DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/186/2022
Date of Institution: 04.08.2022
Date of Decision: 01.07.2024
Jeewan son of Sh. Balram resident of Street No. 06, Tapa Mandi Tehsil Tapa, District Barnala.
…Complainant
Versus
1. Star Health and allied Insurance Company Limited through its Managing Directors registered address at Office No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai.
2. Mr. Ashwani Kumar, intermediary Star Health and allied Insurance Company Limited, Branch Office at SCO 133, 2nd Floor, above Tata Motor Finance, New Hotel Sweet Milan, Goniana Road, Bathinda.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Nitin Bansal Adv counsel for complainant.
Sh. Rohit Jain Adv counsel for opposite party No. 1.
Opposite party No. 2 exparte.
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 medical policy bearing No. P/211217/01/2022/001047 on dated 30.5.2021 from opposite parties for himself, his wife Priyanka and his sons Shivansh Garg and Raghav Garg. The above said policy was continued vide policy No. P/211217/01/2022/001047 on dated 30.5.2021 protected till 29.5.2022, covered an amount of Rs. 6.75 lacs for the whole family health and accident insurance for each member. It is further alleged that on 13.10.2021 the son of complainant Ragav Garg (being aged 11 months) complained of fever and they rushed to Aggarwal Hospital for diagnose and there doctor admitted the son of complainant as the fever was severe and number of tests were conducted while treatment at Sahara Clinical Laboratory and the son of complainant got discharged on 15.10.2021 and during that period number of expenses occurred totaling Rs. 14,120/-. On 22.2.2022 the complainant wrote a letter to opposite party No. 1 to lodge claim of the son of the complainant which the opposite party No. 1 rejected on 16.3.2022 on unjustified grounds and flatly refused to make payment. It is further alleged that the opposite party No. 1 did not paid any heed to reply and reinstitute 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.-
- The opposite parties may be directed to release Rs. 14,120/- and directed the opposite party No. 1 to clear bill of medical treatment alongwith interest upto to date @12% per annum.
- To pay Rs. 1,00,000/- on account of compensation for causing mental harassment to the complainant.
- Further, to pay Rs. 5,000/- as litigation expenses.
3. The opposite party No. 2 was proceeded again exparte vide order dated 16.9.2022 due to non appearance.
4. Upon notice of this complaint, the opposite party No. 1 appeared and filed written version by taking preliminary objections interalia on the grounds that the present complaint is false, frivolous, vague, baseless and misconceived because there was no deficiency in service on the party of opposite party No.1. It is admitted that the insured availed the Family Health Optima Insurance Plan Covering Mr. Jeewan (self), Mrs. Priyanka Rani (spouse), Mst. Shivansh Garg and Mst. Raghav Garg-dependent children for the sum of insured Rs. 5,00,000/- vide policy No. P/211217/01/2022/001047 for the period from 30.5.2021 to 29.5.2022. It is clearly stated in the policy schedule “THE INSURNACE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC. It is submitted that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming pat of the policy and the complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form. The insured was hospitalized on 13.10.2021 at Aggarwal Hospital for the treatment of FEVER and discharged on 15.10.2021. It is further alleged that complainant submitted medical documents in support of his claim for reimbursement of medical expenses and on scrutiny of the claim documents it is observed that;-
(i) There is no sign and seal in the discharge summary and the investigation reports.
(ii) Moreover, the insured was admitted in a non-network hospital on 13.10.2021 and intimated the claim only on 26.2.2022. Hence, deprived the company to verify the fact of the case during hospitalization.
(iii) Hospital has not provided required documents to FVR Doctor and Hospital has been designated as Excluded provider on 23.6.2022. Therefore, there are multiple gross discrepancies which amounts to misrepresentation of facts. Hence, the claim was rejected and communicated to the insured vide letter dated 16.3.2022.
5. On merits, it is admitted that the complainant wrote letter dated 22.2.2022 to lodge claim of the son of the complainant in order to claim the expenses occurred on the treatment of his son and the same was repudiated by the answering opposite party vide letter dated 16.3.2022. It is further alleged that claim of Pt. Raghav is preferred in the 1st year of the policy and Prev/Subsequent claim- one claim if for insured Pt. Master Raghav is paid. It is further alleged that financial medical treatment is not right of the complainant rather the same is as per terms and conditions of the policy which were supplied to the complainant alongwith policy. However, the repudiation of claim is on justified grounds based on terms and conditions of the policy. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
6. Ld. Counsel for complainant on 4.1.2023 suffered the statement that I do not want to file any rejoinder on behalf of complainant.
7. To prove the case the complainant tendered into evidence affidavit of complainant Ex.C-1, copy of policy Ex.C-2 (containing 5 pages), copy of claim form, report and bill receipts Ex.C-3 (containing 25 pages), copy of repudiation of claim dated 16.3.2022 Ex.C-4, copy of legal notice Ex.C-5, postal receipts Ex.C-6 and closed the evidence.
8. To rebut the case the opposite party No. 1 tendered into evidence affidavit of Sumit Kumar Sharma Ex.O.P1/1, copy of proposal form Ex.OP1/2 (containing 4 pages), copy of policy Ex.O.P1/3 (containing 4 pages), copy of letter dated 24.5.2021 Ex.O.P1/4, copy of terms and conditions Ex.O.P1/5 (containing 6 pages), copy of Field visit report Ex.O.P1/6 (containing 3 pages), copy of claim form Ex.O.P1/7 (containing 3 pages), copy of medical record Ex.O.P1/8 (containing 12 pages), copy of repudiation letter Ex.O.P1/9 (containing 3 pages), copy of status of intimation Ex.O.P1/10, copy of bill assessment sheet Ex.O.P1/11 (containing 3 pages) and closed the evidence.
9. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments filed by opposite party No. 1.
10. The complainant alleged in the complaint that the complainant purchased medical policy bearing No. P/211217/01/2022/001047 for himself, his wife Priyanka and his sons Shivansh Garg and Raghav Garg. The policy period was 30.5.2021 to 29.5.2022 and the same was insured for an amount of Rs. 6.75 lacs. It is further alleged that on 13.10.2021 the son of complainant Ragav Garg complained of fever and they rushed to Aggarwal Hospital for diagnose and doctor admitted the son of complainant as the fever was severe and number of tests were conducted while treatment at Sahara Clinical Laboratory and the son of complainant got discharged on 15.10.2021 and during that period the complainant spent Rs. 14,120/-. The complainant further alleged that on 22.2.2022 the complainant wrote a letter to opposite party No. 1 to lodge claim which was rejected by the opposite party No. 1 on 16.3.2022 on unjustified grounds and flatly refused to make payment.
11. On the other hand, the opposite party No. 1 alleged in the written version that the present complaint has been filed on false, frivolous, vague, baseless and misconceived grounds because there was no deficiency in service on the part of opposite party No.1. The opposite party No. 1 further alleged that the insured hospitalization on 13.10.2021 for the treatment of fever and discharged on 15.10.2021. The opposite party No. 1 further alleged that there is no sign and seal in the discharge summary and the investigation reports, the insured was admitted in a non-network hospital on 13.10.2021 and intimated the claim only on 26.2.2022. Hence, deprived the company to verify the fact of the case during hospitalization and hospital has not provided required documents and hospital has been designated as Excluded provider on 23.6.2022. Therefore, there are multiple gross discrepancies which amounts to misrepresentation of facts. Hence, the claim was rejected and communicated to the insured vide letter dated 16.3.2022.
12. On the perusal of the entire facts and evidence produced by both the parties it is established that the opposite party No. 1 has admitted the insurance policy and the insurance company also admitted that the son of the complainant was got admitted in the alleged hospital and he has taken the treatment. It is alleged by the opposite party No. 1 that the insured was admitted in the hospital on 13.10.2021 but intimated the claim only on 26.2.2022. Hence, deprived the company to verify the fact of the case during hospitalization. Ld. Counsel for the complainant argued that as per policy benefits the complainant is entitled for pre-hospitalization bills of 60 days and post hospitalization bills of 90 days. Ld. Counsel for complainant further argued that after the completion of 90 days of hospitalization the complainant immediately lodged the claim before the opposite party No. 1. The rejection ground of delay intimation is unjustified and the claim was rejected wrongly by the opposite party No. 1 vide letter dated 16.3.2022. The complainant has produced the claim form Ex.C-3 alongwith entire hospital bills, pharmacy bills and test reports and its bills from which it is established that the son of the complainant Raghav Garg was got admitted in the hospital on 13.10.2021 and discharged on 15.10.2021. We have perused the above said bills placed on record by the complainant from which it is established that the complainant has spent an amount of Rs. 11,520/- on the treatment of his son (as per Ex.C-3). However, the complainant has alleged in his complaint that he has spent an amount of Rs. 14,120/- on the treatment of his son.
13. On the other hand, the opposite party No. 1 has produced repudiation letter dated 16.3.2022 as Ex.O.P1/9. On the perusal of the said letter there is no where mentioned the specific reasons for repudiation of claim. Ld. Counsel for complainant further argued that the opposite party No. 1 has not supplied the terms and conditions of the policy. Ld. Counsel for the complainant argued that the claim was wrongly repudiated on the false and baseless grounds. The opposite party No. 1 has failed to establish that the terms and conditions of the policy were supplied to the complainant with the insurance policy. The complainant has submitted all the documents in his evidence to prove the genuineness of the claim.
14. In view of the above discussion, the present complaint is partly allowed against the opposite party No. 1 and the opposite party No. 1 is directed to pay an amount of Rs. 11,520/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite party No. 1 is further directed to pay Rs. 5,500/- on account of consolidated amount of compensation as well 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:
1st Day of July, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
(Navdeep Kumar Garg)
Member
