DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/95/2023
Date of Institution: 08.08.2023
Date of Decision: 19.07.2024
Sourav Kumar age about 31 years son of Rajnish Kumar resident of Street No. 8, Lakhi Colony, Barnala, Tehsil & District Barnala, Punjab.
…Complainant
Versus
1. Star Health and Allied Insurance Company Limited, Corporate Office;- Claim Dept. No. 15, Balaji Complex, White Lanes, 1st Floor, Royapettah, Chennai-600014, through its Manager/Authorized Signatory.
2. Star Health and Allied Insurance Company Limited, Branch Office, SCF-12-13, Improvement Trust Market, Above ICICI Bank, G.T. Road, Moga, through its Manager/Authorized Signatory.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Gagandeep Garg 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 earlier complainant was residing at Moga, and now residing at Barnala. The opposite party No. 1 is the Corporate Office having its claim department to settle the claim Being insurance company. The opposite parties No. 1 & 2 both are doing the business of insurance and providing services to the customers. 2. It is alleged that complainant purchased one Health insurance policy named as Young Star Insurance Policy bearing policy no. P/211222/01/2022/004171 from opposite party No. 2 for the period of 2022 to 2023 and thereafter complainant renewed the said policy for the period of 2023 to 2024 and from opposite parties have issued Young Star Insurance Policy bearing policy no. P/211222/01/2003/005251 for the period of 2023-2024 after paying the premium amount of Ra 15,711/, in which my complainant, his wife Sunita Rani and two minor child named Koshika and Sakshi are insured for the Rs.5,00,000/- for the next one year for any type of aliment and medical need to the whole members of the family. It is further alleged that in the month of March 2023 minor child of complainant named as Sakshi suffered from Severe Fever and she remained admitted in hospital Named as Dr. Bharati Children Hospital, Handaya Bazar, Bamala where she remained admitted under the treatment of doctor from the period of 07.03.2023 to 12.03.2023 and treatment was started by doctors with from opposite parties prior authorization because the policy purchased by complainant was cashless and an amount of Rs. 22,250/- was charged by said hospital which was paid by complainant in cash in spite of cashless policy and which makes clearly that there is deficiency on the part of from opposite parties. It is alleged that immediately complainant approached from opposite parties for submission of the claim documents and after completion of all required documents opposite parties accepted all the original documents and generated claim information No.CIR/2023/211222/1611595 of the claim and assured that claim will be paid very soon to complainant by cheque or through account. It is further alleged that opposite parties have rejected the genuine claim of complainant without any reason that there is discrepancy in the documents submitted and detail regarding Investigation and treatment of the insured patient are not transparently evident and full facts may not have been presented and claim to repudiated, whereas it is very much clear from the medical record that minor child remain under the treatment and vital chart is attached also and labs reports also stamped by the pathologist, inspite of that opposite parties with malafide intention, without any justified reason repudiated the claim of complainant. As such, the act and conduct of the opposite parties comes within the definition of the unfair trade practice as well as deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to pay the claim of complainant Rs. 22,250/- alongwith interest @ 18% per annum from the date of deposit of documents 13.3.2023 till realization.
- To pay Rs. 50,000/- towards mental tension and harassment.
- Further, to pay Rs. 15,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking preliminary objections interalia on the grounds that the complainant has no locus-standi to file the present complaint. The present complaint is not legally maintainable. The complainant has no cause of action to file the present complaint. The complainant has not come with clean hands etc.
4. On merits, it is admitted to the extent that the complainant purchased one Health Insurance policy named as Young Star Insurance Policy bearing policy no. P/211222/01/2022/004171 from opposite party No. 2 for the period of 2022 to 2023 and the complainant renewed the said policy for the period of 2023 to 2024 and the opposite parties have issued Young Star Insurance Policy bearing policy No. P/211222/01/2023/005251 for the period of 2023- 2024 after paying the premium amount of Rs.15,711/- in which complainant, his wife Sunita Rani and two minor child named Koshika and Sakshi are 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 submitted that as per the documents in the month of March 2023 minor child of complainant named as Sakshi suffered from severe fever and she remained admitted in hospital Named as Dr. Bharti Children Hospital, Handayia Bazar, Barnala where she remained admitted under the treatment of doctor from the period of 07.03.2023 to 12.03.2023 and treatment was started by doctors and an amount of Rs. 22.250/-was charged by said hospital which was paid by complainant. It is admitted to the extent that the complainant approached the opposite parties for submission of the claim documents and after completion of all required documents opposite parties accepted all the original documents and generated claim information no. CIR/2023/211222/1611595 of the claim. It is further alleged that the insured has submitted the reimbursement of the medical expenses towards the treatment of Typhoid at Dr. Bharti Children Hospital on 07.03.2023. The opposite parties observed various discrepancies in the documents submitted to the opposite parties.
(1) There is no proper diagnosis mentioned in discharge summary;
(2) There is no hospital seal and proper sign in lab reports, icps are stereotypical, -, written in single hand writing and multiple tampering noted;
It is further submitted that the opposite parties are not in a position to admit claim of the complainant, as per the terms and Specific conditions No.18 of the Policy issued to the complainant along with policy and therefore unable to settle the claim under the above policy and hereby repudiate the claim. Hence, claim was rejected and conveyed to Insured by the opposite parties vide letter dated 26.03.2023. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
5. Ld. Counsel for complainant on 21.11.2023 suffered the statement that I do not want to file any rejoinder against the version of opposite parties.
6. To prove the case the complainant tendered into evidence affidavit of complainant Ex.C-1, copy of policy Ex.C-2, copy of discharge summary Ex.C-3, copy of treatment chart Ex.C-4, copy of authorization to Star Health letter Ex.C-5, copies of lab test reports Ex.C-6 to Ex.C-11, copies of bill file Ex.C-12 to Ex.C 14. copy of cancel cheque Ex.C-15, copies of payment receipts Ex.C-16 to Ex.C-20, copy of claim form Part A Ex.C-21, copy of claim form part B Ex.C-22, copy of medical claim rejection letters Ex.C-23 to Ex.C-25, copy of Aadhaar card of complainant and pan card Ex.C-26 and Ex.C-27 and closed the evidence.
7. To rebut the case the opposite parties tendered into evidence affidavit of Sumit Kumar Sharma Ex.O.Ps-1, copy of proposal form Ex.Ops-2 (3 pages), copy of policy Ex.O.Ps-3 (4 pages), copy of terms and conditions Ex.O.Ps-4 (7 pages), copy of claim form Ex.O.Ps-5 (4 pages), copy of prescription slips Ex.O.Ps-6 to Ex.O.Ps-8, copy of lab report Ex.O.Ps-9 (2pages), copy of certificate by hospital Ex.O.Ps-10, copy of repudiation letter Ex.O.Ps-11 (3 pages), copy of bill assessment sheet Ex.O.Ps-12 and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments filed by complainant.
9. It is admitted case of the opposite parties that the complainant purchased one Health Insurance policy named as Young Star Insurance Policy bearing policy no. P/211222/01/2022/004171 from opposite party No. 2 for the period of 2022 to 2023 and the complainant renewed the said policy for the period of 2023 to 2024 and the opposite parties have issued Young Star Insurance Policy bearing policy No. P/211222/01/2023/005251 for the period of 2023- 2024 after paying the premium amount of Rs.15,711/- in which complainant, his wife Sunita Rani and two minor child named Koshika and Sakshi are 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 (as per Ex.C-2 & Ex.O.Ps-3). It is also not disputed between the parties that in the month of March 2023 minor child of complainant named as Sakshi suffered from severe fever and she remained admitted in hospital Named as Dr. Bharti Children Hospital, Handayia Bazar, Barnala where she remained admitted under the treatment of doctor from the period of 07.03.2023 to 12.03.2023 (as per ExC-3 & Ex.O.Ps-6). It is also admitted case of the opposite parties that the complainant approached the opposite parties for submission of the claim documents and after completion of all required documents opposite parties accepted all the original documents and generated claim information no. CIR/2023/211222/1611595 of the claim (as per Ex.C-5).
10. Ld. Counsel for the complainant argued that the policy purchased by complainant was cashless and an amount of Rs. 22,250/- was charged by said hospital which was paid by complainant in cash in spite of cashless policy and which makes clearly that there is deficiency on the part of from opposite parties. It is further argued that the opposite parties assured that claim will be paid very soon to complainant by cheque or through account. It is further argued that opposite parties have rejected the genuine claim of complainant without any reason that there is discrepancy in the documents submitted and detail regarding Investigation and treatment of the insured patient are not transparently evident and full facts may not have been presented and claim to repudiated, whereas it is very much clear from the medical record that minor child remain under the treatment and vital chart is attached also and labs reports also stamped by the pathologist, inspite of that opposite parties with malafide intention, without any justified reason repudiated the claim of complainant.
11. On the other hand, Ld. Counsel for opposite parties argued that the insured has submitted the reimbursement of the medical expenses towards the treatment of Typhoid at Dr. Bharti Children Hospital on 07.03.2023 and the opposite parties observed various discrepancies in the documents submitted to the opposite parties.
(1) There is no proper diagnosis mentioned in discharge summary;
(2) There is no hospital seal and proper sign in lab reports, icps are stereotypical, -, written in single hand writing and multiple tampering noted;
It is further argued that the opposite parties are not in a position to admit claim of the complainant, as per the terms and Specific conditions No.18 of the Policy issued to the complainant along with policy and therefore unable to settle the claim under the above policy and hereby repudiate the claim. Hence, claim was rejected and conveyed to Insured by the opposite parties vide letter dated 26.03.2023 (as per Ex.O.Ps-11).
12. The case of the opposite parties is that the complainant has submitted the reimbursement of the medical expenses towards the treatment of his son at Dr. Bharti Children Hospital on 07.03.2023 and the opposite parties observed various discrepancies in the documents submitted to the opposite parties, as such the opposite parties are not in a position to admit claim of the complainant as per the terms and Specific conditions No.18 of the Policy issued to the complainant along with policy and therefore unable to settle the claim under the above policy and the claim was rejected and conveyed to insured by the opposite parties vide letter dated 26.03.2023 (Ex.O.Ps-11). On the other hand, the Ld. Counsel for the complainant argued that all the medical records/prescriptions slips of are duly signed by Dr. Bharti Garg and the lab test report are also duly signed by the Delta Clinical Laboratory Barnala and this fact is proved from the perusal of file. On the other hand, the opposite parties have failed to place on record any cogent evidence in order to rebut the case of the complainant. Ld. Counsel for the complainant further argued that the claim of the complainant is repudiated by the opposite parties on unjustified and unreasonable grounds. The complainant to prove his claim has placed on record copy of bills and receipts Ex.C-16, Ex.C-17, Ex.C-18, Ex.C-19 and Ex.C-20 from which it is established that an amount of Rs. 22,250/- has been spent on the treatment of son of complainant. Therefore, from the perusal of the file it is established that the opposite parties have repudiated the claim of the complainant on such flimsy grounds. 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 and the opposite parties are directed to pay an amount of Rs. 22,250/- 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:
19th Day of July, 2024
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
