DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/59/2023
Date of Institution: 17.05.2023
Date of Decision: 08.07.2024
Jiwan Kumar age about 50 years son of Bant Ram resident of H.No. B-XI/206, KC Road, Street No. 6, Ward No. 21, Barnala, Teshil and District Barnala (Mobile No. 73078-80700).
…Complainant
Versus
1. Star Health and Allied Insurance Company Ltd., 2nd Floor, Above Delhi Tractor and Combines, Opposite PNB Bank, College Road, Barnala.
2. Star Health and Allied Insurance Company Ltd., No. 15, SRI Balaji Complex, 1st Floor, Whites Lane, Roy Apettah, Chennai-600014.
3. Rinku Goyal (Agent/Representative of Star Health and Allied Insurance Company Ltd.) resident of KC Road, Near Balmik Mandir, Banala (Mobile No. 97790-00340.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Ms. Kuljeet Kaur Adv counsel for complainant.
Sh. Rohit Jain Adv counsel for opposite parties No. 1 & 2.
Opposite party No. 3 deleted.
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 representative of the opposite parties i.e. opposite party No. 3 visited the complainant and asked the complainant to get his Health Insurance Policy from Star Health and Allied Insurance Company Ltd. It is alleged that the complainant believing upon the words and purchased a Health Insurance Policy (Type of Policy: Family Health Optima Insurance- 2017) of opposite parties vide policy No. P/211229/01/2022/001134 for the period from 13.12.2021 to 12.12.2022 and a premium of Rs. 19,369/- was charged from the complainant against insurance upto Rs. 6,25,000/- for the complainant Jiwan Kumar, his wife Ranju Rani, his son Prince Jindal and his daughter Prachi Jindal. The premium was collected at Barnala and was deposited in the account of opposite party No. 1 at Barnala by the representative of opposite party No. 1. It is further alleged that on 22.6.2022, the Prince Jindal the son of the complainant suffered from Acute Diarsrhoea and Dehydration and he has admitted to Singla Hospital, New Grain Market Road, Barnala for treatment from where he was discharged on 24.6.2022 and total expenditure on the treatment was Rs. 10,138/- for which the complainant could retain bills. The intimation was given to the opposite party No. 1, but on enquiry it came to the knowledge of the complainant that the claim of the complainant was rejected. It is further alleged that the complainant was shocked to receive a letter dated 25.7.2022 from the opposite parties stating that the claim of the complainant has been repudiated on the ground that “On a perusal of submitted records, our medical team is of the opinion that the insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted”. 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 pay the claim of complainant amounting to Rs. 10,138/- alongwith interest @ 12% from the date of filing of claim till realization.
- To pay Rs. 50,000/- towards mental tension and harassment.
- Further, to pay Rs. 10,000/- as litigation expenses.
3. The opposite party No. 3 was deleted from arena of opposite parties vide order dated 24.5.2023 on the statement given by the Ld. Counsel for complainant.
4. Upon notice of this complaint, the opposite parties No. 1 & 2 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.
5. On merits, it is admitted to the extent that the complainant purchased Family Optima Health Insurance plan for himself and his wife Ranju Rani, his son Prince Jindal and his daughter Prachi Jindal from the opposite parties vide policy No. P/211229/01/2022/001134 from 13.12.2021 to 12.12.2022 and sum insured was Rs. 5,00,000/- and this policy is in continuation since 13.12.2020. It is further alleged that from the documents submitted by the complainant it comes that on 22.6.2022 Prince Jindal suffered from Acute Diarrhoea and Dehydration and was got admitted in Singla Hospital, New Grain Market Road, Barnala for treatment and was discharged on 24.6.2022 and the complainant spent Rs. 10,138/- on treatment of Prince Jindal. The claim of the complainant was repudiated by the opposite parties vide letter dated 25.7.2022 on the ground mentioned therein. 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 alongwith the policy schedule. It is further 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. The insured has submitted the claim documents of the medical expenses towards the treatment of ACUTE DIARHOEA at SINGLA HOSPITAL, Barnala from 22.6.2022 to 24.6.2022 under claim No. CIR/2023/211229/0486278 and on a perusal of submitted records, medical team of the opposite parties is of the opinion that the insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted. Nothing has been mentioned on discharge summary and indoor papers which shows that vitals were stable and could be managed as outpatient. Hence, the claim was rejected and conveyed to the insured vide letter dated 25.7.2022. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
6. Ld. Counsel for complainant on 7.2.2024 suffered the statement that I do not want to file any rejoinder against the version of opposite parties No. 1 & 2.
7. To prove the case the complainant tendered into evidence copy of policy with terms and conditions Ex.C-1 (containing 8 pages), discharge summary Ex.C-2, claim form Ex.C-3 (containing 3 pages), bills and receipts Ex.C-4 to Ex.C-7, lab report Ex.C-8 (containing 2 pages), Prescription slip Ex.C-9, bill Ex.C-10, copy of order sheet Ex.C-11, copy of repudiation letter Ex.C-12, affidavit of complainant Ex.C-13 and closed the evidence.
8. To rebut the case the opposite party No. 1 & 2 tendered into evidence affidavit of Sumit Kumar Sharma Ex.O.P1.2/1, copy of proposal form Ex.OP1.2/2 (containing 4 pages), copy of policy Ex.O.P1.2/3 (containing 2 pages), copy of terms and conditions Ex.O.P1.2/4 (containing 6 pages), copy of claim form Ex.O.P1.2/5 (containing 4 pages), copy of discharge summary Ex.O.P1.2/6, copy of order sheet Ex.O.P1.2/7, copy of lab report Ex.O.P1.2/8 (containing 2 pages), copy of bill Ex.O.P1.2/9, copy of receipt Ex.O.P1.2/10, copy of repudiation letter Ex.O.P1.2/11 (containing 3 pages), copy of bill assessment sheet Ex.O.P1.2/12 and closed the evidence.
9. We have heard the learned counsel for the parties and have gone through the record on the file.
10. It is admitted case of the opposite parties that the complainant purchased Family Optima Health Insurance plan for himself and his wife Ranju Rani, his son Prince Jindal and his daughter Prachi Jindal from the opposite parties vide policy No. P/211229/01/2022/001134 from 13.12.2021 to 12.12.2022 and sum insured was Rs. 5,00,000/- and this policy is in continuation since 13.12.2020 (as per Ex.C-1 & Ex.O.P1.2/3). It is further admitted case of the opposite parties that from the documents submitted by the complainant on 22.6.2022, Prince Jindal son of the complainant suffered from Acute Diarrhoea and Dehydration and was got admitted in Singla Hospital, New Grain Market Road, Barnala for treatment and was discharged on 24.6.2022 (as per Ex.C-2 & Ex.O.P1.2/6) and the complainant spent Rs. 10,138/- on treatment of Prince Jindal (as per Ex.C-4, Ex.C-5, Ex.C-7 and Ex.C-10).
11. Ld. Counsel for the complainant argued that the intimation was given to the opposite party No. 1, but on enquiry it came to the knowledge of the complainant that the claim of the complainant was rejected and the complainant received a letter dated 25.7.2022 (Ex.C-12) from the opposite parties stating that the claim of the complainant has been repudiated on the ground that “On a perusal of submitted records, our medical team is of the opinion that the insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted”. Ld. Counsel for complainant argued that the act and conduct of the opposite parties comes within the definition of the unfair trade practice as well as deficiency in service.
12. On the other hand, Ld. Counsel for the opposite parties argued that the insured has submitted the claim documents of the medical expenses towards the treatment of ACUTE DIARHOEA at SINGLA HOSPITAL, Barnala from 22.6.2022 to 24.6.2022 under claim No. CIR/2023/211229/0486278 and on a perusal of submitted records, medical team of the opposite parties is of the opinion that the insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted. It is further argued that nothing has been mentioned on discharge summary and indoor papers which shows that vitals were stable and could be managed as outpatient, hence the claim was rejected and conveyed to the insured vide letter dated 25.7.2022 (as per Ex.O.P1.2/11).
13. From the perusal of the file it is established that on 22.6.2022 son of the complainant suffered from Acute Diarsrhoea and Dehydration and he has admitted to Singla Hospital, New Grain Market Road, Barnala for treatment from where he was discharged on 24.6.2022 and this fact is proved from discharge summary Ex.C-2 and the complainant spent an amount of Rs. 10,138/- on the treatment of his son which proves from the pharmacy bills, hospital bill and lab bill/receipt i.e. Ex.C-4, Ex.C-5, Ex.C-7 and Ex.C-10. Ld. Counsel for the complainant further argued that in this regard the intimation was given to the opposite party No. 1 and complainant lodged his claim along with required documents with the opposite parties and they issued a Claim No. CIR/2023/211229/0486278 to the complainant and assured that the claim will be paid very soon. Ld. Counsel for complainant also argued that on enquiry it came to the knowledge of the complainant that the claim of the complainant was repudiated vide letter dated 25.7.2022 Ex.C-12 by the opposite parties No. 1 & 2 on unreasonable and unjustified grounds. On the other hand, the opposite parties No. 1 & 2 have failed to produce on record any 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 No. 1 & 2 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.
14. From the above discussion, it is proved that the claim of the complainant was repudiated by the opposite parties No. 1 & 2 on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties No. 1 & 2.
15. In view of the above discussion, the present complaint is partly allowed against the opposite parties No. 1 & 2 and the opposite parties No. 1 & 2 are directed to pay an amount of Rs. 10,138/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties No. 1 & 2 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:
8th Day of July, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
(Navdeep Kumar Garg)
Member
