Haryana

Ambala

CC/129/2022

Shobhit Jain - Complainant(s)

Versus

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

Adit Aggarwal

25 Oct 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

 Complaint case no.

:

129 of 2022

Date of Institution

:

22.04.2022

Date of decision    

:

25.10.2023

 

Shobhit Jain, s/o Sh. Parveen Kumar Jain, aged about 37 years, r/o H. No.56, New Ram Nagar, Ambala Cantt.

……. Complainant.

Versus

  1. Star Health and Allied Insurance Company Ltd., 15, Balaji Complex, White Lanes, Ist Floor, Royapettah, Chennai-600014 through its Chairman cum Managing Director
  2. Star Health and Allied Insurance Company Ltd, Ist Floor, 5, Prem Nagar, Near Post Office, Ambala City; through its General Manager/ Branch Manage

….…. Opposite Parties.

 Before:          Smt. Neena Sandhu, President.

                        Smt. Ruby Sharma, Member,

             Shri Vinod Kumar Sharma, Member.           

 

Present:          Shri Adit Aggarwal, Advocate, counsel for the complainant

                       Shri Mohinder Bindal, Advocate, counsel for the OPs.      

Order:         Smt. Neena Sandhu, President.

1.                Complainant has filed this complaint under Section 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 reimburse Rs.1,55,688/-, i.e. medical expenses incurred by the complainant due to illness i.e. Covid 19;
  2. To pay Rs.2,00,000/- as compensation for harassment, mental pain, shock and tension;
  3. To pay Litigation expenses of Rs.11000/-;

OR

Grant any relief which this Hon’ble Commission may deems fit.

 

  1.             Brief facts of this case are that the complainant purchased a medi-claim policy i.e. Family Health Optima Insurance - 2017 (policy no. P/211117/01/2021/004355) valid for the period from 17.11.2020 to 16.11.2021, for which he paid premium to the OPs. During the policy period the complainant got infected with Covid-19 and was hospitalized in Philadelphia Hospital, Ambala City on 20.05.2021. He remained admitted in the said hospital for 16 days and was discharged on 04.06.2021 under patient ID/ unit no. 213095. After discharge from the hospital, the complainant lodged a medi-claim with the OPs alongwith necessary documents for reimbursement of his hospitalization expenses and other treatment expenses total amounting to Rs.1,55,688/-, vide claim intimation no.CIR/2022/211117/2640981. Complainant immediately lodged the claim with the OPs and also supplied all the requisite documents but they rejected the same vide letter dated 11.10.2021 and letter dated 16.10.2021 mentioning baseless and false grounds. In response to the rejection letter dated 16.10.2021, the complainant had again sent his medical records alongwith all the relevant records and requested for reconsideration of his genuine claim but the same was again rejected by the OPs on flimsy and baseless grounds vide letter dated 23.12.2021. The complainant had even sent a legal notice dated 16.02.2022 to the OPs through registered post in the matter but to no avail.   Number of requests made by the complainant to settle the claim filed by him did not yield any result. Hence, the present complaint.
  2.           Upon notice, OPs appeared and filed written version and raised preliminary objections with regard to not come with clean hands and suppressed the material facts and cause of action etc.  On merits, it has been stated that as a matter of fact the complainant availed the policy in question for the sum insured of Rs.5,00,000/- subject to certain terms and conditions with all the exclusions which were duly explained to the complainant while filling the proposal form and the complainant after understanding and admitting them to be correct availed the said policy. All the exclusions and covers were duly mentioned in the insurance certificate itself and were also duly explained to the complainant as well. The terms and conditions of the policy were served to the complainant alongwith policy schedule wherein it is clearly stated that "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC. ATTACHED." Every ailment and treatment like general outdoor treatment except certain specified treatments like operations on the nose and the nasal sinus, operations of eye, operation of tongue, glands, tonsils, breast, chemotherapy, radiation etc. are not covered under a mediclaim policy floated by all the companies. There is a specific criteria and procedure for the claims under a medi-claim policy and all the claims therein are entertained and decided within such parameters. In the present case, the complainant submitted a claim against his alleged treatment for reimbursement of medical expenses towards the treatment of Covid Positive at Philadelphia Hospital, Ambala City from 20.05.2021 to 04.06.2021. The entire set of papers were scrutinized by the expert medical team of the OPs and found certain discrepancies in the treatment record and hospital report as provided to the OPs. On scrutiny of the submitted medical records, it was observed that inspite of repeated requests, the indoor register of the said hospital with regard to the admission and treatment of the complainant was not provided by the hospital due to reasons best known to the complainant and the concerned hospital staff.  The entire set of papers were scrutinized by the expert medical team of the OPs and found certain discrepancies in the treatment record and hospital reports. Inspite of repeated requests, the indoor register of the said hospital with regard to the admission and treatment of the complainant was not provided by the hospital due to reasons best known to the complainant and the concerned hospital staff. The complainant further stated that he had not made the complete payment of treatment to the hospital and was treated on loan which was also contradictory. It was also observed that as per the discharge summary, the SPO2 was mentioned as 98%, whereas, as per doctor, the complainant SPO2 level was 85% and the complainant submitted that he was on oxygen support for 12 days in contradiction to the treatment record as provided by the complainant. Condition no.6 of the policy says that" Disclosure to information norms: The policy shall become void and all premium paid thereon shall be forfeited to the Company. In the event of mis-representation, mis description or non-disclosure of any material fact by the policy holder". Since as per the terms and condition of the policy, if there any misrepresentation is found whether on his part or anybody else acting on his behalf then the company is not liable to make any payment in respect of any claim. Accordingly, the claim of the complainant was rejected and repudiated as per the terms of the policy and the complainant was duly informed about the repudiation of his claim vide letter dated 16.10.2021. Even the representation made by the complainant for reconsideration was again considered by the expert medical team of the OPs which found no discrepancy or illegality in the repudiation of said claim due to misrepresentation of facts and again informed the complainant vide letter dated 23.12.2021 that the repudiation of his claim was in order. The complainant has been aware of the legal position and preposition but inspite of all these facts and even very much aware about the fate of his claim, he has filed this false complaint by exploiting the process of law in order to put undue pressure. Without prejudice to whatever has been stated earlier in the written version, even assuming without conceding that the company is liable to pay the claim in terms of the contract of insurance then the maximum quantum of liability under the terms of the policy shall be Rs.1,41,551/-. Rest of the averments of the complainant were denied by OPs and prayed for dismissal of the present complaint with special costs.
  3.           Learned counsel for the complainant tendered affidavit of the complainant as Annexure CW1/A alongwith documents as Annexure C-1 to C-11 and closed the evidence on behalf of the complainant.  On the other hand, learned counsel for the OPs tendered affidavit of Sumit Kumar Sharma, Authorized Signatory, Star Health and Allied General Insurance Company Limited, New Delhi as Annexure OP/A alongwith documents as Annexure OP-1 to OP-31 and closed the evidence on behalf of the OPs.
  4.            We have heard the learned counsel for the parties and have also carefully gone through the case file.
  5.           Learned counsel for the complainant submitted that the OPs repudiated the claim of the complainant vide letter dated 11.10.2021, Annexure C-6 qua the treatment taken by him for COVID-19 in the hospital referred to above, despite the fact that the OPs were legally bound to pay for the amount spent on the treatment, as it was taken during existence of the policy in question. By repudiating the genuine claim of the complainant, the OPs are deficient in providing service and also adopted unfair trade practice.
  6.           On the contrary, the learned counsel for the OPs while reiterating the objections taken in the written version submitted that the claim of complainant was rightly repudiated on the grounds of misrepresentation of facts and discrepancies found in the documents attached with the claim form. He further submitted that the OPs repudiated the claim of the complainant on the grounds that the claim filed by the complainant was not genuine and the hospitalization documents suppress/conceal/misrepresent material facts about the treatment taken as per the documentary evidence available. Learned counsel for the OP has placed reliance upon the case titled as M/s Sadguru Oil Mils Vs. M/s New India Assurance Company Limited & Anr. 2019(4) C.P.J. 601, wherein the Hon’ble National Commission, New Delhi has observed that if it is shown that any part of the claim is false and fraudulent to the knowledge of the insured, no claim is payable to him/her even in respect of that part of the claim, which is not shown to be fraudulent. He has also placed reliance on the judgment dated 29.01.2018, passed by the Hon’ble National Commission, New Delhi, in the case of Kaustubh Gajanan Dixit Versus Oriental Insurance Company Limited & Anr. wherein it has been held that the complainant suppressed the material facts from insurer by making false and misleading statements, hence, insurer is justified in repudiating the claim.
  7.           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 letter 16.10.2021, Annexure OP-28 and also the stand taken by the OPs in their written version. Relevant portion of Annexure OP-28 is reproduced hereunder:-
  1. As per internal verification, IP register was not provided by the Hospital.
  2. Payment was not done completely and was treated only on loan.
  3. As per discharge summary the SPO2 was mentioned as 98% but as per doctor statement patient SPO2 levels were 85% and patient mentioned that he was on oxygen support for 12 days

 

  1.           First coming to the ground taken by the OPs that IP 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 to prove that they every demanded the IP 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.
  2.           Now coming to the second ground taken by the OPs to the effect that payment made by the complainant towards treatment was not done completely and was treated only on loan, it may be stated here that the OPs have failed to convince this Commission as to what prejudice has been caused to them, if the said hospital has received the payment installments from the complainant. The only obligation of the complainant was to prove that he took treatment from the hospital concerned on payment basis, which he has proved by placing on record receipt dated 04.06.2021 for a amount of Rs.1 lac and 01.07.2021, for an amount of Rs.13,500/- Annexure C-4 and C-5 respectively over and above the expenditure incurred by him for medicines etc.  In this view of the matter, even this ground was not sufficient to reject the claim of the complainant.
  3.           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 98% but as per doctors statement patient SPO2 level was 85% , it may be stated here that if in the document dated 07.06.2021, Annexure OP-8, it has been mentioned by the Doctor concerned that  at the time of admission the SPO2 level of the complainant was 85% and at the same time while giving him oxygen continuously at the time of admission itself, his oxygen level raised upto 98% as has been mentioned in the discharge summary, Annexure OP-7 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.
  4.           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, it is also held that in case, there was allegedly any discrepancies found by the surveyor 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 vide letter dated 11.10.2021, Annexure C-6, 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.  
  5.           It may be stated here that though the complainant has claimed an amount of Rs.1,55,688/- towards the treatment taken in the said hospital, yet, the OPs while placing reliance on calculation sheet, Annexure OP-31, has fairly admitted that an amount of Rs.1,41,551/- is final admissible amount  payable to the complainant, without prejudice. This calculation sheet is a detailed one and has not been challenged by the complainant by way of placing any contrary evidence/document. 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.1,41,551/- only, spent by him on his treatment in the hospital aforesaid.
  6.           It may be stated here that the facts of the present case are different from the facts of the cases referred to above, relied upon by the OPs, therefore, no help can be drawn by them from the said cases. 
  7.           In view of the aforesaid discussion, we hereby partly allow the present complaint and direct the OPs, in the following manner:-  
    1. To reimburse the amount of Rs.1,41,551/-, to the complainant alongwith interest @6% p.a. w.e.f 11.10.2021 i.e the date of repudiation, till realization.
    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:- 25.10.2023

 

(Vinod Kumar Sharma)

(Ruby Sharma)

(Neena Sandhu)

Member

Member

President

                                                     

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