Haryana

Ambala

CC/207/2022

Tarun Deep Sekhri - Complainant(s)

Versus

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

Ramesh Chand Rana

16 Aug 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	207 of 2022
Date of Institution	:	15.06.2022
Date of decision	:	16.08.2024

Tarun Deep Sekhri s/o Shri Tarsem Lal R/o House No.2035/3, Khatarwara, Ambala City District Ambala

          ……. Complainant

Versus

1. Star Health and Allied Insurance Co. Ltd. No.15, SriBalaji Complex, 1st Floor, White Lane, Royapettah, Chennai (T.N.), 600014 Through its Authorized Signatory/G.M.

 

2. Star Health and Allied Insurance Co. Ltd. SCO 180-183, 3rd Floor, Minerva Complex Rai Market, Ambala Cantt through its Branch Manager.

….…. Opposite Parties

Before:        Smt. Neena Sandhu, President.

                     Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:       Shri Ramesh Chand Rana, Advocate, counsel for the complainant. 

                     Shri Mohinder Bindal, Advocate, counsel for the OPs.

Order:        Smt. Neena Sandhu, President.

                   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 pay the claim amount of Rs.2,12,230/-, spent by him on his treatment
2. To pay Rs.50,000/- as compensation for harassment and mental agony
3. To pay Rs.33,000/- on account of litigation expenses.

Or

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

 

2.             Brief facts of the case are that the complainant was having a policy in the name 'Family Health Optima-2017' i.e. policy No. P/21111/01/2021/003568 effective from 30.09.2020 to 29.09.2021. Under the said policy, the complainant as well his family members were covered for any health related exigencies. The  OPs undertook to indemnify or to pay the amount of hospitalization charges, medicines, charges or ancillary charges to the complainant. On 30.04.2021, the complainant fell sick and was admitted in Mehndritta Hospital, Ambala, where he was diagnosed as Covid Pneumonia and remained admitted in the said hospital till 06.05.2021. After treatment, he was discharged by the doctors with the advice of complete bed rest for about 2 months. At the time of admission in the hospital the OPs were well informed about the sickness and hospitalization of the complainant. The OPs assured that all the hospitalization charges and all other charges incidental to ailment will be paid to the complainant. Thereafter, the complainant informed the OPs about the expenditure met by him to the tune of Rs.2,12,230/- in the hospital and about an amount of Rs.50,000/- met for purchasing the medicines etc. The OPs told the complainant to submit the claim and that the same will be paid without any delay. As such, the complainant submitted the claim along with all relevant papers for payment to the complainant. However, vide letter dated 25.10.2021, the OPs repudiated the claim of the complainant. Requests made to the OPs to reconsider the claim did not yield any result and again vide letter dated 16.11.2021, the OPs rejected the claim.   The complainant served legal notice dated 10.01.2022 calling the OPs to make the payment of bill submitted by the complainant but to no avail.  Hence, the present complaint.
3.           Upon notice, OPs appeared and filed written version and raised preliminary objections to the effect that the complainant has not approached this Commission with clean hands and has suppressed material facts; the present complaint is liable to be dismissed for non disclosure of material facts and the present complaint has been filed without any cause of action etc. On merits, it has been stated that the complainant has tried to manipulate the facts for imposing this false and frivolous case. The complainant availed the policy in question for the sum insured of Rs.10,00,000/- covering self, spouse and 2 dependent children 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 coverage 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 along with policy schedule wherein it is clearly stated that "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC. ATTACHED."I The policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. 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. 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 Mehandiratta Hospital. Ambala City from 30.04.2021 to 06.05.2021. The entire set of papers were scrutinized by the expert medical team of the OPs and found certain discrepancies and multiple tempering in the indoor case papers/treatment record and hospital report as provided to the OPs. It was also observed that as per the doctor notes the BP of the complainant at the time of admission was 130/90, pulse rate 78/ min, temperature 98 degree fever, SPO2 86% which was found not compatible with the details mentioned in the discharge summary and even it was found that insured patient stayed in general ward followed by private room with no ICU stay but in the final bill, charges against ICU were shown for 4 days. Since as per the terms and condition of the policy, if 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 15.07.2021. Even the representation made by Dr. Vishwas Bhardwaj through Email 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. The team which re-examined the claim papers further observed that the assessment date of Covid test was shown as 23.04.2021 whereas sample was taken on 27.04.2021 and report shown to be received on 28.04.2021. The hospital even failed to provide the Indoor Patient register which was required to substantiate the claim of the complainant about treatment and admission. The hospital even failed to provide the receipt of the amount of Rs.2.12 lakh allegedly received from the complainant proving certain manipulation in the treatment and claim papers just to exaggerate the claim. Vide letter dated 25.10.2021, the repudiation of his claim was reaffirmed as legal. 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; hence the present complaint deserves dismissal. 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 the complainant as Annexure C-A alongwith documents as Annexure C-1 to C-13 and closed the evidence on behalf of the complainant. On the other hand, learned counsel for the OPs tendered affidavit of Sumit Kumar, Sharma, Senior Manager of the OPs-Company-Star Health and Allied Insurance Co. Ltd., 1^st Floor, Himalaya House, 23, Kasturba Gandhi Marg, New Delhi-110001 as Annexure OP-A alongwith documents as Annexure OP-1 to OP-27 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, on account of treatment of his COVID 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 records, where the  complainant has allegedly taken treatment of COVID-19 and also other discrepancies as stated above.
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 aforesaid 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 25.10.2021, and 16.11.2021, Annexure OP-22 to OP-24, and found that the claim of the  complainant has been repudiated on following grounds:-
   1. IP register is not available;
   2. The insured patient's SPO2 level on admission was 86%; BP was 130/90 and Pulse Rate was 78/minute and Temperature was 98 degree fever, which is not compatible with the details mentioned in the discharge summary;
   3. Assessment date of COVID test is shown as 24.04.2021 but sample was taken on 27.04.2021 and report received on 28.04.2021 and that as per information available denied admission in ICU but now he claims to be in ICU, complete indoor case records are stereotyped.
9.           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 Investigator/Surveyor or report of their Medical Team to prove that they ever 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.
10.           Now coming to the ground taken by the OPs to the effect that as per discharge summary, the details of SPO2; level on admission was 86%; BP was 130/90 and Pulse Rate was 78/minute and Temperature was 98 degree fever, which is not compatible with the details mentioned in the discharge summary; it may be stated here that if in the doctor progress notes, Annexures OP-12 to OP-14 colly. starting from 30.04.2021, the level/rate of  SPO2, BP, Pulse Rate and Temperature of the complainant was found fluctuating at differential intervals i.e. at the time of admission itself till the date of his discharge and the life of the complainant was ultimately saved, under those 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, especially, when the report dated 28.04.2021, Annexure OP-15 clearly says that the complainant was found SARS COVID-19-POSITIVE. In this view of the matter, even this ground was also not sufficient to reject the claim of the complainant.
11.           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 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 disproved by the OPs. At the same time, it 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 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.  
12.           It may be stated here that receipts/bill dated 06.05.2021, Annexure OP-16 proves that the complainant had paid an amount of Rs.2,12,230/-, qua treatment/purchase of medicines, admission charges etc. taken by him in the said hospital. The OPs have failed to prove any contrary evidence against the said receipt.  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.2,12,230/-, spent by him on his treatment.
13.           In view of the aforesaid discussion, we hereby allow the present complaint and direct the OPs, in the following manner:-  
    1. To reimburse/pay to the complainant the amount of Rs.2,12,230/- alongwith interest @6% p.a. from 15.07.2021 i.e. the date when firstly the claim was repudiated, till its realization.
    2. To pay Rs.5,000/- as compensation for the mental agony and physical harassment suffered by the complainant.
    3. To pay Rs.3,000/- 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:- 16.08.2024

 

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