DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/208/2021
Date of Institution: 21.09.2021
Date of Decision: 05.07.2024
Madan Lal Garg aged 57 years s/o Chiranji Lal Garg, Subash Street, Near Shama Public School, Tapa Mandi, District Barnala-148031.
…Complainant
Versus
1. Star Health & Allied Insurance Co. Ltd., Branch Office S.C.O-70, 2nd Floor, Opposite Tata Indicom, New Leela Bhawan, Patiala-147001 through its Branch Manager.
2. Star Health & Allied Insurance Co. Ltd. 1, New Tank Street, Valluvar Kottam High Road, Nungambakam, Chennai-600034.
…Opposite Parties
Complaint Under Section 35 of Consumer Protection Act, 2019.
Present: Sh. Amit Goyal 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 subscribed “FAMILY HEALTH OPTIMA INSURANCE PLAN” for the period 29.6.2019 to 28.6.2020 and the policy No. P/211115/01/2020/001185 bearing customer code No. AA0009061063 was issued and a premium of Rs. 26,781/- was charged by opposite parties which was paid by the complainant vide cheque No. 260024 dated 28.6.2019 issued from account No. 65006958952 dated 28.6.2019 maintained with State Bank of India Branch Barnala. It is alleged that the complainant had to go to Delhi to meet his brother for some family work and at the residence of his brother the complainant felt some uneasiness in the chest which the complainant was having for two three days, but took it for some minor discomfort due to traveling. The brother of the complainant suggested getting medical consultation and the complainant went to Maharaja Aggarsain Hospital, Punjabi Bagh, Delhi, where the doctors after initial evaluation decided to conduct angiography, so the complainant underwent angiography and the complainant was advised to coronary bypass surgery and the complainant had to pay Rs. 15,300/- for the angiography in the above said hospital. It is further alleged that as per the advise of the doctors of above said hospital, the complainant got admitted at Fortis Escorts Heart Institute and Research Centre, New Delhi and a request was made through hospital for cashless authorization which was declined by the opposite parties vide letter dated 5.8.2019. The complainant remained in hospital from 3.8.2019 to 14.8.2019 and the complainant had to make payment of Rs. 4,82,710/- rendering the cashless facility promised by opposite parties at the time of selling the policy. It is further alleged that while the complainant was admitted in Hospital the opposite parties vide letter dated 13.8.2019 demanded the entire record of treatment as well as final bill alongwith other records a demand which was impossible to be met as the complainant was still under treatment at hospital and the hospital was yet to issue bills and records to the complainant. The letter was followed by another letter dated 28.8.2019 reiterating the earlier demand which was again not possible to be fulfilled as the complainant was bed ridden after major surgery. The opposite parties in a hurry to close the claim issued yet again another letter dated 12.9.2019 and ultimately vide letter dated 26.9.2019 closed the claim of the complainant despite the fact that all the claim papers were duly submitted to the opposite parties.
3. It is further alleged that on 9.10.2019 Sh. C.S. Sharma investigator appointed by the opposite parties visited the complainant and collected copies of all the documents alongwith a authorization letter to collect the medical information/record from hospital and doctors, which showed that the letter dated 26.9.2019 was unfounded and was not based on true facts. The complainant got served a legal notice through counsel Naveen Kumar Garg Advocate District Courts, Barnala, which was replied by the opposite parties vide letter dated 11.10.2019. It is alleged that the complainant filed a consumer complaint bearing No. CC/194/2019 on 8.11.2019 in which all the relevant documents were again attached and were served on opposite parties alongwith notice of complaint, yet instead of settling the claim the opposite parties again took benefit of the fact that in good faith the complainant submitted the claim documents to Branch Office Patiala without obtaining proper receipt. The complaint was disposed of vide order dated 29.6.2020 with the direction that the complainant will again submit the documents to the opposite parties, who will then settle the claim within 30 days and the complainant was at liberty for filing fresh complaint in case the complainant not satisfied with the decision of the opposite parties. It is further alleged that vide letter dated 11.9.2020 demanded additional documents which was nothing but another attempt to deny the claim and the complainant had already vide letter dated 27.7.2020 explained that he had not taken any previous treatment. It is further alleged that the complainant had authorized the opposite parties to collect from the hospital whatever records they want, so the demand of the opposite parties that the complainant should provide complete set of indoor case papers is also unreasonable. Thereafter, the complainant filed an execution application No. EA/58/2020 where again the stand of the opposite parties was that the complainant had supplied the record to settle the claim and the complainant again supplied the copies of the record in open Forum to the counsel of opposite parties and the execution application had been disposed of vide order dated 12.8.2021. The opposite parties vide letter dated 3.7.2021 repudiated the claim on flimsy grounds that the hospital records reveal that the insured had chest pain for two three days and has failed to submit the record for the treatment taken for the same. Thus, there is deficiency in service on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.-
i) To pay the claim of the complainant amounting to Rs. 4,98,010/- alongwith interest @ 12% per annum from the date of accident till realization.
ii) Further, to pay the amount of Rs. 1,00,000/- on account of compensation for harassment and Rs. 22,000/- as litigation expenses.
4. Upon notice of this complaint, the opposite parties appeared and filed written version taking preliminary objections interalia on the grounds that the complainant has got no locus-standi or cause of action to file the present complaint, the present complaint is not maintainable, the complainant dragged the opposite parties in false litigation, not come with clean hands etc. It is further alleged that the complainant availed FAMILY HEALTH OPTIMA INSURANCE PLAN vide policy No. P/211115/01/2020/001185 for the period 29.6.2019 to 28.6.2020 covering Mr. Madan Lal Garg-Self, Mrs. Vinod Kumari-Spouse and Mr. Cherub Garg-Dependent Child for the sum insured of Rs. 5,00,000/-. 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 policy schedule. It is further alleged that the insured patient, Mr. Madan Lal Garg was hospitalized Escorts Heart Institute And Research Centre Ltd., on 3.8.2019 for the treatment of Unstable Angina and submitted Pre Authorization Request for cashless treatment and the same denied vide letter dated 5.8.2019 stating that further evaluation required to ascertain the exact onset. Hence, requested the insured to submit documents towards reimbursement of medical expenses vide letter dated 5.8.2019. Thereafter, the opposite parties have sent letter dated 13.8.2019 requesting the insured to submit the following claim documents towards reimbursement of medical expenses;-
a) Discharge Summary
b) Investigation reports with X-ray films, Scan reports, etc.
c) Main Hospital bills, payment receipts with break-up
d) Prescriptions, Medical bills, Investigation bills, Receipts etc.
e) Earlier treatment records, if any.
f) If the claim is admitted, admissible amount will be transferred to your account, if you so desire kindly, therefore send us
g) a cancelled cheque also alongwith the foregoing documents.
h) Mandatory Documents: As per the provisions of the Anti-Money Laundering Act (AML), you are required to submit a
i) Copy of PAN of the complainant which is mandatory in case claim of the complainant is of value one lakh Rupees and above.
Even, after repeated reminders dated 28.8.2019, 12.9.2019 & 26.9.2019 the complainant has not submitted the claim records towards reimbursement of medical expenses. It is further alleged that without submitting the documents, the complainant issued legal notice and thus once again the opposite parties have called for the above mentioned document, vide reply letter dated 11.10.2019. Thereafter, the complainant again without submitting the claim documents filed complaint CC/194/2019 before the DCDRC, Barnala, and thus the following documents vide letter dated 11.9.2020 were demanded;-
- a letter from treating doctor stating that exact duration of heart disease.
- As per submitted records patient has chest pain since 2-3 days; submit previous consultation papers.
- Submit referral letter for admission of CAG.
- Complete set of indoor case papers.
Even, after repeated reminders dated 26.9.2020, 11.10.2020 & 26.10.2020 the complainant had not submitted the claim records to enable the opposite parties to process the claim records which deprived the right of the opposite parties to verify the claim records. Thereafter, the insured filed an execution application and the claim was again reviewed by medical team of the opposite parties and on the expert opinion it is noted the complainant was hospitalized for treatment of coronary artery disease- unstable angina, CAG- triple vessel disease, LVEF- 60%. It is observed from indoor case records that the insured patient has complaints of chest pain 2-3 days. Hence, the opposite parties request the insured to furnish the previous consultation reports related to the same but the same was not furnished. In the absence of above documents/details the opposite parties are not able to further process claim of the complainant. Hence, claim was rejected vide letter dated 3.7.2021 which was based upon the report dated 11.6.2021 of Dr. Arun Kumar Krishnasamy of Chennai and copy of the same was served to the complainant alongwith copy of repudiation letter dated 3.7.2021. It is further alleged that the complainant was submitted the bills for Rs. 1,85,982/- whereas submitted the payment receipts for Rs. 4,98,010/-. Hence, the complainant was liable to submit the proper bills and payment receipts for the claimed amount as stated in the complaint. On merits, it is submitted that the complainant filed complaint No. CC/194/2019 on 8.11.2019 in which the complainant alleged that all of sudden the complainant suffered from heart attack and was moved to Delhi for treatment, but now the complainant took a U turn and has changed the facts with malafide intension. Further, all other allegations of the complaint are denied by the opposite parties and prayed for the dismissal of complaint.
5. The complainant has filed rejoinder to the written version filed by the opposite parties and reiterated the averments as mentioned in the complaint.
6. To prove his case the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy Ex.C-2 (containing 13 pages), copy of letter dated 5.8.2019 Ex.C-3 (containing 3 pages), copy of receipt Ex.C-4 (containing 2 pages), copy of discharge summary alongwith medical record of Fortis Hospital New Delhi Ex.C-5 (containing 30 pages), copy of final bill cum receipt of Fortis Hospital New Delhi Ex.C-6 (containing 6 pages), copy of self declaration Ex.C-7, copy of order dated 29.6.2020 Ex.C-8 (containing 5 pages), copy of letter dated 27.7.2020 Ex.C-9, copy of letter dated 11.9.2020 Ex.C-10, copy of order dated 12.8.2021 Ex.C-11, copy of repudiation of claim letter dated 3.7.2021 Ex.C-12 (containing 4 pages), copy of claims verification report Ex.C-13 (containing 2 pages) and closed the evidence.
7. To rebut the case of the complainant the opposite parties tendered into evidence affidavit of Sumit Kumar Sharma Ex.O.Ps-1, copy of policy Ex.O.Ps-2 (containing 6 pages), copies of terms and conditions Ex.OPs-3 (containing 12 pages), copy of proposal form Ex.OPs-4 (containing 4 pages), copy of request for cashless Ex.O.Ps-5 (containing 2 pages), copy of CAG report Ex.O.Ps-6 (containing 2 pages), copy of field visit report Ex.O.Ps-7 (containing 2 pages), copies of letters Ex.O.Ps-8 to Ex.O.Ps-10, copy of clinical report Ex.O.Ps-11 (containing 2 pages), copies of discharge summaries Ex.O.Ps-12 & Ex.O.Ps-13, copy of final bill Ex.O.Ps-14, copies of letters Ex.O.Ps-15 to Ex.O.Ps-20, copy of postal receipt Ex.O.Ps-21, copies of letters Ex.OPs-22 to Ex.O.Ps-25, copy of doctor opinion Ex.O.Ps-26, copy of order dated 12.8.2021 Ex.O.Ps-27 (containing 2 pages), copy of Notice/complaint Ex.O.Ps-28 and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on file. Written arguments filed by the complainant and opposite parties.
9. It is not disputed between the parties that the complainant subscribed “FAMILY HEALTH OPTIMA INSURANCE PLAN” for the period 29.6.2019 to 28.6.2020 and the policy No. P/211115/01/2020/001185 (Ex.C-2 & Ex.O.Ps-2) was issued and a premium of Rs. 26,781/- was charged by opposite parties which was paid by the complainant vide cheque No. 260024 dated 28.6.2019 and covering Mr. Madan Lal Garg-Self, Mrs. Vinod Kumari-Spouse and Mr. Cherub Garg-Dependent Child for the sum insured of Rs. 5,00,000/-. It is also admitted case of the opposite parties that the complainant got admitted in Fortis Escorts Heart Institute and Research Centre, New Delhi on 3.8.2019 and was discharged on 14.8.2019 (as per Ex.C-5 & Ex.O.Ps-12).
10. Ld. Counsel for the complainant argued that the complainant had to go to Delhi to meet his brother for some family work and the complainant felt some uneasiness in the chest which the complainant was having for 2-3 days and the brother of the complainant suggested getting medical consultation and the complainant went to Maharaja Aggarsain Hospital, Punjabi Bagh, Delhi, where the doctors after initial evaluation decided to conduct angiography, so the complainant underwent angiography and the complainant was advised to coronary bypass surgery and the complainant had to pay Rs. 15,300/- for the angiography in the above said hospital. It is further argued that as per the advise of the doctors of above said hospital, the complainant got admitted at Fortis Escorts Heart Institute and Research Centre, New Delhi and a request was made through hospital for cashless authorization which was declined by the opposite parties vide letter dated 5.8.2019 (Ex.C-3) and the complainant remained in hospital from 3.8.2019 to 14.8.2019 (Ex.C-5) and the complainant had to make payment of Rs. 4,82,710/- (Ex.C-6). It is further argued that on 9.10.2019 Sh. C.S. Sharma investigator appointed by the opposite parties visited the complainant and collected copies of all the documents alongwith an authorization letter to collect the medical information/record from hospital and doctors, which showed that the letter dated 26.9.2019 was unfounded and was not based on true facts. Thereafter, the complainant got served a legal notice dated 27.7.2020 (C-9) through counsel, which was replied by the opposite parties vide letter dated 11.10.2019. It is also argued that the complainant filed a consumer complaint bearing No. CC/194/2019 on 8.11.2019 (Ex.C-8) in which all the relevant documents were again attached and were served on opposite parties alongwith notice of complaint, yet instead of settling the claim the opposite parties again took benefit of the fact that in good faith the complainant submitted the claim documents to Branch Office Patiala without obtaining proper receipt and the complaint was disposed of vide order dated 29.6.2020 with the direction that the complainant will again submit the documents to the opposite parties, who will then settle the claim within 30 days and the complainant was at liberty for filing fresh complaint in case the complainant not satisfied with the decision of the opposite parties. It is further argued that vide letter dated 11.9.2020 (Ex.C-10) demanded additional documents which was nothing but another attempt to deny the claim and the complainant. It is further argued that thereafter, the complainant filed an execution application No. EA/58/2020 where again the stand of the opposite parties was that the complainant had supplied the record to settle the claim and the complainant again supplied the copies of the record in open Forum to the counsel of opposite parties and the execution application had been disposed of vide order dated 12.8.2021 (Ex.C-11) and the opposite parties vide letter dated 3.7.2021 (Ex.C-11) repudiated the claim on flimsy grounds that the hospital records reveal that the insured had chest pain for two three days and has failed to submit the record for the treatment taken for the same.
11. Ld. Counsel for the opposite parties argued that the insured patient Mr. Madan Lal Garg was hospitalized at Escorts Heart Institute And Research Centre Ltd., on 3.8.2019 for the treatment of Unstable Angina and submitted Pre Authorization Request for cashless treatment and the same denied vide letter dated 5.8.2019 (Ex.O.Ps-9) stating that further evaluation required to ascertain the exact onset, hence the claim denied. Thereafter, the opposite parties have sent letter dated 13.8.2019 (Ex.O.Ps-15) requesting the insured to submit the claim documents towards reimbursement of medical expenses as mentioned in the written version. It is further argued that even after repeated reminders dated 28.8.2019, 12.9.2019 & 26.9.2019 (Ex.O.Ps-16 to Ex.O.Ps-18) the complainant has not submitted the claim records towards reimbursement of medical expenses. It is further argued that without submitting the documents, the complainant issued legal notice and thus once again the opposite parties have called for the above mentioned document, vide reply letter dated 11.10.2019. It is also argued that the complainant again without submitting the claim documents filed complaint CC/194/2019 before the DCDRC, Barnala, and thus the required documents vide letter dated 11.9.2020 (Ex.O.Ps-22) were demanded as mentioned in the written version. It is further argued that even after repeated reminders dated 26.9.2020, 11.10.2020 & 26.10.2020 (Ex.O.Ps-23 & Ex.O.Ps-24) the complainant had not submitted the claim records to enable the opposite parties to process the claim records which deprived the right of the opposite parties to verify the claim records. Thereafter, the insured filed an execution application and the claim was again reviewed by medical team of the opposite parties and on the expert opinion it is noted the complainant was hospitalized for treatment of coronary artery disease- unstable angina, CAG- triple vessel disease, LVEF- 60% and it is observed from indoor case records that the insured patient has complaints of chest pain 2-3 days, hence the opposite parties requested the insured to furnish the previous consultation reports related to the same but the same was not furnished. So, in the absence of above documents/details the opposite parties are not able to further process claim of the complainant and hence the claim was rejected vide letter dated 3.7.2021 (Ex.O.Ps-25) which was based upon the report dated 11.6.2021 of Dr. Arun Kumar Krishnasamy of Chennai. It is further argued that the complainant was submitted the bills for Rs. 1,85,982/-, whereas submitted the payment receipts for Rs. 4,98,010/-, hence the complainant was liable to submit the proper bills and payment receipts for the claimed amount as stated in the complaint.
12. In order to prove his case the complainant has placed on record copy of letter dated 27.7.2020 Ex.C-9 from which it is proved that the complainant with reference to complaint No. CC/194/2019 decided on 29.6.2020 titled as Madal Lal Garg Vs Star Health & Allied Insurance Company Ltd. & others has submitted the requisite documents (as mentioned in the letter) to the opposite parties for settlement of complaint as per the directions of the District Forum (now Commission). So, the plea of the opposite parties that the complainant has not submitted the requisite documents with them is not tenable. Further, the another plea of the opposite parties is that the insured patient has complaints of chest pain 2-3 days, hence the opposite parties requested the insured to furnish the previous consultation reports related to the same but the same was not furnished and the opposite parties are unable to settle the claim of the complainant. But perusal of the record shows that the complainant has sought the claim when he got admitted at Fortis Escorts Heart Institute and Research Centre, New Delhi on 3.8.2019 as per doctors advise and in this regard a request was made through hospital for cashless authorization which was declined by the opposite parties vide letter dated 5.8.2019 (Ex.C-3) and the complainant remained in hospital from 3.8.2019 to 14.8.2019 (Ex.C-5) and the complainant had to make payment of Rs. 4,82,710/- and the admission and discharge of the complainant in the above said hospital is admitted by the opposite parties in their written version, so this plea of the opposite parties is also not tenable. Moreover, the complainant to prove his claim has placed on record Final Bill Cum Receipt Ex.C-6 vide which the settled/paid amount shows as Rs. 4,82,710/-. 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 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 against the opposite parties and the opposite parties are directed to pay an amount of Rs. 4,82,710/- 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. 15,000/- 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:
5th Day of July, 2024
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
