DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

 

Complaint Case No : CC/357/2020

Date of Institution : 19.11.2020

Date of Decision : 08.11.2023

1.Manoj Kumar son of Ved Parkah resident of H.No. B-293, Near Geeta Bhawan, Barnala, Tehsil and District Barnala (M. 92563-05246).

2.Kashish Chugh son of Sh. Manoj Kumar resident of H.No. B-293, Near Geeta Bhawan, Barnala, Tehsil and District Barnala.

3.Lakshay Chugh minor son of Sh. Manoj Kumar resident of H.No. B-293, Near Geeta Bhawan, Barnala, Tehsil and District Barnala through his guardian Manoj Kumar son of Ved Parkash. 

                  …Complainants

Versus

1. Star Health and Allied Insurance Company Limited, New Tank Street, Valluvar Kottam High Road, Nungambakam, Chennai-600034 through its Manager/Authorized Signatory. 

2. Star Health and Allied Insurance Company Limited, SCO-133, 2nd floor, above TATA Motor Finance, Near Hotel Sweet Milan, Goniana Road, Bathinda-151001 through its Manager/Authorized Signatory.   

              …Opposite Parties

Complaint under Section 35 of the Consumer Protection Act, 2019

Present: Sh. Varun Singla Advocate counsel for complainant.

Sh. Rohit Jain Advocate counsel for opposite parties.

Quorum.-

1. Sh. Jot Naranjan Singh Gill : President

2.Sh. Navdeep Kumar Garg : Member

 

(ORDER BY JOT NARANJAN SINGH GILL, PRESIDENT):

    The complainant Manoj Kumar & others filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Star Health and Allied Insurance Company Limited and others. (in short the opposite parties). 

2. The facts leading to the present complaint are that the complainant purchased FAMILY HEALTH OPTIMA INSURANCE PLAN and complainant alongwith his wife namely Mamta Rani and two children namely Kashish and Lakshay Chugh were medically examined.  Thereafter, the complainant paid an amount of Rs. 15,287/- through cheque number 452299 duly drawn in Punjab National Bank, Barnala on 13.8.2018 and the opposite parties issued one Policy No. P/211217/01/2019/000723 which was valid from 13.8.2018 to 12.8.2019. It is further alleged that the complainant continued the said policy regularly without any discrimination and paid the premium amount for the year 2019-2020 and issued Renewal Endorsement No. P/211217/01/2020/001221 which was valid till 12.8.2020. Thereafter, the complainant again continued the said policy regularly without any discrimination and paid the premium amount for year 2020-2021 and issued Renewal Endorsement No. P/211217/01/2021/002403 which was valid till 13.8.2021. It is alleged that the above said policy covered the risk related to any disease, illness, bodily injury and hospitalization expenses upto limit coverage of Rs. 5,00,000/- to an extent as agreed. It is further alleged that it was assured by the opposite parties that the complainant and his entire family will be covered under this policy for any treatment for next one year. But in the month of April 2020, the complainant's wife Mamta Rani suffering from Nausea and some digestive problem. On 24.4.2020 the complainant took his wife to Orison Super Specialty Hospital Infertility & Trauma Centre, Opp. Grand Walk Mall, Barewal Road, Ludhiana for her treatment where the complainant's wife remained admitted from 24.4.2020 to 28.4.2020 and an expenditure of near about Rs. 52,000/- has been charged by the said hospital. It is further alleged that the complainant's wife died on 22 July 2020. Thereafter, the complainant approached opposite party No. 2 for medical claim which is covered under the policy and the complainant submitted all the original documents as said by them and the opposite party No. 2 assured the complainant that they will incur all the expenses of treatment as per the policy bought and will give the claim amount within a week. But thereafter the opposite party No. 2 did not pay even a single penny of claim as assured till today which is withheld by the opposite parties without any justified cause. Thereafter, the complainant approached the opposite party No. 2 number of times but they putting off the matter on one pretext or the other by stating that it is under process. The complainant sent a legal notice dated 2.11.2020 through his counsel to the opposite parties but they flatly refused to do so. 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 amount of Rs. 52,000/-.  

ii) Further, to pay the amount of Rs. 50,000/- on account of compensation for harassment and Rs. 10,000/- as litigation expenses.

3. 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.  

4. On merits, it is admitted that the complainant purchased FAMILY HEALTH OPTIMA INSURANCE PLAN for his family including his wife Mamta Rani, two children namely Kashish and Lakshay Chugh and complainant paid Rs. 15,287/- and policy was issued from 13.8.2018 to 12.8.2019  and thereafter the policy was renewed from 13.8.2019 to 12.8.2020 and after that from 13.8.2020 to 12.8.2021. It is further admitted that the complainant and his above said family members are covered under the policy for treatment for next one year but the same was subject to terms and conditions of the policy. It is also admitted that wife of the complainant was admitted in the Orison Super Specialty  Trauma and Infertility Centre, Ludhiana in April, 2020. 

5. 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 policy schedule. It is alleged that the insured was hospitalized in the Orison Super Specialty  Trauma and Infertility Centre, Ludhiana on 24.4.2020 towards the Provisional treatment of RA/RENAL PARENCHYMAL DISEASE/LIVER PARENCHYMAL DISEASE and on scrutiny of the cashless request and document received, it is observed that further evaluation required to ascertain the exact onset of rheumatoid arthritis, chronic liver disease, renal parenchymal disease. Hence, the pre authorisation was rejected vide letter dated 27.4.2020. Subsequently, the insured submitted claim for reimbursement for Rs. 41,157/- of medical expenses for treatment of hiatus hernia/essophagitis with esophageal candidiasis/ acute kidney injury and known cases of RA. It is observed from the submitted records that the insured patient has undergone treatment for hiatus hernia which is during the second year of the policy. As per Waiting Period. 3 (ii(a)) of the policy issued to the complainant the company is not liable to make any payment in respect of any expenses incurred by the insured person for treatment of the above mentioned ailment during the first two years of continuous operation of the insurance cover. It is further alleged that the Waiting Period.3 (ii(a)) reads as under-;

“Treatment of Cataract and diseases of the anterior and posterior chamber of the Eye, Diseases of ENT, Diseases related to Thyroid, Prolapse of Intervertebral Disc (other than caused by accident), Varicose veins and Varicose ulcers, Desmoid Tumor, Umbilical Granuloma, Umbilical Sinus, Umbilical Fistula, all Diseases of Prostate, Stricture Urethra, all Obstructive Uropathies, all types of Hernia, Benign Tumours of Epididymis, Spermatocele, Varicocele, Hydrocele, Fistula, Fissure in Ano, Hemorrhoids, Pilonidal Sinus and Fistula, Rectal Prolapse, Stress Incontinence and Congenital Internal disease/defect”.

6. It is further alleged that despite the request of the opposite parties the complainant has not submitted a letter from treating doctor stating that duration of rheumatoid arthritis, renal disease and liver disease; complete medical records taken for RA (including medical records taken for RA) renal disease and liver disease since its diagnosed.  In the absence of above said document the opposite parties are not able to process the complainant's claim further. Further, as per Condition No. 3 of the above said policy, the insured person has to submit all the required  documents and details to the opposite parties. Hence, claim was rejected vide letter dated 15.9.2020. Hence, claim is not payable under policy terms and conditions and the claim was rejected and the rejection of claim was conveyed to the insured vide letter dated 1.2.2020 by the opposite parties. It is further submitted that the legal notice was duly replied and the complainant has furnished claim documents for Rs. 41,157/- only. It is further submitted that the maximum quantum of liability under the terms of the policy shall be Rs. 37,121/-. All other allegations of the complaint are denied. Therefore, there is no deficiency in service on the part of opposite parties and prayed for the dismissal of complaint. 

7. In support of his complaint, the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy Ex.C-2, copy of letter dated 7.8.2019 Ex.C-3, copy of letter dated 14.8.2020 Ex.C-4, copy of Ultrasound report Ex.C-5, copy of discharge summary Ex.C-6, copy of Prescription slip Ex.C-7, copy of report dated 24.4.2020 Ex.C-8, copy of prescription slip dated 24.4.2020 Ex.C-9, copy of OP receipt dated 24.4.2020 Ex.C-10, copy of lab report dated 25.4.2020 Ex.C-11, copy of lab report dated 27.4.2020 Ex.C-12, copy of lab report dated 28.4.2020 Ex.C-13, copy of Advance receipt dated 28.4.2020 Ex.C-14, copy of invoice dated 28.4.2020 Ex.C-15, copy of bill dated 20.4.2020 Ex.C-16, copy of claim form Ex.C-17, copy of death certificate Ex.C-18, copy of legal notice Ex.C-19, postal receipts Ex.C-20 & Ex.C-21, copy of Adhaar Card Ex.C-22 and closed the evidence. Ld. Counsel for complainant on 7.7.2021 has suffered the statement that I do not want to file any rejoinder on behalf of complainant.  

8. To rebut the case of the complainant the opposite parties tendered in evidence copy of policy alongwith terms and conditions Ex.O.Ps-1, copy of all policy schedules Ex.O.Ps-2, copy of proposal from Ex.O.Ps-3, copy of pre-authorization request Ex.O.Ps-4, copy of field visit report Ex.O.Ps-5, copy of query letters dated 24.4.2020 & 25.4.2020 Ex.O.Ps-6, copy of pre-authorization denial letter dated 27.4.2020 Ex.O.Ps-7, copy of claim form Ex.O.Ps-8, copy of discharge summary Ex.O.Ps-9, copy of final bill Ex.O.Ps-10, copy of query letter dated 30.5.2020 Ex.O.Ps-11, copy of repudiation letter dated 15.9.2020 Ex.O.Ps-12, copy of reply to legal notice dated 30.11.2020 Ex.O.Ps-13, copy of bill assessment sheet Ex.O.Ps-14, affidavit of Rajiv Jain Ex.O.Ps-15 and closed the evidence. 

9. We have heard learned counsel for the parties and have gone through the record on file. Written arguments filed by the complainant and opposite parties. 

10. It is not disputed between the parties that the complainant purchased FAMILY HEALTH OPTIMA INSURANCE PLAN and the complainant alongwith his wife namely Mamta Rani and two children namely Kashish and Laksay Chugh were medically examined and policy bearing No. P/211217/01/2019/000723 (Ex.C-2) was issued to the complainant by paying the premium amount of Rs. 15,287/-. It is further not disputed between the parties that the above said policy was valid from 13.8.2018 to 12.8.2019 and thereafter the complainant continued the said policy regularly without any discrimination and paid the premium amount for the year 2019-2020 and issued renewal endorsement No. P/211217/01/2020/001221 which was valid till 12.8.2020 and the complainant again continued the said policy regularly without any discrimination and paid the premium amount for year 2020-2021 and issued Renewal Endorsement No. P/211217/01/2021/002403 which was valid till 13.8.2021 and the above said policy covered the risk related to any disease, illness, bodily injury and hospitalization expenses upto limit coverage of Rs. 5,00,000/- to an extent as agreed as per terms and conditions of the policy which was issued to the complainant alongwith policy. 

11. Ld. Counsel for the complainants argued that in the month of April 2020, the complainant's wife Mamta Rani suffering from Nausea and some digestive problem and on 24.4.2020 the complainant took his wife to Orison Super Specialty Hospital Infertility & Trauma Centre, Opp. Grand Walk Mall, Barewal Road, Ludhiana for her treatment where the complainant's wife remained admitted from 24.4.2020 to 28.4.2020 and an expenditure of near about Rs. 52,000/- has been charged by the said hospital. It is further argued that the complainant's wife died on 22 July 2020 and thereafter the complainant approached opposite party No. 2 for medical claim which is covered under the policy and the complainant submitted all the original documents as said by them and the opposite party No. 2 assured the complainant that they will incur all the expenses of treatment as per the policy bought and will give the claim amount within a week,but the opposite party No. 2 did not pay even a single penny of claim without any justified cause. It is also argued that the complainant approached the opposite party No. 2 number of times but they putting off the matter on one pretext or the other by stating that it is under process. It is argued that the complainant sent a legal notice dated 2.11.2020 (Ex.C-19) through his counsel to the opposite parties but they flatly refused to release the claimed amount.   

12. Ld. Counsel for opposite parties argued that the insured was hospitalized in the Orison Super Specialty Trauma and Infertility Centre, Ludhiana on 24.4.2020 towards the Provisional treatment of RA/RENAL PARENCHYMAL DISEASE/LIVER PARENCHYMAL DISEASE and on scrutiny of the cashless request and document received, it is observed that further evaluation required to ascertain the exact onset of rheumatoid arthritis, chronic liver disease, renal parenchymal disease, as such the pre authorization was rejected vide letter dated 27.4.2020 (Ex.O.Ps-7). It is further argued that the insured submitted claim for reimbursement for Rs. 41,157/- of medical expenses for treatment of hiatus hernia/essophagitis with esophageal candidiasis/ acute kidney injury and known cases of RA and it is observed from the submitted records that the insured patient has undergone treatment for hiatus hernia which is during the second year of the policy. Further, as per clause of Waiting Period. 3 (ii(a)) of the policy issued to the complainant the company is not liable to make any payment in respect of any expenses incurred by the insured person for treatment of the above mentioned ailment during the first two years of continuous operation of the insurance cover. It is further argued that despite the request of the opposite parties the complainant has not submitted a letter from treating doctor stating that duration of rheumatoid arthritis, renal disease and liver disease; complete medical records taken for RA (including medical records taken for RA) renal disease and liver disease since its diagnosed and in the absence of above said document the opposite parties are not able to process the complainant's claim further. It is also argued that as per Condition No. 3 of the above said policy, the insured person has to submit all the required documents and details to the opposite parties, therefore the claim was rejected vide letter dated 15.9.2020 (Ex.O.Ps-12). It is further argued that the legal notice was duly replied and the complainant has furnished claim documents for Rs. 41,157/- only and the maximum quantum of liability under the terms of the policy shall be Rs. 37,121/-.

13. From the perusal of records it is established that the opposite parties have rejected the claim of the complainant on such flimsy grounds as we are of the view that generally the insurance companies not ensured the clauses specifically or to the notice of the person concerned, in fact like all these conditions which are generally hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy and these types of activities on the part of insurance companies must be checked and stopped.

14. In the present case the opposite parties rejected the claim of the complainant on 15.9.2020 (Ex.O.Ps-12) as per Waiting Period. 3 (ii(a)) of the policy issued to the complainant, the company is not liable to make any payment in respect of any expenses incurred by the insured person for treatment of the above mentioned ailment during the first two years of continuous operation of the insurance cover. Further, despite the request of the opposite parties the complainant has not submitted a letter from treating doctor stating that duration of rheumatoid arthritis, renal disease and liver disease; complete medical records taken for RA (including medical records taken for RA) renal disease and liver disease since its diagnosed and in the absence of above said document the opposite parties are not able to process the complainant's claim further. We are of the view after gone through the nature of the policy that this clause does not appear to be justified in any manner. Further, the policy is renewed from 13.8.2019 to 12.8.2020 (Ex.C-3) for the period of one year by the opposite parties than again renewed from 14.8.2020 to 13.8.2021 (Ex.C-4) and the condition like that the insured patient has undergone treatment for hiatus hernia which is during the second year of the policy is not justified and also the very purpose of purchasing the policy for one year shall become redundant. Further, the complainant alleged in his complaint that an expenditure of near about Rs. 52,000/- has been charged by the said hospital. On the other hand, the opposite parties submitted that the complainant has submitted claim for reimbursement for Rs. 41,157/- of medical expenses for treatment (Ex.O.Ps-8). Complainant claimed an amount of Rs. 41,157/- which is evident from claim form Ex.O.Ps-8 duly signed by the complainant.   

15. In support of his case the complainant relied the upon the Judgment of the Hon'ble Punjab and Haryana High Court, Chandigarh in case titled Religare Health Insurance Vs The Chairman Peremanent Lok Adalat CWP No. 107 of 2020, decided on 7 January 2020, vide which it is held that since the company itself is issuing policies for the tenure of 1 year then the company cannot claim that the company shall not pay any claim before the period of 2 years. In another case LPA No. 1537 of 2011 titled as Iffco Tokio General Insurance Company Ltd. Vs Permanent Lok Adalat Gurgaon and others 2012(1)R.C.R.(Civil) 901:2012(2)PLR 547 decided on 26.08.2011. The Hon'ble Punjab and Haryana High Court held that the law is well settled with regard to the standard form of contracts. When the bargaining powers of the parties is unequal and consumer has no real freedom to contract the Courts would strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power. It was also held that claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the Policy. It was for insurance company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. Claim cannot be denied. 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. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The insurance company in such cases reply upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. 

16. From the above discussion, it 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 on the part of opposite parties. Therefore, the present complaint is partly allowed against the opposite parties and the opposite parties are directed to pay Rs. 41,157/- alongwith interest @ 7% per annum to complainant No. 1 (Manoj Kumar) from the date of filing the present complaint till realization. The opposite parties are further directed to pay Rs. 5,500/- on account of consolidated amount of compensation alongwith litigation expenses to the complainant. 

17. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order.

18. Copy of this order be supplied to the parties free of costs as per rules. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

       8th Day of November, 2023

 

            (Jot Naranjan Singh Gill)

            President

 

(Navdeep Kumar Garg)

Member