 to 17.09.2021 by paying premium of Rs.28,350/- and limit of coverage insurance enhanced to Rs.6,75,000/-. The complainant submitted that in the month of October 2021, she suffered pain in knees and got therapies from a physiotherapist for her knew pain and on getting eight therapies, she got reliefs from pain for some time. After that again pain started in the month of November, 2021 and on 11.11.2021, she visited Dayanand Medical College & Hospital, Ludhiana and was diagnosed by Dr. Rajnish Garg, Head of Department of Orthopedic DMC, Ludhiana. After doing X-ray of both knees, said doctor suggested the complainant to undergo a surgery for knees replacement. The complainant filed a claim for medical treatment which was initiated by the opposite parties. On the same day, corporate staff of the hospital sent prescription of doctor, admit card, copy of X-ray, details of disease and treatment to the opposite parties but they denied the request for approval of cashless treatment of the complainant with remarks “It is observe from the hospital records that the insured patient has the above disease which is a long standing ailment. We are not able to ascertain the duration of the disease based on the documents/details submitted by the hospital. It requires further evaluation.” on 24.11.2021, the complainant further made request to the opposite parties through her son Gurminder Singh via email

1. The opposite parties have received the premium as stated in previous paras and covered the claim of the complainant as the last premium was received by opposite party up to 17.09.2022, whereas the complainant suffered pain and admitted in hospital on 11.11.2021, as such the claim of the complainant within the ambit of insured policy.
2. That the hospital i.e. Dayanand Medical College & Hospital, Ludhiana had sent all the requisite papers estimate of surgery to the opposite parties for approval the cashless claim, but the opposite parties have denied the claim of the complainant by writing one line i.e. “It is observe from the hospital records that the insured patient has the above disease which is a long standing ailment. We are not able to ascertain the duration of the disease based on the documents/details submitted by the hospital. It requires further evaluation.” This denial of the opposite parties is not tenable in the eyes of law, rather it is a unfair trade practice.

                   The complainant further stated that he has suffered loss of mental pain and agony and is entitled to compensation. In the end, the complainant has prayed for issuing direction to the opposite parties to approve the cashless claim for her knee surgery and to pay Rs.2,00,000/- as compensation  for mental pain, agony, harassment and litigation expenses.

2.                Upon notice, the opposite parties appeared and filed joint written statement by taking preliminary objections that the complaint is not maintainable; the complainant estopped by her act and conduct and concealment of material facts. The opposite parties alleged that on receipt of the claim, it was duly registered, entertained and processed. The opposite parties further alleged that the complainant had obtained Family Health Optima Insurance policy No.P/161114/01/2022/004362 valid from 18.09.2021 to 17.09.2022 covering the complainant herself, Sh. Manjit Singh spouse for a sum insured of Rs.5,00,000/-. Previously, the complainant got renewal of the policy vide policy No.P/161114/01/2020/002943 from 18.09.2019 to 17.09.2020 and No.P/161114/01/2021/003838 from 18.09.2020 to 17.09.2021. The insurance policy is issued on the principles uberrimae fides. Utmost good faith is a cardinal principle of insurance which 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 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 complainants 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 the complainant submitted a preauthorization quotation and requested for cashless authorization to approve the cashless facility to get admitted at D.M.C. Hospital, Ludhiana for treatment of OA knee which is a surgical management vide claim No.CIR/2022/161114/3446569. After the receipt of pre-authorization quotation, the opposite parties vide letter i.e. query on authorization for cashless facility dated 11.11.2021 had called upon DMC Hospital, Civil Lines, Ludhiana to provide the documents/details which is reproduced as under:-

• Letter from the treating doctor with seal and sign clarifying the exact duration of present ailment – provide its all previous consultation and treatment record.

The opposite parties further alleged that on scrutiny of the cashless claim authorization letter received by them, it is observed from the hospital record that the complainant had the above said disease which is a long standing ailment and they were not able to ascertain the duration of the disease based on the documents/details submitted by the complainant and the same required further evaluation hence the cashless authorization was rejected vide letter dated 22.11.2021 and 24.11.2021 which was duly communicated to the complainant as well as the hospital. The opposite parties alleged that as they did not approve the cashless facility, the complainant did not get admitted and treated in DMC Hospital, Ludhiana but subsequently, she was hospitalized at Orison Super Specialty Hospital, Ludhiana from 20.03.2022 to 24.03.2022 for the diagnosis and treatment of Bilateral OA Knee. The insured submitted claim documents for reimbursement of medical expenses vide  Claim No.CIR/2023/161114/0353965 and on the basis of submitted documents an amount of Rs.3,41,491/- against claimed amount of Rs.3,75,512/- was settled to the insured through NEFT transaction vide UTR No.207090817450 on 12.07.2022.

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections and has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                In support of her claim, the complainant tendered her affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. In her affidavit Ex. CA the complainant has submitted that she got severe pain in her knees during the pendency of the present complaint and she has to gone for surgery for replacement of  knees, which was done by the doctor of Orison Super Specialty Hospital Infertility & Trauma Centre for that she has to incurred expenditures for the amount of Rs.3,50,000/. Thereafter, the details of bills of expenditure has been sent to the opposite parties and they have reimbursed the amount of Rs.3,41,491/- to her against the claim of Rs.3,75,512/-.  The complainant also tendered documents Ex. C1 is the copy of private OPD card of DMC Hospital, Ludhiana, Ex. C2 is the copy of insurance policy from 18.09.2019 to 17.09.2020, Ex. C3 is the copy of policy from 18.09.2020 to 17.09.2021, Ex. C4 is the copy of insurance policy from 18.09.2021 to 17.09.2022, Ex. C5 is the copy of customer information sheet- Family Health Optima Insurance Plan, Ex. C6 is the copy of denial of preauthorization request for cashless treatment dated 22.11.2021, Ex. C7 is the  certificate of DMC Hospital, Ludhiana dated 24.11.2021, Ex. C8 is the letter dated 24.11.2021 written by the complainant to the opposite parties, Ex. C9 is the copy of OPD slip dated 08.03.2022 of Orison Super Specialty Hospital, Ex. C10 is the copy of discharge summary of Orison Super Specialty Hospital, Ex. C11 to Ex. C15 are the investigation reports of the complainant, Ex. C16 to Ex. C23 and EX. C25  are the copies of bills/receipts, Ex. C24 is the copy of OPD slip dated 04.04.2022 of Orison Super Specialty Hospital closed the evidence.

4.                On the other hand, counsel for opposite parties tendered affidavit Ex. RA of Sh. Rajinder Bansal, ADM of the opposite parties along with documents Ex. R1 is the copy of common proposal form, Ex. R2 is the copy of insurance policy from 18.09.2019 to 17.09.2020, again Ex. R2 is the copy of insurance policy from 18.09.2020 to 17.09.2021, again Ex. R2 is the copy of insurance policy from 18.09.2021 to 17.09.2022, Ex. R3 is the  copy of customer information sheet-Family Health Optima Insurance Plan, Ex. R4 is the copy of circular dated 22.07.2020 of IRDA, Ex. R5 is the copy of request for cashless hospitalization for health insurance  dated 11.11.2021, Ex. R6 is the copy of query on authorization for cashless treatment dated 11.11.2021, Ex. R7 is the copy of denial of preauthorization request for cashless treatment dated 22.11.2021 issued to DMC Hospital, Ludhiana, again Ex. R7 is the copy of denial of preauthorization request for cashless treatment dated 22.11.2021 sent to the complainant, again Ex. R7 is the copy of denial of preauthorization request for cashless treatment dated 24.11.2021 issued to the complainant, again Ex. R7 is the copy of denial of preauthorization request for cashless treatment dated 24.11.2021 issued to DMC Hospital, Ludhiana, Ex. R8 (six times) are the copies of reminders dated 05.12.2021, 10.12.2021, 20.12.2021, 25.12.2021, rejection letters 04.01.2022 and 09.01.2022 respectively, Ex. R9 is the  copy of claim form, Ex. R10 is the copy of discharge summary of Orison Super Specialty Hospital, Ex. R11 is the  copy of bill dated 25.03.2022 of Orison Super Specialty Hospital, Ex. R12 is the copy of bill assessment sheet dated 07.07.2022 and closed the evidence.

5.                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.

6.                In the present case, the complainant a holder of the policy in question during the second renewal period of the policy i.e. 18.09.2021 to 17.09.2022, was advised to undergo a surgery for knees replacement by Dr. Rajnish Garg, Head of Department of Orthopedic, Dayanand Medical College and Hospital, Ludhiana on 11.11.2021. Thereupon which the complainant presented pre-authorization request for approval of cashless treatment along with complete set of  as the waiting period of 24 consecutive months of coverage from the inception of policy has since elapsed. But the opposite parties rejected the cashless authorization by observing as under:-

“It is observe from the hospital records that the insured patient has the above disease which is a long standing ailment. We are not able to ascertain the duration of the disease based on the documents/details submitted by the hospital. It requires further evaluation.”

7.                The complainant also made another request for cashless authorization through her son but the same was also not acceded by the opposite parties. Finding no solution, the complainant was constrained to leave the hospital. The complainant presented the present complaint on 14.01.2022 before this Commission praying for seeking direction for approval of cashless claim for her knee replacement surgery on the basis of estimate of expenditure submitted by Dayanand Medical College and Hospital, Ludhiana. However, feeling deterioration of her medical condition, the complainant underwent for treatment of Bilateral OA Knee in Orison Super Specialty Hospital from 20.03.2022 to 24.03.2022. She submitted the claim documents for reimbursement of the medical expenses which was approved and the opposite parties paid Rs.3,41,491/- out of total claimed amount of Rs.3,75,512/-. This fact was also admitted by the complainant while tendering her affidavit Ex. CA. it may be noticed that the claim of the complainant was settled during the pendency of the complaint. Subsequent settlement of the claim by the opposite parties is in stark contradiction to the pre-authorization denial by them. While denying the pre-authorization claim, the opposite parties did not refer to any clause of the policy and just ignored the specific diagnosis of a medical specialist. Had the opposite parties acted judiciously and accorded pre-authorization request, the complainant must not have undergone the pain, harassment and mental agony. Her treatment was delayed for more than 4 months and as such, this amounts to deficiency of service on the part of the opposite parties. As such, in our considered view, the complainant is held entitled for composite cost of rs.20,000/- from the opposite parties.

8.                As a result of above discussion, the complaint is partly allowed with an order that the opposite parties shall pay a composite compensation of Rs.20,000/- (Rupees Twenty Thousand only) to the complainant within 30 days from the date of receipt of copy of order, failing which the complainant shall be held entitled for interest @8% per annum from the date of filing of complaint till actual payment. Copies of the order be supplied to the 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)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

Announced in Open Commission.

Dated:08.02.2023.

Gobind Ram.

Sarabjeet Kaur Vs Star Health & Allied Insurance                    CC/22/14

Present:       Sh. A.K. Rana, Advocate for complainant.

                   Sh. Rajeev Abhi, Advocate for OPs.

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with an order that the opposite parties shall pay a composite compensation of Rs.20,000/- (Rupees Twenty Thousand only) to the complainant within 30 days from the date of receipt of copy of order. 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:08.02.2023.

Gobind Ram.