DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/207/2022
Date of Institution: 12.09.2022
Date of Decision: 20.09.2024
Mohit Kumar aged about 35 years son of Rajinder Kumar resident of Sukhanand Basti, Ward No. 7, Tapa Mandi, Tehsil Tapa, District Barnala, Punjab.
…Complainant
Versus
- Star Health and Allied Insurance Company Limited, Registered Office; New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034, through its Manager/Authorized Signatory.
- Star Health and Allied Insurance Company Limited, Corporate Office; Claims Dept. No. 15, Balaji Complex, Whites Lanes, Ist Floor, Royapettah, Chennai-600034, through its Manager/Authorized Signatory;
- Star Health and Allied Insurance Company Limited, SCF No. 133, 2nd Floor, G.T Road, Goniana Road, Bathinda-151001, through its Manager/Authorized Signatory.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Gagandeep Garg counsel for complainant.
Sh. Rohit Jain 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 opposite party No. 1 is the registered office and the opposite party No. 2 is the Corporate Office having its claim department to settle the claims being insurance company and opposite party No. 3 is the branch office for issuing policies. It is alleged that the complainant purchased one Health Insurance Policy from the opposite party No. 3 through their agent at Barnala namely Young Star Insurance Policy/Family Health Optima Insurance Plan bearing policy No. P/211217/01/2022/000954 and the said policy was valid from 20.5.2021 to 19.5.2022 in which the complainant, his wife and minor son named Aarav Garg were insured for the Rs. 5,00,000/- for the next one year for any type of ailment and medical need to the whole members of the family. It is further alleged that in the month of May 2022 minor child of the complainant Aarav Garg suffered from Severe Pneumonia and he remained admitted in hospital named Aggarwal Hospital, Rampura Phool, Bathinda where he remained admitted from 11.5.2022 to 19.5.2022 and treatment was started by doctors with opposite parties prior authorization because the policy purchased by complainant was cashless and an amount of Rs. 30,485/- was charged by the said hospital which was paid by the complainant in cash inspite of cashless policy. Thereafter, the complainant immediately approached the opposite parties for submission of claim documents and completion of all required documents and opposite parties accepted all the original documents and generated claim information No. CIR/2023/211217/0288323 of the claim and assured that claim will be paid very soon to complainant by cheque or through account. But the opposite parties have committed default in paying the claim amount to complainant in spite of number of requests and meetings. It is alleged that now the opposite parties have rejected the genuine claim of complainant without any justified reason that there is discrepancy in temperature of the patient, as per discharge summary, it is 101 degree F and as per vitals chart of ICP, it is 99.4 degree F, Mismatch is noted in the vitals written and treatment provided and no pathologist sign and seal is noted in the lab reports, whereas it is very much clear from the medical record that minor child remain under treatment and vital chart is attached also and lab reports also stamped by the doctor, in spite of the fact that the claim of complainant rejected by the opposite parties with malafide intention and without any justified reason. The complainant also sent legal notice dated 6.8.2022 through counsel for the payment of genuine claim but the opposite parties never replied to the same and also did not pay the amount of the claim. Thus, the above said act and conduct of the opposite parties falls under the deficiency in service and unfair trade practice on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.-
- To pay the genuine claim of insurance of the complainant of Rs. 30,485/- alongwith interest @ 18% per annum from the date of admission i.e. 11.5.2022 till realization.
- To pay Rs. 1,00,000/- for mental shock, pain, agony and Rs. 50,000/- 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 one Health Insurance Policy Young Star Insurance Policy for himself, his wife and minor son Aarav Garg and paid premium to the opposite parties and they issued policy No. P/211217/01/2022/000954 which was valid from 20.5.2021 to 19.5.2022 for Rs. 5,00,000/-. It is further admitted that the minor son of the complainant was admitted in Aggarwal Hospital, Rampura Phool, Bathinda from 11.5.2022 to 19.5.2022 for the treatment of Severe Pneumonia and policy was cashless. It is also admitted that the complainant submitted claim form with the opposite parties and claim information No. CIR/2023/211217/0288323 was generated. It is further alleged that the terms and conditions of the policy was served to the complainant alongwith policy schedule and it is clearly stated in the policy schedule that the insurance under this policy is subject to conditions, clauses, warranties, exclusions attached. It is further alleged that the insured preferred claim in the 1st year of the policy; Prev/Subsequent claim- one claim is for insured Pt Master Aarav Garg is paid i.e. CIR/2022/211217/3263890 Aarav Garg Red Acute Exaccer Bation 31.8.2021 Approved (FA) Rs. 5,725/-, CIR/2022/211217/3081811 Aarav Garg Fever 16.8.2021 Approved (FA) Rs. 5,515/-. It is further alleged that the insured submitted the reimbursement of medical expenses towards the treatment Severe Pneumonia at Aggarwal Hospital, Rampura Phul, Punjab admitted from 11.5.2022 to 19.5.2022. It is observed from the claim documents that;
- Tampering in time is noted in the time of admission.
- Discrepancy is noted in temperature of the patient.
- As per Discharge Summary it is 101 F as per vital chart it is 99.4 F.
- Mismatch is noted in the vital written and treatment provided.
- No Pathologist/technician sign and seal is noted in the lab reports.
Thus, there is discrepancy in the records which amount to misrepresentation of facts. As per condition No. 6 of the policy in question, if there is any misrepresentation of material facts whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim. Hence, claim was rejected and conveyed to the insured vide letter dated 29.6.2022. All other allegations of the complainant are denied. Therefore, there is no deficiency in service on the part of opposite parties and prayed for the dismissal of complaint.
5. Complainant has filed rejoinder to the written reply of opposite parties and denied the averments of the opposite parties.
6. To prove his case the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy Ex.C-2 (containing 6 pages), copies of bills and receipts Ex.C-3 to Ex.C-27, copies of reports Ex.C-28 to Ex.C-34, copies of prescription slips Ex.C-35 & Ex.C-36, copy of Xray Ex.C-37, copy of patient record Ex.C-38 & Ex.C-39, copy of treatment chart Ex.C-40 (containing 9 pages), copy of discharge card Ex.C-41, copy of claim form part A & B Ex.C-42 (containing 3 pages), copy of repudiation letter Ex.C-43, copy of legal notice Ex.C-44, postal receipts Ex.C-45 & Ex.C-46, copy of adhaar card Ex.C-47 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 proposal form Ex.O.Ps-2 (containing 4 pages), copy of policy Ex.O.Ps-3 (containing 6 pages), copy of claim form Ex.O.Ps-5 (containing 4 pages), copy of discharge summary Ex.O.Ps-6 (containing 2 pages), copy of indoor papers Ex.O.Ps-7 (containing 11 pages), copy of lab reports Ex.O.Ps-8 (containing 6 pages), copy of radiography report Ex.O.Ps-9, copy of Xray report Ex.O.Ps-10, copy of final bill Ex.O.Ps-11 (containing 4 pages), copy of repudiation letter Ex.O.Ps-12 (containing 3 pages), copy of bill assessment sheet Ex.O.Ps-13 (containing 4 pages) and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on file.
9. It is admitted case of the opposite parties that the complainant purchased one Health Insurance Policy from the opposite party No. 3 through their agent at Barnala namely Young Star Insurance Policy/Family Health Optima Insurance Plan bearing policy No. P/211217/01/2022/000954 (Ex.C-2 & Ex.O.Ps-3) and the said policy was valid from 20.5.2021 to 19.5.2022 in which the complainant, his wife and minor son named Aarav Garg were insured for the Rs. 5,00,000/- for the next one year for any type of ailment and medical need to the whole members of the family. It is further admitted case of the opposite parties that the minor son of the complainant was admitted in Aggarwal Hospital, Rampura Phool, Bathinda from 11.5.2022 to 19.5.2022 (Ex.C-41 & Ex.O.Ps-6) for the treatment of Severe Pneumonia and policy was cashless and the complainant submitted claim form with the opposite parties and claim information No. CIR/2023/211217/0288323 was generated.
10. Ld. Counsel for the complainant argued that in the month of May 2022 minor child of the complainant Aarav Garg suffered from Severe Pneumonia and he remained admitted in hospital named Aggarwal Hospital, Rampura Phool, Bathinda where he remained admitted from 11.5.2022 to 19.5.2022 and treatment was started by doctors with opposite parties prior authorization because the policy purchased by complainant was cashless and an amount of Rs. 30,485/- was charged by the said hospital which was paid by the complainant in cash inspite of cashless policy. It is further argued that the complainant immediately approached the opposite parties for submission of claim documents and completion of all required documents and opposite parties accepted all the original documents and generated claim information No. CIR/2023/211217/0288323 of the claim and assured that claim will be paid very soon to complainant by cheque or through account but the opposite parties have failed to do so. It is further argued that the opposite parties have rejected the genuine claim of complainant without any justified reason that there is discrepancy in temperature of the patient, as per discharge summary, it is 101 degree F and as per vitals chart of ICP, it is 99.4 degree F, Mismatch is noted in the vitals written and treatment provided and no pathologist sign and seal is noted in the lab reports. It is further argued that the complainant also sent legal notice dated 6.8.2022 Ex.C-44 through counsel for the payment of genuine claim but the opposite parties never replied to the same and also did not pay the amount of the claim.
11. On the other hand, Ld. Counsel for the opposite parties argued that the terms and conditions of the policy was served to the complainant alongwith policy schedule and it is clearly stated in the policy schedule that the insurance under this policy is subject to conditions, clauses, warranties, exclusions attached. It is further argued that the insured submitted the reimbursement of medical expenses towards the treatment Severe Pneumonia at Aggarwal Hospital, Rampura Phul, Punjab admitted from 11.5.2022 to 19.5.2022 and there is discrepancy in the records which amount to misrepresentation of facts. It is further argued that as per condition No. 6 of the policy in question if there is any misrepresentation of material facts whether by the insured person or any other person acting on his behalf the company is not liable to make any payment in respect of any claim, hence claim was rejected and conveyed to the insured vide letter dated 29.6.2022 Ex.O.Ps-12.
12. On the perusal of the record it shows that the opposite parties have repudiated the claim of the complainant on the ground that in the submitted medical records there is tampering in time is noted in the time of admission and discrepancy is noted in temperature of the patient. Further, as per Discharge Summary it is 101 F as per vital chart it is 99.4 F, mismatch is noted in the vital written and treatment provided. No Pathologist/technician sign and seal is noted in the lab reports. Thus, there is discrepancy in the records which amount to misrepresentation of facts. We have gone through the copy of discharge summary (Ex.C-41 & Ex.O.Ps-6) vide which it is clearly mentioned that on the date of admission of patient Aarav Garg on 11.5.2022 the patient admitted in the hospital with complaint of fever 3 days, cough 3 days and vomiting 1 day and temperature was mentioned as 101'. We have also gone through the Ex.C-40 at Page No. 6 of Vitals Records of patient Aarav Garg vide which the temperature of patient was mentioned as 99.4 F and it further shows that the temperature was decreased and increased on different times and dates. So, we are of the view that both the documents are issued by the Aggarwal Hospital and the units or degree of temperature was mentioned by the doctors or hospital staff on duty and the same are not filled by the complainant. Therefore, we are of the view that it was the duty or responsibility of the doctors/hospital to check or monitor the temperature and written in the medical record of patient and the complainant had no role with regard to the above said discrepancy which was raised by the opposite parties. Moreover, there is nothing on record from the side of opposite parties that they have verified the above said medical records of patient Aarav Garg from the doctors/hospital. Moreover, it is very much clear from the medical records produced by the complainant that all the lab reports are stamped by the doctor. Therefore, it is established that the opposite parties have rejected the claim of the complainant on such unreasonable and flimsy grounds.
13. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. 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/insured 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.
15. The complainant to prove his claim has placed on record copies of receipts and pharmacy bills as Ex.C-3 to Ex.C-15, Ex.C-18, Ex.C-21 to Ex.C-26 which shows that Rs. 29,585/- has been spent on the treatment of the complainant in the above said hospital. However, the complainant in the present complaint has claimed Rs. 30,485/-.
16. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 29,585/- 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:
20th Day of September, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
(Navdeep Kumar Garg)
Member
