DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/32/2024
Date of Institution: 02.04.2024
Date of Decision: 19.11.2024
1. Anuj Mohan aged about 42 year, son of Surinder Mohan;
2. Lalita Rani aged about 40 years, wife of Anuj Mohan son of Surinder Mohan both residents of #B-XIII/1514, Street No. 1, Court Chowk, Sangrur Road, Barnala-148101.
…Complainants
Versus
1. Star Health and Allied Insurance Company Ltd., No. 15, SRi Balaji Complex, 1st Floor, Whites Lane, Roy Apettah, Chennai-600014, through its Authorized Signatory.
2. Star Health and Allied Insurance Company Ltd., Pakka College Road, Near PNB Bank Handiaya Bazar Branch, Barnala through its Branch Manager.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Ms. Himani Bansal Adv counsel for complainant.
Sh. Rohit Jain Adv counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. 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 the complainant No. 1 Anuj Mohan purchased one Health insurance policy named as Star Group Health Insurance Policy Gold bearing No. P/211229/01/2023/002030 from OP No. 2 and said policy was valid from 07.03.2023 to 06.03.2024 in which complainant No. 1 Anuj Mohan, his wife Lalita Rani complainant No. 2 and his two children are insured for Rs.5,00,000/- for any type of aliment and medical need to the whole members of the family and the total limit of coverage is of Rs. 5,00,000/-. It is further alleged that prior to the said policy, complainant No. 1 had also previously purchased the same policy in the last year, which was valid from 07.03.2022 to 06.03.2023. It is alleged that in the month of September, 2023 complainant No. 2 Lalita Rani experienced some behavioral changes like loss of sleep and appetite, restlessness and too much anger and when the problems persisted complainant No.1, on 23.09.2023, consulted Midha Neuropsychiatry & Deaddiction Hospital, Bathinda and took complainant No.2 to the hospital for check-up and on diagnose complainant No.2 was diagnosed as suffering from depression and thus was admitted by the hospital. It is further alleged that she remained admitted in the hospital for five days and after being treated for Major Depressive Disorder and was discharged on 28.09.2023 and expenses of Rs. 34,300/- have been incurred by the complainants on the said treatment. It is further alleged that after treatment complainants immediately approached OPs for submission of the claim documents and the OPs accepted all the requisite documents for the total claim amount of Rs. 34,300/- and generated claim intimation No. CIG/2024/211229/0916825 of the said claim of the complainants and thereafter vide letter dated 10.11.2023, OPs requested for submission of some additional documents from the complainants which were submitted by the complainants within the time stipulated in the letter. It is further alleged that the complainants approached the OPs many times to pay the amount of claim but the OPs never accede the legitimate request of the complainants. It is further alleged that the Ops have rejected the genuine claim of the complainants without any justified reason vide rejection letter dated 25.01.2024 by mentioning that, "It is observed from the submitted medical records that the insured patient is predominantly treated with oral medications only. Our medical team is of the opinion that the hospitalization of the insured patient is not warranted". It is further alleged that the doctors at MIDHA Neuropsychiatry & Deaddiction Hospital, who first attended complainant No.2 Lalita Rani, were rightly of the opinion to admit her in the hospital to give medical aid and they did not consider it proper to remain content by thinking that patient be sent back home, advising oral treatment. It was those medical officers who first attended complainant No. 2 Lalita Rani, who would in better way formed an opinion for treatment by admitting her in the hospital and the doctors of the medical team of the insurance company, by sitting in their air conditioned office cannot understand the position of the patient at that moment only by reading the medical history and medical prescription. It is further alleged that the Ops have rejected the claim of the complainants without any rhyme and reason and without any legal right to exclude the complainants from the benefits of policy on the false and flimsy grounds. As such, the act and conduct of the opposite parties comes within the definition of the unfair trade practice as well as deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to release the claim amount of Rs. 34,300/- alongwith interest @ 18% per annum from the date of admission in the hospital i.e. 23.9.2023 till realization.
- To pay Rs. 1,00,000/- towards mental tension and harassment.
- Further, to pay Rs. 22,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking preliminary objections interalia on the grounds that the complainant has no locus-standi to file the present complaint. The present complaint is not legally maintainable. The complainant has no cause of action to file the present complaint. The complainant has not come with clean hands etc.
4. On merits, it is admitted that complainant No.1 Anuj Mohan purchased one health insurance policy named as Star Group Health Insurance Policy Gold bearing no. P/211229/01/2023/002030 from OP No. 2 and said policy was valid from 07.03.2023 to 06.03.2024 in which complainant No. 1 Anuj Mohan, his wife Lalita Rani complainant No. 2 and his two children Arshia and Aayush Gupta are insured for Rs.5,00,000/-. It is further alleged that the policy is subject to the terms and conditions of the policy which were sent to Anuj Mohan along with insurance policy, thus the total limit of coverage is of Rs. 5,00,000/- and prior to the said policy complainant No. 1 had also previously purchased the same policy in the last year, which was valid from 07.03.2022 to 06.03.2023. It is denied that the Ops have rejected the genuine claim of the complainants without any justified reason vide rejection letter dated 25.01.2024. It is submitted that the repudiation was legal, enforceable and as per the policy terms and conditions. It is denied that in the case in hand, the doctors at MIDHA Neuropsychiatry & Deaddiction Hospital, who first attended complainant No. 2 Lalita Rani, were rightly of the opinion to admit her in the hospital to give medical aid. It is wrong and denied that they did not consider it proper to remain content by thinking that patient be sent back home, advising oral treatment. It is wrong and denied that the Ops have rejected the claim of the complainants without any rhyme and reason and without any legal right to exclude the complainants from the benefits of policy on the false and flimsy ground of misrepresentation. 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 submitted that the Policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. It is further alleged that the insured requested for the reimbursement of the medical expenses towards treatment of MAJOR DEPRESSIVE ORDER at MIDHA HOSPITAL MIAN since 23.09.2023 TO 28.09.2023 for an amount of Rs. 34,300/-. It is observed from the submitted medical records that the insured patient is predominantly treated with oral medications only and the medical team of the insured is of the opinion that the hospitalization of the insured patient is not warranted. It is further alleged that as per the terms and conditions of the policy, the first most condition for claim to be admissible is 24 hours necessary hospitalization which is not fulfilled in the present case and the patient was only admitted as she denied taking the medicine and hence the hospitalization was necessary. It is further alleged that as per Exclusion -Code Excl 36 of the above policy, the Company is not liable to make any payment under this policy in respect of any hospitalization which are not medically necessary/does not warrant hospitalization and the opposite parties therefore regret to inform the insured that for the reasons stated above the opposite parties are unable to settle the claim of the insured under the above policy and the opposite parties hereby repudiate the claim of the insured. Hence claim was rejected and conveyed to insured vide letter dated 25.01.2024 of the opposite parties. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
5. Ld. Counsel for complainants on 26.7.2024 suffered the statement that I do not want to file any rejoinder against the version of opposite parties.
6. To prove the case the complainants tendered into evidence affidavit of complainant as Ex.C-1, copy of Insurance policy for years 2022-2023 as Ex.C-2 (5 pages), copy of Insurance policy for the years 2023-2024 as Ex.C-3( 6 pages), copy of treatment chart and indoor case papers as Ex.C-4 (8 Pages) copy of medical test reports Ex.C-5 (10 pages), copy of Medical Bills as Ex.C-6 (7 pages), copy of discharge summary as Ex.C-7, copy of certificate of doctor as Ex.C-8, copy of claim form as Ex.C-9 (2 Pages), copy of letter dated 10.11.2023 as Ex,C-10, copy of claim repudiation letter dated 25.01.2024 as Ex.C-11 (2 Pages) and closed the evidence.
7. To rebut the case the opposite party tendered into evidence affidavit of Sumit Kumar Sharma as Ex.OPs-1, copy of proposal form as Ex.OPs-2 (2 Pages), copy of policy as Ex.OPs-3 (5 Pages), copy of term and conditions as Ex.OPs-4 (12 Pages), copy of claim form as Ex.OPs-5 (5 Pages), copy of discharge summary as Ex.OPs-6, copy of indoor paper as Ex.OPs-7 (7 pages), copy of prescription slip as Ex.OPs-8, copy of bill as Ex.OPs-9 (7 Pages), copy of test report as Ex.OPs-10 (5 Pages), copy of lal path report as Ex.OPs-11 (6 Pages), copy of medical bill as Ex.OPs-12 (6 pages), copy of repudiation letter as Ex.OPs-13 (3 Pages) and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file.
9. It is admitted case of the opposite parties that the complainant No.1 Anuj Mohan purchased one health insurance policy named as Star Group Health Insurance Policy Gold bearing no. P/211229/01/2023/002030 from opposite party No. 2 and said policy was valid from 07.03.2023 to 06.03.2024 in which complainant No. 1 Anuj Mohan, his wife Lalita Rani complainant No. 2 and his two children Arshia and Aayush Gupta are insured for Rs.5,00,000/- (as per Ex.C-3 & Ex.O.Ps-3). It is further admitted case of the opposite parties that prior to the said policy complainant No. 1 had also previously purchased the same policy in the last year, which was valid from 07.03.2022 to 06.03.2023 (Ex.C-2).
10. Ld. Counsel for the complainants argued that in the month of September, 2023 complainant No. 2 Lalita Rani experienced some behavioral changes like loss of sleep and appetite, restlessness and too much anger and the complainant No.1 on 23.09.2023 consulted Midha Neuropsychiatry & Deaddiction Hospital, Bathinda and took complainant No. 2 to the hospital for check-up and on diagnose complainant No.2 was diagnosed as suffering from depression and thus was admitted by the hospital. It is further argued that she remained admitted in the hospital for five days and after being treated for Major Depressive Disorder and was discharged on 28.09.2023 and expenses of Rs. 34,300/- have been incurred by the complainants on the said treatment. It is further argued that after treatment complainants immediately approached the opposite parties for submission of the claim documents and the opposite parties accepted all the requisite documents for the total claim amount of Rs. 34,300/- and generated claim intimation No. CIG/2024/211229/0916825 of the said claim of the complainants and thereafter vide letter dated 10.11.2023, opposite parties requested for submission of some additional documents from the complainants which were already submitted by the complainants. It is further argued that the complainants approached the opposite parties many times to pay the amount of claim but the opposite parties have rejected the genuine claim of the complainants without any justified reason vide rejection letter dated 25.01.2024 by mentioning that, "It is observed from the submitted medical records that the insured patient is predominantly treated with oral medications only. Our medical team is of the opinion that the hospitalization of the insured patient is not warranted". It is further argued that the opposite parties have rejected the claim of the complainants without any rhyme and reason and without any legal right to exclude the complainants from the benefits of policy on the false and flimsy grounds.
11. On the other hand, Ld. Counsel for the opposite parties 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. 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 argued that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. It is further argued that the insured requested for the reimbursement of the medical expenses towards treatment of MAJOR DEPRESSIVE ORDER at MIDHA HOSPITAL MIAN since 23.09.2023 TO 28.09.2023 for an amount of Rs. 34,300/-. It is further argued that it is observed from the submitted medical records that the insured patient is predominantly treated with oral medications only and the medical team of the insured is of the opinion that the hospitalization of the insured patient is not warranted. It is further argued that as per the terms and conditions of the policy the first most condition for claim to be admissible is 24 hours necessary hospitalization which is not fulfilled in the present case and the patient was only admitted as she denied taking the medicine and hence the hospitalization was necessary. It is further argued that as per Exclusion -Code Excl 36 of the above policy, the company is not liable to make any payment under this policy in respect of any hospitalization which are not medically necessary/does not warrant hospitalization and therefore the claim was rejected and conveyed to insured vide letter dated 25.01.2024 Ex.O.Ps-13 of the opposite parties.
12. We have gone through the facts and evidence produced by both the parties. From the perusal of discharge summary i.e. Ex.C-7 it is established that on 23.9.2023 wife of the complainant suffered from loss of sleep and appetite, restlessness and too much anger and she was admitted in MIDHA Neuropsychiatry and Deaddiction Hospital, Bathinda for treatment from where she was discharged on 28.9.2023 and the complainant No. 1 spent an amount of Rs. 34,300/- on the treatment of his wife which proves from the Bill Break-up/Summary i.e. Ex.C-6. Ld. Counsel for the complainant further argued that in this regard the intimation was given to the opposite parties and complainants lodged claim along with required documents with the opposite parties and they issued a Claim No. CIG/2024/211229/0916825 to the complainants and assured that the claim will be paid very soon, but the opposite parties have failed to pay the genuine claim of the complainants. Ld. Counsel for complainant also argued that the claim of the complainants was repudiated vide letter dated 25.1.2024 Ex.C-11 by the opposite parties on unreasonable and unjustified grounds. On the other hand, the opposite parties have failed to produce on record any cogent evidence to prove the fact that the insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted. Therefore, it is established that the opposite parties have repudiated the claim of the complainant on such flimsy grounds. 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.
13. From the above discussion, it is proved that the claim of the insured/complainants was repudiated by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties.
14. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 34,300/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainants. The opposite parties are further directed to pay Rs. 10,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainants. 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:
19th Day of November, 2024
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
