DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

                            Complaint Case No: CC/63/2023

                                                           Date of Institution: 31.05.2023

                            Date of Decision: 01.08.2024

Sunita Rani w/o Pardeep Kumar Jindal Ag 59 years R/o H.No. B-V/24/42, Near Dadu Ice Factory, Near Geeta Bhawan, Barnala.

                                    ﾅComplainant

                                                   Versus

1. Star Health and Allied Insurance Company Ltd. Registered Office No. 1, New Tank Street, Valluvarkottam High Road, Nungambakkam, Chennai 600034 through its Managing Director.

2. Star Health and Allied Insurance Company Ltd. Branch Office Barnala-148101 through its Branch Manager IInd Floor, Above Delhi Tractor and Combines, Opposite PNB Bank, College Road, Barnala-148101. Ph. 01679-511011.                                                                                                                                                    ﾅOpposite Parties

Complaint Under Section 35 of the Consumer Protection Act, 2019.

Present: Sh. Chitesh Singla Adv counsel for complainant.

              Sh. Rohit Jain Adv 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 parties are engaged in the business of Health Insurance and the complainant is the consumer of the opposite parties. It is alleged that the complainant was insured with opposite parties vide Invoice No. 31650Y23P0000179, Policy No. P/211229/01/2023/001690 dated 27/12/2022 for the period from 27/12/2022 to 26/12/2023 and the sum insured was Rs. 10 Lakh and proposal date of policy was 23/12/2022 and two persons were insured under the above said policy namely Sunita Rani and Pardeep Kumar Jindal (Both Husband and Wife). It is further alleged that the opposite parties had issued the said policy after their satisfaction from all corners regarding the complainant and her husband and the complainant had paid her premium up to date against the said policy. It is further alleged that the insured Mr. Pardeep Kumar Jindal suffered from a chest pain and he was brought to Dr. Taneja's Heart Care Centre on 30/12/2022 and the Doctor after giving a first aid advised the patient to go to a better Health Institution. In the evening of 30/12/2022 the patient was admitted to Dayanand Medical College & Hospital Managing Society Unit-Hero DMC HEART INSTITUTE and this hospital comes under the cashless treatment domain of opposite parties. The opposite parties demanded some documents including ICP, BPTPR and other investigation supporting diagnosis to process the cashless treatment through an email on 31/12/2022 1.45 PM and it is unfortunate to say that the cashless treatment was denied on 31/12/2022. The opposite parties denied the request on the ground that the report of ECHO, CAG was not submitted. It alleged that it is a matter of common sense that the hospital cannot provide the report of ECHO, CAG immediately on the request and it shows the malafide intention to deny the cashless treatment of the patient. The opposite parties requested to submit the documents of claim form signed by the insured, Discharge Summary, hospital final bills, investigation reports, X-rays, Scan, prescription of the treating Doctor, earlier treatment records etc. The Patient was discharged on 7/1/2023 and it is again a matter of common sense that a patient cannot submit his all these documents on 31/12/2022 when he is actually discharged on 7/1/2023. It further alleged that the insured however submitted those documents and reports which were provided by the hospital and the reports of those tests which were already done and again on 4/1/2023 opposite parties denied the cashless treatment on the ground that a further evaluation is required to ascertain the onset of cardiac ailment. It is alleged that the complainant purchased the policy for better service and for cashless treatment but due to the acts of opposite parties complainant was forced to pay the hospital in cash which was difficult for her to arrange on the spot and this is a clear act of deficiency in service of opposite parties. The complainant had paid an amount of Rs. 1,87,076.99/- (Hospital Final bill) against the treatment at Dayanand Medical College and Hospital, Ludhiana, from his own pocket. It is further alleged that after the discharge of the patient complainant submitted all the documents to the Branch Office as demanded by them for the reimbursement of treatment expenses borne by her and the branch office assured that all the documents demanded have been uploaded through online portal to the insurance company. It is alleged that on 6/2/2023 in e-mail opposite parties again demanded additional documents which were already submitted to it by the complainant. It is alleged that on 18/2/2023 opposite parties sent the repudiation of claim on the ground of non submission of documents this was again deficiency of opposite parties service and causing mental harassment to the complainant by asking for submission of documents which already has been provided to them. The complainant has also sent a legal notice dated 28.03.2023 to the opposite parties, but they have not replied the said notice. 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.-

i. The opposite parties may be directed to pay the claim amount of Rs. 1,87,076/- the final bill of DMC Ludhiana, Rs. 3,091 bill of Dr. Taneja Total Rs. 1,90,167/- with interest @ 12% per annum from the date of treatment to the complainant till realization. 

ii. To pay Rs. 50,000/- towards mental tension and harassment.

iii. 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 that the complainant was insured with opposite parties vide Invoice No. 31650Y23P0000179, under Star Health Assure Insurance policy vide Policy No. P/211229/01/2023/001690 dated 27/12/2022 for the period from 27/12/2022 to 26/12/2023 and the sum insured was Rs. 10 Lakh and proposal date of policy was 23/12/2022 and the above said policy covering Sunita Rani and Pardeep Kumar Jindal (Both husband and wife). It is further admitted that the complainant had paid her premium up to date against the said policy. It is further alleged that as per the document submitted by the complainant the insured Mr. Pardeep Kumar Jindal suffered from chest pain and he was brought to Dr. Taneja's Heart Care Centre on 30/12/2022. It is alleged that as per the document submitted by the complainant that in the evening of 30/12/2022 the patient was admitted to Dayanand Medical College & Hospital Managing Society Unit-Hero DMC HEART INSTITUTE and this hospital comes under the cashless treatment domain of opposite parties and the Patient was discharged on 7/1/2023. It is admitted to the extent that the opposite parties denied the request on the ground that the report of ECHO, CAG was not submitted. It is admitted to the extent that the opposite parties requested to submit Summary, hospital final bills, investigation reports, X-rays, Scan, prescription of the treating Doctor, earlier treatment records etc. It is also admitted to the extent that again on 4/1/2023 the opposite parties denied the cashless treatment on the ground that a further evaluation is required to ascertain the onset of cardiac ailment. It is further alleged that as per the documents submitted by the insured the complainant was discharged from the hospital on 7.1.2023 and the complainant had paid an amount of Rs.1,87,076.99/- (Hospital Final bill) against the treatment of Dayanand Medical College and Hospital, Ludhiana from his own pocket. It is further submitted that the opposite parties on 6.2.2023 in e-mail demanded documents. It is denied that the demanded documents were submitted to the opposite parties by the complainant. It is admitted to the extent that the opposite parties on 18.2.2023 sent the repudiation of claim on the ground of non-submission of documents. It is further alleged that on scrutiny of claim documents, the following documents are necessary to process the claim, hence we advised the insured vide our letter dated 06.02.2023 to furnish the following documents;-

1. Admission referral details

2. ECG reports prior to admission

3. All past admission records.

4. Pre Anaesthesia Notes

It was observed that the insured has not submitted the documents called for by the insurance company which amounts to non submission of required documents and in the absence of the above documents/details, the insurance company is not able to further process the claim but the required documents are not provided despite queried. As per Condition No. 2 of the above policy, the insured person has to submit all the required documents and details called for by the insurance company. Hence, the claim was repudiated vide letter dated 18.02.2023. All other allegations are denied and prayed for the dismissal of complaint. 

5. The complainant filed rejoinder to the written version filed by the opposite parties vide which the complainant denied the averments as mentioned in the written version. 

6. The complainant tendered into evidence copy of policy with terms and conditions are Ex.C-1 (containing 24 pages), copies of letter are Ex.C-2 to C-9, copy of Ist reminder as Ex.C-10, copy of letter of requirement of additional documents as Ex.C-11, copy of repudiation of claim as Ex.C-12, copies of bills and receipts are Ex.C-13 to C-19, copy of Final bill as Ex.C-20, copy of registration card as Ex.C-21, discharge summary as Ex.C-22, Echocardiography report as Ex.C-23, Coronary Angiography as Ex.C-24, Coronary Angioplasty as Ex.C-25, copies of Lab Reports are Ex.C-26 to C-28, copy of Bill of Dr. Taneja as Ex.C-29, prescription slip as Ex.C-30, copy of Echocardiography report of Dr.Taneja as Ex.C-31, copy of Initial Evaluation report as Ex.C-32, (containing 11 pages), copy of DMC Treatment form as Ex.C-33, (containing 18 pages), copy of critical care flow sheet as Ex.C-34, (containing 6 pages), copy of Echocardiography report as Ex.C-35, (containing 2 pages), copy of lab report as Ex.C-36 (containing 12 pages), copy of Echocardiography as Ex.C-37 (containing 2 pages), copy of Angiography as Ex.C-38 (containing 4pages), copy of Lab report as Ex.C-39, copy of angioplasty as Ex.C-40 (containing 2 pages), copy of Claim form as Ex.C-41, copy of legal notice as Ex.C-42, postal receipts are Ex.C-43 & C-44, copies of tracking report as Ex.C-45 & C-46, claim form as Ex.C-47, affidavit of complainant as Ex.C-48 and closed the evidence.

7. The opposite parties tendered into evidence affidavit of Sumit Kumar Sharma as Ex.OPs-1, copy of proposal form as Ex.OPs-2 (containing 4 pages), copy of policy as Ex.OPs-3 (containing 8 pages), copy of terms and conditions are Ex.OPs-4 (containing 10 pages), copy of request for cashless as Ex.OPs-5 (containing 4 pages), copies of letters are Ex.OPs-6 to OPs-9, copy of claim form as Ex.OPs-10 (containing 4 pages), copy of discharge summary as Ex.OPs-11 (containing 2 pages), copy of Final bill as Ex.OPs-12 (containing 2 pages), copies of receipts are Ex.OPs-13 (containing 5 pages), copy of letter dated 06.02.2023 as Ex.OPs-14 (containing 2 pages), copy of repudiation letter as Ex.OPs-15 (containing 3 pages), copy of bill assessment sheet as Ex.OPs-16 and closes the evidence.

8. We have heard the learned counsel for the parties and have gone through the record on the file. 

9. It is admitted case of the opposite parties that the complainant was insured with opposite parties vide Invoice No. 31650Y23P0000179, under Star Health Assure Insurance policy vide Policy No. P/211229/01/2023/001690 dated 27/12/2022 for the period from 27/12/2022 to 26/12/2023 and the sum insured was Rs. 10 Lakh and proposal date of policy was 23/12/2022 and the above said policy covering Sunita Rani and Pardeep Kumar Jindal (Both husband. and wife) (as per Ex.C-1 & Ex.O.Ps-3). It is further admitted case of the opposite parties that the complainant had paid her premium up to date against the said policy. It is also not disputed that the insured Mr. Pardeep Kumar Jindal suffered from chest pain and he was brought to Dr. Taneja's Heart Care Centre on 30/12/2022 (as per Ex.C-30). It is also not disputed that the complainant in the evening of 30/12/2022 was admitted to Dayanand Medical College & Hospital Managing Society Unit-Hero DMC HEART INSTITUTE and this hospital comes under the cashless treatment domain of opposite parties and the Patient was discharged on 7/1/2023 (as per Ex.C-22). 

10. Ld. Counsel for the complainant argued that the opposite parties denied the request of cashless treatment on the ground that the report of ECHO, CAG was not submitted. It is further argued that the opposite parties requested to submit the documents of claim form signed by the insured, Discharge Summary, hospital final bills, investigation reports, X-rays, Scan, prescription of the treating Doctor, earlier treatment records etc. It is also argued that the Patient was discharged on 7/1/2023 and it is matter of common sense that a patient cannot be submitted his all these documents on 31/12/2022 when he is actually discharged on 7/1/2023. It further argued that the insured however submitted those documents and reports which were provided by the hospital and the reports of those tests which were already done. It is further argued that again on 4/1/2023 (as per Ex.C-7 to Ex.C-9) opposite parties denied the cashless treatment on the ground that a further evaluation is required to ascertain the onset of cardiac ailment. It is argued that the complainant purchased the policy for better service and for cashless treatment but due to the acts of opposite parties complainant was forced to pay the hospital in cash which was difficult for her to arrange on the spot and this is a clear act of deficiency in service of opposite parties. It is argued that the complainant had paid an amount of Rs. 1,87,076.99/- (Hospital Final bill) (Ex.C-2) against the treatment at Dayanand Medical College and Hospital, Ludhiana, from his own pocket. It is further argued that after the discharge of the patient complainant submitted all the documents to the Branch Office as demanded by them for the reimbursement of treatment expenses borne by her and the branch office assured that all the documents demanded have been uploaded through online portal to the insurance Company. It is argued that on 6/2/2023 in e-mail opposite parties again demanded additional documents which were already submitted to it by the complainant. It is alleged that on 18/2/2023 (Ex.C-12) opposite parties sent the repudiation of claim on the ground of non submission of documents.

11. On the other hand, Ld. Counsel for the opposite parties argued that on scrutiny of claim documents, the following documents are necessary to process the claim, hence opposite parties advised the insured vide our letter dated 06.02.2023 (Ex.O.Ps-14) to furnish the required additional documents i.e. Admission referral details, ECG reports prior to admission, All past admission records and Pre Anaesthesia Notes. But the insured has not submitted the above said required documents which amounts to non submission of required documents and in the absence of the above documents/information, the insurance company is not able to further process the claim and as per Condition No.2 of the above policy, the insured person has to submit all the required documents and details called for by the insurance company. Hence, the claim was repudiated vide letter dated 18.02.2023 (Ex.O.Ps-15).

12. The case of the opposite parties is that despite the above said letters sent by the opposite parties to the complainant for requirement of additional documents/information as mentioned in the said letters, the complainant has failed to submit the required documents, as such the opposite parties have repudiated the claim of the complainant vide letter dated 18.2.2023 (Ex.O.Ps-15). On this, the Ld. Counsel for complainant argued that after the discharge of the patient the complainant submitted all the required documents alongwith medical reports to the Branch Office as demanded by them for the reimbursement of treatment expenses borne by her and the branch office assured that all the documents demanded have been uploaded through online portal to the insurance company, but on 6/2/2023 vide an e-mail opposite parties again demanded additional documents which were already submitted to them. Moreover, from the perusal of the file it shows that all the medical records (including test reports) of the patient are already on the Court file (Ex.C-22 to Ex.C-28, Ex.C-30 to Ex.C-40) and we are of the view that if the opposite parties required the same to settle the claim of the complainant, then they could have procure the same from the Court file but at this stage they cannot escaped from their liabilities by taking these types of unreasonable and unjustified grounds. Therefore, it is established that the opposite parties have repudiated the claim of the complainant on such flimsy grounds. The complainant to prove her claim has placed on record In-Patient Final Bill Ex.C-20 and Ex. C-29 from which it is established that an amount of Rs. 1,87,076/ has been spent on the treatment of insured at Dayanand Medical College & Hospital, Ludhiana and Rs. 3,091/- has been spent on the treatment of insured at Dr. Taneja's Heart Care Centre, Patiala and the total amount comes to the tune of Rs. 1,90,167/-. 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 rejected 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. 1,90,167/- 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:

1st Day of August, 2024

 

       (Ashish Kumar Grover)

                                                          President

         

                                    (Urmila Kumari)

                                                          Member

 

          (Navdeep Kumar Garg)

                                                             Member