Haryana

Ambala

CC/196/2022

Rajinder Kumar - Complainant(s)

Versus

Star Health and Allied Insurance Co Ltd - Opp.Party(s)

19 Mar 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	196 of 2022
Date of Institution	:	08.06.2022
Date of decision	:	19.03.2024

Rajinder Kumar aged about 66 years s/o Shri Ram Chander, R/o H.No.419, Sector-08, Urban Estate, Ambala City.

          ……. Complainant.

Versus

1. Star Health and allied Insurance Company, SCO-180, 1 to 3, 3rd Floor, Minerva Complex, Rai Market, Ambala Cantt-133 001, through its' Branch Manager.

 

2. Star Health and allied Insurance Company, 15, Shri Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai-600 014, through its' Branch Manager/Authorised Signatory.

 

….…. Opposite Parties

Before:         Smt. Neena Sandhu, President.

                       Smt. Ruby Sharma, Member,

           Shri Vinod Kumar Sharma, Member.           

 

Present:       Shri Abhishek Bansal, Advocate, counsel for the complainant. 

                     Shri Mohinder Bindal, Authorized, counsel for the OPs.

Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Sections 34 and 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay the amount of Rs.56,091/- spent by him on his treatment alongwith interest @18% p.a. from 25.04.2021, till the date of entire payment.
2. To pay Rs.3 lacs as compensation for harassment and mental agony
3. To pay Rs.22,000/- on account of litigation expenses.
4. Grant any other relief which this Hon’ble Commission may deems fit.

 

2.             Brief facts of the case are that the complainant had purchased a Medi-Claim Policy bearing No.P/211117/01/2021/001883 valid from 13.07.2020 to 12.07.2021. The said policy was purchased  from OP No.2 and the  OP No.1 is head office of the  OP No.2. The complainant got the said policy renewed from time to time and lastly it was renewed having validity upto 12.07.2021. The complainant, who is a Senior Citizen unfortunately suffered Covid-19 and was got admitted in the Philadelphia Hospital Ambala on 25.04.2021 and was discharged on 30.04.2021. He incurred a total sum of Rs.56,091/- on his treatment. However, when the claim was filed with the OPs, the complainant was astonished and surprised to see the letters sent by the OPs stating there that his claim has been repudiated on the ground that “….Our medical team has perused your representation and has noted the contents. The team which re- examined the claim records has observed that as per the documents and details available us, IPD register is not available; the IPD number, room number are not mentioned; the insured patient's SPO2 level on admission is 90% but in the discharge summary it is mentioned as 95%; also in consent letter it is mentioned as 88%. Thus, there is discrepancy in the records which amount to misrepresentation of facts…”. The complainant got served a legal notice dated 09.05.2022 through Registered AD to the  OPs  for enabling them to pay claim amount of Rs.56,091/- alongwith interest and costs with compensation for causing unnecessary harassment but to no avail. Hence, the present complaint.
3.            Upon notice, the OPs appeared and filed written version wherein they raised preliminary objections to the effect that the complaint filed by the complainant is false, frivolous, vague, baseless, and misconceived; the present complaint is without any cause of action etc. On merits, it has been stated that  the insured  availed the   Family Health Optima Insurance plan through Branch  Office Ambala Covering Mr. RAJENDER KUMAR- Self (PED- Diabetes & Hypertension and their complications) and Mrs. ACHLA RANI-Spouse(PED- Diabetes & Hypertension and their complications) for the sum insured of Rs.5,00,000/- vide policy in question, valid from 13/07/2020 to 12/07/2021. It has been clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED". The Policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. 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 25/04/2021 at Philadelphia Hospital - AMBALA for the treatment of COVID 19 and discharged on 30/04/2021. The insured complainant submitted medical documents for reimbursement of medical expenses and subsequently approached for reconsideration of the claim. On scrutiny of the claim documents, it was observed that,

• There is no IPD Register.

• The IPD number and room number is not mentioned.

• As per the indoor case papers, the insured patient's SPO2 is 90% but as per the discharge summary, it is 95%.

• The letter of Dr.K.G.Gupta MBBS AFMC (PA), Consultant Physician of the treating hospital submitted during reconsideration stated that the insured patient's SPO2 on admission was 88% but as per the IPD records the SPO2 was 90%.

Thus there was discrepancy in the records which amounts to misrepresentation of facts. As per condition no.6 of the policy," The Company shall not be liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be incorrect or false or such claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation whether by the Insured Person or by any other person acting on his behalf". Hence, the claim was rejected and communicated to the insured vide letters dated 29/06/2021, 08/10/2021 and 15/12/2021 respectively. Without prejudice, even assuming without conceding that the company is liable to pay the claim amount in terms of the contract of insurance issued to the insured, the maximum quantum of liability under the terms of the policy shall be Rs.51,706/- as per Annexure-R-11. Rest of the averments of the complainant were denied by the OPs and prayed for dismissal of the present complaint with special costs.

4.           Learned counsel for the complainant tendered affidavit of complainant as Annexure C/A alongwith documents as Annexure C-1 to C-21 and closed the evidence on behalf of the complainant. On the other hand, learned counsel for OPs tendered evidence by way of affidavit of Sumit Kumar Sharma, Senior Manager of the OPs-Company-Star Health and Allied Insurance Co. Ltd., New Delhi as Annexure OP-1/A alongwith documents as Annexure OP-1 to OP-14 and closed the evidence on behalf of OPs.
5.           We have heard the learned counsel for the parties and have also carefully gone through the case file.
6.           Learned counsel for the complainant submitted that by repudiating the genuine claim of the complainant on flimsy grounds and not paying him the amount, incurred by him, for the treatment of COVID-19 during subsistence of the policy in question, the OPs are deficient in providing service, negligent and adopted unfair trade practice. 
7.           On the contrary, the learned counsel for the OPs while reiterating the objections taken in the written version submitted that the claim of the complainant was rightly repudiated, when it was found that there were some misrepresentation of facts in the medical documents of the complainant qua the readings of the oxygen level noted down in the said hospital, IPD no., room/bed no. etc. where the complainant has allegedly taken treatment of COVID-19.
8.           The moot question which falls for consideration is, as to whether, the claim filed by the complainant qua treatment taken by him in the said hospital for COVID-19 during currency of the policy in question was rightly repudiated by the OPs or not. It may be stated here that we have gone through the repudiation letters dated 29.06.2021, 08.10.2021 and 15.12.2021, Annexures C-14 to C-16 respectively  and found that the claim of the  complainant has been repudiated only on following grounds:-
   1. IPD register is not available;
   2. the IPD number, room number are not mentioned;
   3.  the insured patient's SPO2 level on admission is 90% but in the discharge summary it is mentioned as 95%; also in consent letter it is mentioned as 88%
9.           First coming to the ground taken by the OPs that IPD register was not provided by the Hospital, it may be stated here that not even a single document has been placed on record by the OPs or their Investigator/Surveyor or report of their Medical Team to prove that they every demanded the IPD register from the Hospital concerned and the same was refused to be provided. Bald ground taken the OPs, in the absence of any documentary evidence, in the shape of any letter followed by reminders having been sent to the hospital/doctor concerned, has no significant value in the eyes of law and as such, this ground was not sufficient to reject the claim of the complainant.
10.           Now coming to the second ground taken by the OPs that the IPD number, room number are not mentioned in the discharge summary, Annexure OP-7, it may be stated here that the OPs have miserably failed to see the IPD No.212300 mentioned on the document, Annexure OP-10 issued by the Philadelphia Hospital and which has been placed on record by the OPs themselves. As far as non mentioning of room number is concerned, it may be stated here that this ground is not sufficient to reject the claim of the complainant, especially, when the OPs have never doubted the fact that the complainant suffered from COVID-19 and took treatment in the said hospital, nor have they been able to prove anything doubtful after placing on record any cogent and convincing evidence.
11.           Now coming to the ground taken by the OPs to the effect that as per discharge summary the SPO2 of the complainant was mentioned as 95% but on admission it was found to be 90% and in the consent letter it has been mentioned as 88%, it may be stated here that if in the document dated 29.05.2021, Annexure C-4, it has been mentioned by the Doctor concerned that  at the time of admission the SPO2 level of the complainant was 88% and at the same time while giving him oxygen continuously at the time of admission itself, his oxygen level raised upto 95% as has been mentioned in the discharge slip, Annexure C-3 and the life of the complainant was ultimately saved, under these circumstances, the OPs have failed to justify as to how such an event could be a ground for repudiation of claim of the complainant, for the treatment taken by him in the said hospital.  It is settled law that only doctor and not the insurance company can decide the line of the treatment to be given to patient. Thus, to prove their ground, the OPs were legally bound to place on record some cogent and convincing evidence/report having been prepared by the medical expert/Doctor which they miserably failed to do so. In this view of the matter, even this ground was also not sufficient to reject the claim of the complainant.
12.           In the peculiar facts and circumstances of this case, it can easily be said that all the  grounds taken by the OPs to repudiate the claim of the complainant  are based on fictions, presumptions and assumptions only and are vague. Nothing has been placed on record to prove that there was any misrepresentation or fraud on the part of the complainant, while filing the claim for reimbursement of the amount spent by him for his treatment aforesaid, under the currency of the policy in question, especially, when the admission of the complainant and the treatment taken by him for COVID-19 in the said hospital has expressly not been doubted by the OPs. At the same time, it4 is also held that in case, there was allegedly any discrepancies found by the surveyor/medical experts team of the OPs on the part of the Hospital concerned, in maintaining their record, then the complainant who has taken the treatment in the said hospital under the policy in question for which he has paid hefty premium to the OPs, cannot be made a scapegoat. Thus, by repudiating the genuine claim of the complainant despite the fact that he took treatment during currency of the policy in question, the OPs are deficient in providing service and also adopted unfair trade practice.  
13.           From the receipts Annexure C-7 to C-13, it is quite clear that the complainant had paid an amount of Rs.56019/- for purchase of medicines and also admission charges qua treatment taken by him in the said hospital. The OPs have failed to prove any contrary evidence against the said receipts.  In this view of the matter, since it has been held that the genuine claim has been repudiated by the OPs, as such, the complainant is therefore held entitled to get the amount of Rs.56019/-, spent by him on his treatment.
14.           In view of the aforesaid discussion, we hereby allow the present complaint and direct the OPs, in the following manner:-  
    1. To reimburse to the complainant the entire amount of Rs.56,019/- alongwith interest @6% p.a. from 29.06.2021 i.e. the date when firstly the claim was repudiated, onwards.
    2. To pay Rs.3,000/- as compensation for the mental agony and physical harassment suffered by the complainant.
    3. To pay Rs.2,000/- as litigation expenses.   

The OPs are further directed to comply with the aforesaid directions within the period of 45 days, from the date of receipt of the certified copy of the order, failing which the OPs shall pay interest @ 8% per annum on the awarded amount, from the date of default, till realization. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.  

   Announced:- 19.03.2024

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President