Punjab

Ludhiana

CC/21/348

Vineet Gupta - Complainant(s)

Versus

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

Suresh Kumar

28 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No: 348 dated 20.07.2021.                              Date of decision: 28.08.2024.

 

1. Vineet Gupta son of Shri Shantinath,
2. Bhavesh Gupta son of Vineet Gupta,
3. Varun Gupta son of Vineet Gupta,

All residents of House No.147/06, Mohalla Inderpuri, Khanna, District Ludhiana...…Complainant

                                                Versus

1. Star Health & Allied Insurance Co. Ltd., No.15, Sri Balaji Complex, Ist Floor, Whites Lane, Royapettah, Chennai-600014 through its Managing Director.
2. Star Health & Allied Insurance Co. Ltd., SCF 6, First Floor, GTB Market G.T. Road, Khanna, District Ludhiana through its Branch Manager.                                                                               …..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 complainants            :         Sh. Suresh Kumar, Advocate.

For OPs                          :         Sh. Rajeev Abhi, Advocate.

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Succinctly put, the case of the complainants is that complainant No.2 and 3 are sons of complainant No.1, who has been availing health insurance policy from the OPs for himself and his family members each and every year. Complainant No.1 availed a cashless Family Health Optima Insurance, 2017 policy from the OPs bearing No.P/211211/01/2020/003959 w.e.f. 08.03.2020 to 07.03.2021 covering himself, his wife Pratibha Gupta and sons Bhavesh Gupta and Varun Gupta having sum insured of Rs.6,50,000/-.

                   The complainants stated that they along with Pratibha Gupta and other family members were found COVID-19 positive for which they got treatment.  Complainant No.1 was admitted in Fortis Hospital, Mohali on 01.08.2020 due to serious health condition where huge amount was incurred on his treatment. Further complainant No.2 and 3 along with Pratibha Gupta remained hospitalization in Gian Sagar Medical College & Hospital, Tohfapur where they remained admitted from 02.08.2020 to 11.08.2020. The complainants further stated that although the policy was cashless but the OPs did not pay the entire hospitalization charges to the hospital authorities and only settled an amount of Rs.2,28,510/- qua complainant No.1 and rest amount of Rs.73,246/- was not paid despite written request of Fortis Hospital authorities and refused to pay the amount. Further hospital charges for complainant No.2 were not paid by the OPs to the tune of Rs.17,000/- whereas qua complainant No.3, out of total Rs.12,000/- an amount of Rs.7998/- was paid and remaining amount was not paid. The complainants further stated that they had to pay the charges from their own pocket. However, the OPs paid the entire amount of Rs.11,500/- qua Pratibha Gupta wife of complainant No.1. After discharge from the hospital, the OPs lodged claim with the OPs but the OPs repudiated the claims vide letters dated 19/21.09.2020 qua complainant No.1 and 2 on flimsy grounds. The OPs vide letter dated 19.09.2020 qua complainant No.1 mentioned that the charges towards experimental therapy is not payable as per the policy whereas at the time of taking policy, it was assured that everything is covered under the policy.

                   The complainants further stated that in the letter dated 21.09.2020 qua complainant No.2, it is mentioned that as per the guidelines of All India Institute of Medical Sciences, New Delhi and Ministry of Health and Family Welfare, Government of India regarding treatment of Covid-19 patients, the patient needs only self-isolation by home quarantine based on submitted claim documents but the patient was admitted and treatment which is not payable. According to the complainants, this ground is totally false and frivolous. Further it is to be determined by the treating doctors on seeing the condition of the patient that what kind of treatment is required and whether admission of patient in hospital is necessary and essential or the home quarantine is sufficient. The health condition of each and every patient is different and all the patients cannot be treated with the same yardstick. All family members of the complainants were found Covid-19 positive and remained hospitalized. The complainants approached the OPs with request to disburse the claim amount but the OPs failed to do the needful. The act of the OPs amounts to deficiency in service and unfair trade practice due to which the complainants claimed to have suffered harassment and humiliation for which they are entitled to compensation. In the end, the complainants prayed for directing the OPs to disburse the claim amount of Rs.94,358/- along with compensation of Rs.2,00,000/-, damages of Rs.1,00,000/- and litigation expenses of Rs.50,000/-.

2.                Upon notice, the OPs appeared and filed joint written statement by taking preliminary objections that the complaint is not maintainable; the complainants are estopped by their act and conduct and concealment of material facts; lack of jurisdiction etc. The OPs alleged that immediately on the receipt of the claim, it was duly registered, entertained and processed. The complainants had obtained Family Health Optima Insurance policy No.P/211211/01/2020/003959 valid from 08.03.2020 to 07.03.2021 covering Mr. Vineet Gupta, Self, Mrs. Pratibha Gupta spouse, Bhavesh Gupta and Varun Gupta dependent children for a sum insured of Rs. 10,00,000/- with disclosed pre-existing disease (as per proposal form) disease of nose and related complication qua Bhavesh Gupta. According to the OPs, the policy incepts for the first time from 08.03.2017 as per the details reproduced as under:-

P/211211/01/2017/002179 valid from 08.03.2017 to 07.03.2018

P/211211/01/2018/002636 valid from 08.03.2018 to 07.03.2019

P/211211/01/2019/003269 valid from 08.03.2019 to 07.03.2020

 

The OPs further stated that the 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 insurance policy was issued to the complainant after their being accepting and agreeing to the terms and conditions of the policy. The complainants preferred the claim in the 4th year of Family Health Optima Policy with the history of four previous claims.

                   The OPs further stated that there are four Covid Claims of all members of the policy holders.

Claim No.1 - CLI/2021/211211/0204970

                   Complainant Vineet Gupta made a request for cashless authorization for hospitalization at Fortis Hospital, Mohali from 01.08.2020 to 11.08.2020 for the treatment of Covid-19 vide claim No.CLI/2021/211211/0204970.  On the basis of submitted cashless documents, the claim was processed and an amount of Rs.2,28,510/- was approved and paid to the aforesaid hospital through NEFT N237201222114752 on 24.08.2020. Further pre and post hospitalization claim of Rs.4,700/- was paid to the insured through NEFT 010109986989 on 12.10.2020. The deduction of Rs.73,246/- was made and the reasons for the deductions of cashless hospitalization at Fortis Hospital are reproduced as under:-

• As per the other excluded expenses of the policy, the charges of nutritionist for Rs.250/- are not payable.
• As per the other excluded expenses No. 190 of the policy, the charges pertaining to Glucometer for Rs.2,660/- are not payable.
• As per the other excluded expenses of the policy, the charges pertaining to Spirometer (No.139), mask (No.183), fabrics (No.92), gloves (No.181), shoe cover (No.13), suits (No.92), hood disposables, kit (No.180), gown (No.30), electrodes (No.162), sets, paper tape (No.90), further the is an Experimental therapy and as per exclusion No.21, the deducted towards the same is not payable, hence an amount of Rs.61,636/- are not payable.
• As per the Exclusion No.27, of the policy, the charge towards - the hospital charges, admission fee, registration, patient diet charges etc. are not payable Rs.8,700/- are deducted.

 

Hence, the maximum payable amount is Rs.2,85,510/- which has already been paid to the insured/complainant and Rs.73,246/- was not payable which has been deducted as per the above said details. Further the complainant was also intimated about the said deductions as per bill assessment sheet - hospital payment and to the hospital vide cashless authorization letter dated 11.08.2020. As per cashless authorization letter dated 11.08.2020 it is clearly stated that the total authorization amount is Rs.2,28,510/- and experimental therapy are not payable as per policy terms and conditions (same was already communicated in the previous interim letter dated 02.08.2020.

Claim No.2 - CLI/2021/211211/0219920

                   The insured Varun Gupta submitted a reimbursement claim for Rs.12,000/- for hospitalization at Gian Sagar Medical College & Hospital, Patiala with date of admission from 02.08.2020 to 11.08.2020 for the treatment of Covid-19 in respect of which claim No.CLI/2021/211211/0219920 was registered. Further on the basis of submitted reimbursement documents, the claim was processed in accordance with the terms and conditions of the policy and an amount of Rs.7,998/- was paid to the insured through NEFT-010275084484 on 27.10.2020. The reasons for the deductions are for reimbursement hospitalization at Gian Sagar Medical College & Hospital at Patiala  ground that “the insured has not submitted break for the amount incurred towards the hospitalization. Hence, an amount of Rs.1333/- as per day was allowed towards reasonable and necessary charges.”

Claim No.3-CLI/2021/211211/0219926

                   The insured Bhavesh Gupta submitted a reimbursement claim of Rs. 17,000/- for hospitalization at Gian Sagar Medical College & Hospital, at Patiala from 2.8.2020 to 11.8.2020 for the treatment of Covid 19 which was registered at claim No.CLI/2021/211211/0219926. After scrutinizing the documents including the medical records placed in the claim file and after due application of mind by the officials of the respondents, it was observed from the treating doctor certificate that, the insured Bhavesh Gupta, the patient of asymptomatic and did not warrant any invasive intervention. Even the payment receipt is made for the room rent.

                   The OPs further stated that  as per the guidelines from All India Institute of Medical Sciences, New Delhi and Ministry of Health and Family Welfare, Government of India regarding the treatment of Covid-19 patient, this patient needs only self-isolation by home quarantine based on submitted claim documents. Instead the patient is admitted and treated, which is not payable. Hence, claim was rejected vide letter of the respondents dated 21.09.2020 which was duly communicated to the complainant.

Claim No.4 - CLI/2021/211211/0219913

                    A claim for the treatment of Smt. Pratibha Gupta for treatment of Covid-19 in respect to her hospitalization with Gian Sagar Medical College & Hospital was also lodged which was settled and paid for a sum of Rs. 11,500/- in full and final settlement of the claim.

                   According to the OPs, the claim of the complainants Vineet Gupta, Varun Gupta and Smt. Pratibha Gupta have rightly been processed, paid in full and final settlement of the claim and accepted by the aforesaid insured's Vineet Gupta, Varun Gupta and Pratibha Gupta in full and final settlement of the claim voluntarily, unconditionally, without any protest and without reserving any right to recovery any further amount under the claim. The claim of the insured Bhavesh Gupta was rejected as per the guidelines issued by All India Institute of Medical Sciences, New Delhi and Ministry of Health and Welfare, Govt. of India regarding the treatment of Covid-19 patients. The Ops further stated that all the claim of the complainant was processed and settled as per the terms and conditions vide Claim No. CLI/2021/211211/0219913, CLI/2021/211211/0219920 and CLI/2021/211211/0204970. The aforesaid amounts of Rs. 11,500/- had been credited to the accounts of the insured's account No.01121050045828 vide NEFT on 13.10.2020 and the amount of Rs.7,998/- was settled vide NEFT on 27.10.2020 and an amount of Rs.2,28,510/- and Rs.4700/- was settled vide NEFT on 24.08.2020 and 12.10.2020. The complainants are not entitled to any discretionary relief as alleged.

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

3.                The complainants filed rejoinder to the written statement of the OPs reiterating the facts mentioned in the complaint and controverted those mentioned in the written statement of the OPs.

4.                In support of their claim, complainant No.1 Vineet Gupta 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 the cashless authorization letter,  Ex. C2 and Ex. C3 is the copies of medical bill/discharge summary of Vineet Gupta, Ex. C4 to Ex. C6 are the copies of bills of  Bhavesh Gupta, Ex. C7 to Ex. C9 are the copies of bills of Varun Gupta, Ex. C10 is the copy of letter written by Fortis Hospital to the OPs, Ex. C11 is the copy of bill assessment sheet of Vineet Gupta, Ex. C12 to Ex. C16 are the copies of bill of Pratibha Gupta, Ex. C17 is the copy of repudiation letter dated 19.09.2020 of claim of Vineet Gupta, Ex. C18 is the copy of repudiation letter dated 21.09.2020 of claim of Bhavesh Gupta, Ex. C19 is the copy of account statement of the complainant Vineet Gupta and closed the evidence.

5.                On the other hand, counsel for the OPs tendered affidavit Ex. RA of Sh. Sumit Sharma, Senior Manager of the OPs along with documents Ex. R1 is the 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 notification dated 20.02.2013 of IRDA, Ex. R5 is t he copy of Portability Form, Ex. R6 is the copy of cashless hospitalization request of Vineet Gupta, Ex. R7 is the copy of cashless authorization letter dated 02.08.2020 of Vineet Gupta, Ex. R8 is the copy of cashless authorization letter dated 11.08.2020 of Vineet Gupta, Ex. R9 is the copy of bill assessment sheet of Vineet Gupta, Ex. R10 is the copy of Claim Form-Part-A of Vineet Gupta, Ex. R11 is the copy of letter written by Fortis Hospital to the OPs, Ex. R12 is the copy of bill of Vineet Gupta, Ex. R13 is the copy of repudiation letter dated 19.09.2020 of Vineet Gupta, Ex. R14 is the copy of Claim Form-Part-A of Vineet Gupta, Ex. R15 is the copy of bill assessment sheet of Vineet Gupta, Ex. R16 is the copy of discharge summary of Vineet Gupta, Ex. R17 is the copy of Claim Form-Part-A of Vineet Gupta, Ex. R18 is the copy of ICMR Specimen Referral Form for Covid-19 of Bhavesh Gupta, Ex. R19 is the copy of certificate in respect of Bhavesh Gupta, Ex. R20 is the copy of Medical Certificate for home isolation of Bhavesh Gupta, Ex. R21, Ex. R32 is the copy of Covid positive reports of the complainants and Pratibha Gupta, Ex. R22, Ex. R23 are the copies of receipts of Bhavesh Gupta, Ex. R24 is the copy of repudiation letter dated 21.09.2020 of Bhavesh Gupta, Ex. R25 is the copy of Claim Form of Varun Gupta, Ex. R26 is the copy of bill assessment sheet of Varun Gupta, Ex. R27 is the copy of Field Visit Report of Pratibha Gupta, Ex. R28 is the copy of Claim Form of Pratibha Gupta, Ex. R29 is the copy of ICMR Specimen Referral Form for Covid-19 of Pratibha Gupta, Ex. R30 is the copy of Medical certificate for home isolation, Ex. R31 is the copy of certificate issued in favour of Pratibha Gupta, Ex. R33 and Ex. R34 are the copies of receipts/bills of Gian Sagar Hospital for Pratibha Gupta, Ex. R35 is the copy of bill assessment sheet of Pratibha Gupta and closed the evidence.

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

7.                Admittedly, the complainants have been successively availing the insurance policies on yearly basis since 08.03.2017 and lastly they availed the policy Ex. R2 having validity w.e.f. 08.03.2020 to midnight of 07.03.2021 covering the complainant Vineet Gupta, his wife Pratibha Gupta and dependent children Bhavesh Gupta and Varun Gupta. In the first week of August 2020, they were found Covid-19 positive and remained admitted for treatment in different hospitals. They incurred expenses on their treatment out of which the claims were partially settled after making deductions by the OPs. The details of the claims in tabular form are given as under:-

Sr. No.	Name of the insured	Place and period of hospitalization	Amount incurred on treatment	Date and amount of payment	Amounts deducted
1.	Vineet Gupta	Fortis Hospital, Mohali from 01.08.2020m to 11.08.2020	Rs.3,01,756/-	Rs.2,28,510/- on 11.08.2020	Rs.73,246/-
2.	Varun Gupta	Gian Sagar Medical College & Hospital, Patiala from 02.08.2020 to 11.08.2020	Rs.12,000/-	Rs.7,998/- on 27.10.2020	Rs.4002/-
3.	Bhavesh Gupta	Gian Sagar Medical College & Hospital, Patiala from 02.08.2020 to 11.08.2020	Rs.17,000/-	Declined	Declined
4.	Pratibha Gupta	Gian Sagar Medical College & Hospital, Patiala from 02.08.2020 to 11.08.2020	Rs.11,500/-	Rs.11,500/- on 10.10.2020	Nil

 

8.                From the perusal of the aforesaid table, it is evident that the reimbursement claim of Bhavesh Gupta amounting to Rs.17,000/- was declined by the OPs vide letter dated 21.09.2020 Ex. R24 on the grounds that the it is observed from the medical records that the insured patient is asymptomatic and did not warrant any invasive intervention. Perusal of Ex. R19, the certificate of treating doctor of Gian Sagar Medical College & Hospital, Patiala reveals that at the time of admission the complainant Bhavesh Gupta was tested Covid +ve which necessitated his admission in the hospital on 02.08.2020. He remained under treatment till 11.08.2020 for 7 days. Although the cost of treatment and food was borne by the Government but the patient had paid the expenses for private room. The assumption of the OPs for the treatment of the complainant Bhavesh Gupta needed only self isolation by home quarantine defines any logic. As such, the claim No.3 relating to complainant Bhavesh Gupta is required to be settled in terms of the policy terms and conditions.

9.                The claim No.1, 2 and 4 were rightly settled by the OPs. The complainants could not pin point how the deductions made by the OPs were not in conformity with the terms and conditions of the policy or the deductions are ex-facie arbitrary and are illegal. As such, this Commission is of the view that the settlement of these three claims do not warrant any interference or revocation and as such, the prayers of the complainants qua these three claims i.e. claim No.1, 2 and 4 are hereby rejected.

10.              As a result of above discussion, the complaint is partly allowed with direction to the OPs to settle the amount and reimburse the claim No.3 of with respect to hospitalization of the insured Bhavesh Gupta  from 02.08.2020 to 11.08.2020 at Gian Sagar Medical College & Hospital, Patiala in terms of policy terms and conditions along with interest @8% per annum on the settled amount from the date of filing of complaint till its actual payment within 30 days from the date of receipt of copy of order. The OPs shall also pay a composite costs of Rs.5,000/- (Rupees Five Thousand only) to the complainant within 30 days from the date of receipt of copy of order.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

11.              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:28.08.2024.

Gobind Ram.