DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

 

Complaint Case No : CC/195/2021

Date of Institution   : 13.09.2021

Date of Decision    : 29.11.2023

Vakil Chand son of Shambhu Nath son of Shri Ram Ji, R/o Ward No. 6, Jaidan Patti, Dhanaula, Tehsil and District Barnala.        

                          …Complainant Versus

1. Star Health and Allied Insurance Co. Ltd., Regd., and Corporate Office, No. 15, Sri Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai-600014;  

2. Star Health and Allied Insurance Co. Ltd., Branch Office, SCF No. 133, 2nd Floor, Goniana Road, Bathinda-151001. 

                         …Opposite Parties

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

Present: Sh. R.K. Bansal counsel for complainant.

Sh. Rohit Jain counsel for opposite parties.

Quorum:-

1. Sh. Jot Naranjan Singh Gill : President

2.Smt. Urmila Kumari : Member

 

(ORDER BY JOT NARANJAN SINGH GILL, PRESIDENT):

The present complaint has been filed under Section 35 of the Consumer Protection Act 2019, (amended upto date) against Star Health and Allied Insurance Company Limited and others (hereinafter referred as opposite parties).  

2. The facts leading to the present complaint are that the complainant obtained a health policy namely “Family Health Optima Insurance Plan” from the opposite parties for a period of one year w.e.f. 26.12.2020 to 25.12.2021 for a sum assured of Rs. 5,00,000/- and for this complainant paid a premium of Rs. 13,057/- to the opposite party No. 2 in cash through their agent Ms. Jyoti Garg having Intermediary Code: BA0000323870 and in this respect policy No. P/211217/01/2021/005261 was issued by the opposite parties. It is further alleged that in the above said policy Vakil Chand (complainant), Usha Rani and Pratham Bansal (wife and son of the complainant) were duly insured and ID Card Nos. 19559688-1, 19559688-2 and 19559688-3 respectively were issued in the the names of above said persons. On 7.5.2021 the complainant's wife namely Usha Rani was got admitted in Mittal Hospital, Ram Bagh Road, Barnala due to LRTI and hospitalized in Mittal Hospital upto 10.5.2021 and where an amount of Rs. 17,502/- (i.e. Rs. 16,012/- for hospital bill breakup + Rs. 690/- medicine bill of ESS Mittal Medicos + Rs. 800/- for Kamaldeep Clinical Lab) was incurred. That due intimation in this regard was given to the opposite party No. 2 and as per the directions of opposite party No. 2 Vakil Chand on 6.6.2021 submitted the required documents in original alongwith claim form with the opposite parties and thereafter number of times the complainant alongwith her wife visited the office of opposite party No. 2 and requested to pay the claim, but the opposite party No. 2 put the matter on one pretext or the other. It is further alleged that ultimately on 24.6.2021 the opposite parties illegally, arbitrarily and law and facts repudiated the claim of the complainant with remarks “insured patient could have been treated as an out patient and hospitalization is not warranted for the above diagnosis”. Thus, the above said act and conduct of the opposite parties falls under the deficiency in service and unfair trade practice on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.- 

i)To pay the sum of Rs. 17,502/- (i.e. Rs. 16,012/- for hospital bill breakup + Rs. 690/- medicine bill of ESS Mittal Medicos + Rs. 800/- for Kamaldeep Clinical Lab) which was incurred by the complainant on treatment of his wife Usha Rani.

ii)To pay Rs. 1,00,000/- for mental shock, pain, agony and Rs. 30,000/- as litigation expenses.   

3. Upon notice of this complaint, the opposite parties appeared and filed written version taking preliminary objections interalia on the grounds that the complainant has got no locus-standi or cause of action to file the present complaint, the present complaint is not maintainable, the complainant dragged the opposite parties in false litigation, not come with clean hands etc.  

4. On merits, it is admitted that the complainant gave intimation and submitted claim form alongwith documents. It is further admitted that vide letter dated 24.6.2021 the claim of the complainant was repudiated with remarks that insured patient could have been treated as an out patient and hospitalization is not warranted for the above diagnosis. It is further submitted that the policy is contractual in nature and the claims arising therein are subject to terms and conditions forming part of the policy and the same were explained to the complainant at the time of proposing policy and same were served to the complainant alongwith policy schedule. The complainant submitted the claim documents for reimbursement of medical expenses towards the treatment of Lower Respiratory Tract Infection. On a perusal of medical record, it is noted from the ICP and the intvestigation report, that the vitals are normal and medical team of the opposite parties is of the opinion that the insured patient could have been treated as an out patient and hospitalization is not warranted for the above diagnosis. The above decision has been taken as per the terms and conditions of the policy and based upon the claim details documents submitted by the complainant. It is further alleged that once the claim of the complainant was rejected and conveyed to the insured vide letter dated 24.6.2021 by the opposite parties, so there is no deficiency in service and negligence on the part of opposite parties. All other allegations of the complainant are denied. Therefore, there is no deficiency in service on the part of opposite parties and prayed for the dismissal of complaint. 

5. Complainant has filed rejoinder to the written reply of opposite parties and denied the averments of the opposite parties. 

6. To prove his case the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy Ex.C-2 (containing 7 pages), copy of payment receipt Ex.C-3 (containing 2 pages), copies of ID cards Ex.C-4 to Ex.C-6, copy of discharge summary Ex.C-7 (containing 2 pages), copy of hospital bill break up Ex.C-8 (containing 4 pages), copies of bills & receipts Ex.C-9 & Ex.C-10, copy of treatment chart Ex.C-11 (containing 6 pages), copy of lab report Ex.C-12 (containing 3 pages), copy of claim form Ex.C-13 (containing 4 pages), copy of repudiation letter dated 24.6.2021 Ex.C-14 (containing 6 pages) and closed the evidence.  

7. To rebut the case of the complainant the opposite parties tendered into evidence affidavit of Sumit Kumar Sharma Ex.O.Ps-1, copy of policy Ex.O.Ps-2 (containing 7 pages), copy of terms and conditions Ex.O.Ps-3 (containing 6 pages), copy of proposal form Ex.O.Ps-4 (containing 4 pages), copy of field visit report Ex.O.Ps-5 (containing 3 pages), copy of claim form Ex.O.Ps-6 (containing 4 pages), copy of discharge summary Ex.O.Ps-7 (containing 2 pages), copy of hospital bill  Ex.O.Ps-8, copy of medicine bills Ex.O.Ps-9, copy of bill of Mittal hospital Ex.O.Ps-10, copy of repudiation letter Ex.O.Ps-11 (containing 2 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 file.  

9. It is not disputed between the parties that the complainant obtained a health policy namely “Family Health Optima Insurance Plan” from the opposite parties for a period of one year w.e.f. 26.12.2020 to 25.12.2021 for a sum assured of Rs. 5,00,000/- and for this complainant paid a premium of Rs. 13,057/- to the opposite party No. 2 and in this respect policy No. P/211217/01/2021/005261 was issued by the opposite parties (Ex.C-2 & Ex.O.Ps-2). It is further admitted case of the complainant that in the above said policy Vakil Chand (complainant), Usha Rani and Pratham Bansal (wife and son of the complainant) were duly insured. 

10. In order to prove his case the complainant has placed on record his detailed affidavit Ex.C-1. He has further placed on record copy of insurance policy Ex.C-2, which shows that the same was valid from 26.12.2020 to midnight of 25.12.2021. From the policy it further shows that the basic floater sum insured is Rs. 5,00,000/- and the name of the insured Vakil Chand (self), Usha Rani (spouse) and Pratham Bansal (dependent child) is mentioned. The complainant further placed on record copy of policy payment receipt Ex.C-3, which shows that the complainant paid the premium amount of Rs. 13,057/- in cash on 26.12.2020 to the opposite parties. The complainant also placed on record copies of ID cards issued by the opposite parties Ex.C-4 to Ex.C-6, which shows the customer ID No.s, names, date of birth of the insured persons. It further shows that the above said ID cards were valid from 26.12.2020. The complainant also placed on record copy of discharge summary of patient Usha Rani issued by Mittal Hospital, Barnala Ex.C-7, which shows the date of admission on 7.5.2021 and date of discharge on 10.5.2021. In discharge summary it is further mentioned that the patient was admitted with the history fever, cough and SoB for 4-5 days and she was evaluated and was diagnosed to be having LRTI. Complainant further placed on record Hospital Bill Breakup Ex.C-8, which shows that the patient from the date of admission i.e. 7.5.2021 to the date of discharge i.e. 10.5.2021 has paid Rs. 16,012/- to the hospital which includes private room charges, daily doctor visiting fee, nursing charges and medicine charges. Ex.C-9 is the copy of medicine bill of Rs. 690/- dated 9.5.2021 of ESS Mittal Medicos which is situated inside Mittal Hospital, Barnala. Further, Ex.C-10 is the copy of receipt dated 9.5.2021 of Kamaldeep Clinical Laboratory, which shows that the patient Usha Rani has paid Rs. 800/- on account of Blood & Urine Test. Further, Ex.C-11 is the copy of treatment chart of Mittal Hospital, Barnala, which shows the time schedule from 7.5.2021 to 9.5.2021 according to which the medicines were administered to the patient Usha Rani. The complainant further placed on record copy of claim form Ex.C-13, which shows that the complainant lodged the claim of Rs. 17,502/- with the opposite parties. The complainant has further placed on record copy of repudiation letter Ex.C-14 dated 24.6.2021 vide which the opposite parties has repudiated the claim of the complainant. Further, in Ex.C-14 at Page No. 3 Certificate of Doctor vide which it is mentioned as under;-

“This is to certify that the patient Ms. Usha Rani was admitted because she was having lower respiratory infection with shortness of breath. She was having severe respiratory distress alongwith moderate grade fever. She was a suspected c/o Covid and so needed admission”. 

11. On the other hand the opposite parties in order to rebut the case of the complainant has placed on record affidavit of Sumit Kumar Sharma O.Ps-1. Copy of policy and terms & conditions Ex.O.Ps-2 and Ex.O.Ps-3 which is not disputed. The opposite parties further placed on record Ex.O.Ps-4 copy of proposal form, which shows the name of Proposer Vakil Chand and other insured person Usha Rani and Pratham. Further, Ex.O.Ps-6 is the copy of claim form which is duly signed by Vakil Chand and in Ex.O.Ps-6 hospitalization expenses mentioned as Rs. 17,502/-. Ex.O.Ps-7 is the copy of discharge summary of patient Usha Rani which shows the date of admission 7.5.2021 and date of discharge 10.5.2021. Further, Ex.O.Ps-8 is the copy of Hospital Bill Breakup of Rs. 16,012/-. Ex.O.Ps-9 is the prescription and medicine bill, which shows the medicines prescribed by the hospital and price of the medicines. Ex.O.Ps-10 is the copy of Mittal Hospital dated 18.5.2021 of Rs. 16,012/- issued by the hospital in the name of Usha Rani. Further, the opposite parties placed on record repudiation letter dated 24.6.2021 Ex.O.Ps-11 vide which the opposite parties have repudiated the claim of complainant. Ex.O.Ps-12 is the copy of bill assessment sheet/hospital payment which shows the admissible/claimed amount of Rs. 17,502/-. 

12. So, perusal of the record shows that the opposite parties repudiated the claim of the complainant on the ground that the insured patient could have been treated as an out patient and hospitalization is not warranted for the above diagnosis. We have gone through the copy of discharge summary (Ex.C-7 & Ex.O.Ps-7) vide which it is clearly mentioned the date of admission of patient Usha 7.5.2021, 9:30 A.M. and date of discharge 10.5.2021, 10:00 A.M. Moreover, in the hospital bill breakup (Ex.C-8 & Ex.O.Ps-8) the date of admission and date of discharge of patient Usha Rani is also mentioned 7.5.2021 to 10.5.2021. Further, in Ex.C-14 at Page No. 3 doctor certified that the Patient needed admission. We are of the view that the doctor is the best judge to decide that whether the patient Usha Rani is treated as an indoor patient or out door patient. Therefore, it is established as per above said medical record that the patient Usha Rani was admitted in the hospital on 7.5.2021 and was discharged on 10.5.2021 and taken the treatment as indoor patient. Therefore, it is established that the opposite parties have rejected the claim of the complainant on such flimsy grounds. 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 on the part of opposite parties. Therefore, the present complaint is partly allowed against the opposite parties and the opposite parties are directed to pay Rs. 17,502/- alongwith interest @ 7% per annum from the date of filing the present complaint till realization. The opposite parties are further directed to pay Rs. 5,500/- on the account of consolidated amount of compensation alongwith litigation expenses to the complainant. 

14. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order.

15. Copy of this order be supplied to the parties free of costs as per rules. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

       29th Day of November, 2023

 

            (Jot Naranjan Singh Gill)

            President

 

(Urmila Kumari)

Member