DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

                            Complaint Case No: CC/96/2023

                                                           Date of Institution: 08.08.2023

                            Date of Decision: 30.07.2024

Gurjeet Singh aged about 35 years son of Swaran Singh resident of Gali No. 4, Sahibjada Ajit Singh Nagar, Near Bus Stand, Barnala.   

ﾅComplainant

                                                   Versus

1. Star Health and Allied Insurance Company Ltd., No. 15, SRI Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai-600014 through its Authorized Signatory.

2. Star Health and Allied Insurance Company Ltd. 1st Floor, Sunami Gate, Sangrur, Above IDBI Bank, Sangrur-148001 through its Branch Manager.   

                                                                                       ﾅ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. Smt. Urmila Kumari: Member 

3. 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 purchased one Health insurance policy named as Young Star Insurance Plan bearing no. P/211223/01/2023/003814 from OP No. 2 and said policy was valid from 28.01.2023 to 27.01.2024 in which complainant is insured for Rs. 5,00,000/- plus Rs. 2,00,000/- as bonus for the next one year for any type of aliment and medical need to the complainant and the inception of the first policy was 27.01.2021. It is alleged that the complainant had suffered some medical problem and he admitted in Dayanand Medical College & Hospital, Ludhiana on 02.02.2023 and in the said hospital he was diagnosed for Dilated Cardiomyopathy & Left TVC Palsy and discharge on 08.02.2023 and the complainant had incurred Rs. 47,586/- on the said treatment and besides the same the complainant also incurred Rs. 18672/- on medicines. The complainant immediately approached to the opposite parties for submission of the claim documents and after completion of all required documents the opposite parties accepted all the requisite documents and generated claim intimation no. CIR/2023/211223/1447535 of the said claim of the complainant and assured that claim will be paid very soon to the complainant by cheque or through account. The complainant approached the opposite parties many times to pay the amount of claim but they never accede the legitimate request of the complainant. It is further alleged that the opposite parties had sent a letter dated 04.05.2023 to the complainant for requirement of additional documents/information and in the said letter they had demanded letter from treating doctor, 1st OPD consultation, all past consultations and ECG, ECHO and Cardiac marker reports and the complainant thereafter had provided letter from treating doctor dated 15.05.2023 from DMC, 1st OPD consultation and all ECG & ECHO reports and also submitted declaration that no past consultation taken. However, the insurance company against law and facts has wrongly repudiated the claim vide letter dated 14.06.2023 on the sole ground that, "the insured has not submitted the documents called for by us and in the absence of those documents/details, we are not able to further process your claim." It is submitted that the complainant had already submitted all the requisite documents which are in his possession. It is further alleged that the opposite parties with malafide intention, without any justified reason repudiated the claim of the complainant. 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.-

i. The opposite parties may be directed to release the claim amount of Rs. 66,258/- alongwith interest @ 18% from the date of admission i.e. 2.2.2023 till realization. 

ii. To pay Rs. 50,000/- towards mental tension and harassment. 

iii. Further, to pay Rs. 11,000/- 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 the complainant purchased one Health insurance policy named as Young Star Insurance Plan bearing No. P/211223/01/2023/003814 from OP No. 2 and said policy was valid from 28.01.2023 to 27.01.2024 in which complainant is insured for Rs. 5,00,000/- for the next one year for any type of aliment and medical need to the complainant but as per terms and conditions of the policy which was supplied to the complainant along with policy and the inception of the first policy was 27.01.2021. It is further alleged that as per documents submitted by the complainant that he had suffered some medical problem and he admitted in Dayanand Medical college & Hospital, Ludhiana on 02.02.2023 and in the said hospital he was diagnosed for Dilated Cardiomyopathy & Left TVC Palsy and discharge on 08.02.2023 and the complainant had incurred Rs. 47,586/- on the said treatment and also incurred Rs. 18,672/- on medicines. It is further admitted to the extent that the complainant approached to the opposite parties for submission of the claim documents and after completion of all required documents the opposite parties accepted all the requisite documents and generated claim intimation CIR/2023/211223/1447535 of the said claim of the complainant. It is denied that the opposite parties assured that claim will be paid very soon to the complainant by cheque or through account. It is further alleged that the opposite parties had sent a letter dated 04.05.2023 to the complainant for requirement of additional documents/information and in the said letter opposite parties had demanded the required documents as mentioned therein. It is denied that the opposite parties against law and facts has wrongly repudiated the claim of the complainant vide letter dated 14.06.2023 on the sole ground that," the insured has not submitted the documents called for by us. In the absence of those documents/details, we are not able to further process your claim." As such, the opposite parties repudiated the claim on True, valid and legal grounds and as per terms and conditions of the policy. All other allegations of the complaint are denied and prayed for the dismissal of complaint.  

5. Ld. Counsel for complainants on 11.1.2024 suffered the statement that I do not want to file any rejoinder against the version of opposite parties.   

6. The complainant tendered into evidence affidavit of complainant as Ex.C-1, copy of policy as Ex.C-2 (containing 4 pages), copies of bills are Ex.C-3 (containing 26 pages), copy of Medical record/report as Ex.C-4 (containing 42 pages), copy of discharge summary as Ex.C-5 (containing 3 pages), copy of claim form as Ex.C-6 (containing 3 pages), copy of letter dated 04.05.2023 as Ex.C-7 (containing 2 pages), copy of certificate issued by Dr.Gautam Singal dated 15.05.2023 as Ex.C-8, copy of declaration as Ex.C-9, copy of repudiation of claim dated 14.06.2023 as Ex.C-10 (containing 3 pages) and closed the evidence.

7. To rebut the case the opposite parties tendered into evidence affidavit of Sumit Kumar Sharma Ex.O.Ps-1, copy of proposal form Ex.Ops-2 (3 pages), copy of policy Ex.O.Ps-3 (4 pages), copy of terms and conditions Ex.O.Ps-4 (7 pages), copy of request letter Ex.O.Ps-5 (4 pages), copies of letter dated 4.2.2023 Ex.O.Ps-6 & Ex.O.Ps-7, copy of claim form Ex.O.Ps-8 (3 pages), copy of patient record of DMC Ex.O.Ps-9, copy of ECHO report Ex.O.Ps-10 (2 pages), copy of bill Ex.O.Ps-11 (2 pages), copies of receipts Ex.O.Ps-12 to Ex.O.Ps-17, copy of letter dated 19.5.2023 Ex.O.Ps-18, copy of letter dated 19.5.2023 Ex.O.Ps-19 (2 pages), copy of repudiation letter Ex.O.Ps-20 (3 pages), copy of bill assessment sheet Ex.O.Ps-21 (4 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 purchased one Health insurance policy named as Young Star Insurance Plan bearing No. P/211223/01/2023/003814 from OP No. 2 and said policy was valid from 28.01.2023 to 27.01.2024 in which complainant is insured for Rs. 5,00,000/- for the next one year for any type of aliment and medical need to the complainant (as per Ex.C-2 & Ex.O.Ps-3). It is also not disputed between the parties as per documents submitted by the complainant that he had suffered some medical problem and he admitted in Dayanand Medical college & Hospital, Ludhiana on 02.02.2023 and in the said hospital he was diagnosed for Dilated Cardiomyopathy & Left TVC Palsy and discharge on 08.02.2023 (as per Ex.C-5) and the complainant had incurred Rs. 47,586/- on the said treatment and also incurred Rs. 18,672/- on medicines. It is further admitted case of the opposite parties that the complainant approached to the opposite parties for submission of the claim documents and after completion of all required documents the opposite parties accepted all the requisite documents and generated claim intimation CIR/2023/211223/1447535 of the said claim of the complainant.

10. Ld. Counsel for the complainant argued that the opposite parties assured the complainant that claim will be paid very soon to the by cheque or through account. It is also argued that the complainant approached the opposite parties many times to pay the amount of claim but they never accede the legitimate request of the complainant. It is further argued that the opposite parties had sent a letter dated 04.05.2023 (Ex.C-7) to the complainant for requirement of additional documents/information and in the said letter they had demanded letter from treating doctor, 1st OPD consultation, all past consultations and ECG, ECHO and Cardiac marker reports and the complainant had provided letter from treating doctor dated 15.05.2023 (Ex.C-8) from DMC, 1st OPD consultation and all ECG & ECHO reports and also submitted declaration (Ex.C-9) that no past consultation taken. However, the insurance company against law and facts has wrongly repudiated the claim vide letter dated 14.06.2023 (Ex.C-10) on the sole ground that, "the insured has not submitted the documents called for by us and in the absence of those documents/details, we are not able to further process your claim." It is argued that the complainant had already submitted all the requisite documents which are in his possession but the opposite parties with malafide intention, without any justified reason repudiated the claim of the complainant.

11. On the other hand, Ld. Counsel for the opposite parties argued that the opposite parties had sent letters dated 04.05.2023 & 19.5.2023 (Ex.O.Ps-18 & Ex.O.Ps-19) to the complainant for requirement of additional documents/details and in the said letter they had demanded letter from treating doctor, 1st OPD consultation, all past consultations and ECG, ECHO and Cardiac marker reports but the complainant has failed to submit the required documents. It is further argued that the opposite parties have repudiated the claim of the complainant vide letter dated 14.06.2023 (Ex.O.Ps-20) on the sole ground that," the insured has not submitted the documents called for by us. In the absence of those documents/details, we are not able to further process your claim", as such the opposite parties repudiated the claim on True, valid and legal grounds and as per terms and conditions No. 18 of the policy.

12. The case of the opposite parties is that despite the letters dated 04.05.2023 & 19.5.2023 (Ex.O.Ps-18 & Ex.O.Ps-19) sent by the opposite parties to the complainant for requirement of additional documents/details as mentioned in the said letters, the complainant has failed to submit the required documents, as such the opposite parties have repudiated the claim of the complainant vide letter dated 14.06.2023 (Ex.O.Ps-20). On this, the Ld. Counsel for complainant argued that the complainant had provided letter from treating doctor dated 15.05.2023 (Ex.C-8) from DMC, 1st OPD consultation and all ECG & ECHO reports and also submitted declaration (Ex.C-9) that no past consultation taken. So, we are of the view that the complainant had already submitted the required documents with the opposite parties. Therefore, it is established that the opposite parties have repudiated the claim of the complainant on such flimsy grounds. The complainant to prove his claim has placed on record copy of bills and receipts (Ex.C-3 containing 26 pages) from which it is established that an amount of Rs. 66,258/- (i.e. Rs. 47,586/- + Rs. 18,672/-) has been spent on the treatment of complainant. 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 complainant was rejected 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. 66,258/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. 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:

30th Day of July, 2024

 

       (Ashish Kumar Grover)

                                            President

         

                                           (Urmila Kumari)

                                            Member 

 

       (Navdeep Kumar Garg)

                                            Member