DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

Complaint Case No : CC/187/2020

Date of Institution : 04.09.2020

Date of Decision : 01.02.2022

Varinder Kumar aged about 45 years son of Ramesh Kumar resident of House No. 76, Ward No. 8, C/o Ramesh Book Depot, Sadar Bazaar, Dhanaula Tehsil and District Barnala, Mobile No. 94174-51380 …Complainant

Versus

1. Star Health and allied Insurance Company Limited Branch Office Bathinda, SCO-133, 2nd Floor, Above Tata Motor Finance, Near Hotel Sweet Milan, Goniana Road, Bathinda-151001 through its Branch Manager.

2. Star Health and Allied Insurance Company Limited, Branch Office, Barnala, 2nd Floor, Opposite Punjab National Bank, Pakka College Road, Barnala through its Branch Manager.

…Opposite Parties

Complaint under the Consumer Protection Act 2019

Present: Sh. Chander Bansal Adv counsel for complainant.

Sh. Rohit Jain Adv and Sh. Lokeshwar Sewak 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 Varinder Kumar filed the present complaint under Consumer Protection Act 2019 against Star Health and Allied Insurance Company Limited and another. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant purchased Family Health Optima Insurance plan bearing policy No. P/211217/01/2018/000873 issued by the opposite party No. 1. Under the said plan the health insurance of complainant, Ritu Rani wife of complainant, Dhiraj Garg son and Nidhi daughter of the complainant was covered up to Rs. 3,00,000/- for the period from 25.11.2017 to 24.11.2018. The complainant paid the premium of Rs. 11,889/- to the opposite parties and identity cards were also issued by the opposite parties to the complainant and his family members. The complainant got renewal of said policy from the opposite parties with renewal No. P/211217/01/2019/001560 for the period from 4.12.2018 to 3.12.2019 and thereafter got renew the policy vide renewal No. P/211217/01/2020/002678 for the period from 10.12.2019 to 9.12.2020 with bonus of Rs. 1,05,000/- covering up to Rs. 4,05,000/-. The complainant paid the total renewal premium of Rs. 11,889/- to the opposite parties. 

3. It is further alleged that on 16.12.2019 the complainant felt severe pain in his abdomen and he got medically examined from Dr. Parshant Mittal C/o Mittal Hospital, Barnala who advised ultrasound and complainant got ultrasound and paid Rs. 500/-. After checking ultrasound Dr. Parshant Mittal advised to take medicine on prescription slip. Even after taking the said medicine the complainant done vomiting multiple times. Then complainant was got admitted in Dayanand Medical College and Hospital, Ludhiana on the same day i.e. 16.12.2019 due to abdomen pain within 10 hours. The complainant admitted in DMC from 16.12.2019 to 20.12.2019 under the supervision of Dr. Sanjeev Single and he paid total sum of Rs. 55,424.18 P to DMC hospital vide bill dated 20.12.2019 and had spent a total sum of Rs. 60,167.18P on the treatment of complainant who is covered under the policy in question. The complainant informed the opposite parties about his admission in the hospital and thereafter claim No. 0742675 was made by the complainant alongwith bills and documents to the opposite parties. But the opposite parties repudiated the claim of the complainant on 1.2.2020 on the ground that company is not liable to protect the insured person between the policy expiry date and the date of payment of renewal premium. Further, due to clerical mistake it was mentioned that the complainant was suffering pain in his abdomen from last 10 days inspite of writing 10 hours. The said mistake was made correct by the doctor. But the opposite parties repudiated the claim of the complainant. The act of the opposite parties is unfair trade practice and deficiency in service. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to reimburse the expenses incurred by the complainant on his treatment during the period of insurance amounting to Rs. 60,167.18 alongwith interest at the rate of 18% per annum.  

2) To pay Rs. 2,00,000/- on account of compensation for mental agony and harassment and Rs. 30,000/- as litigation expenses. 

3) Any other fit relief may also be given. 

4. Upon notice of this complaint, opposite parties filed written version taking preliminary objections that the complainant has no locus standi to file the present complaint and present complaint is not maintainable. The complainant has not come to this Commission with clean hands. 

5. On merits, it is admitted that the complainant purchased one Health Insurance Policy from the opposite parties. Rest of contents of the complaint are denied by the opposite parties. The true facts are that the insured availed Family Health Optima Insurance plan for himself and his family for the sum assured of Rs. 3,00,000/-. The said policy was renewed after a break of 10 days from the date of expiry by giving good health declaration. The terms and conditions of the policy were explained to the complainant at the time of proposing the policy and it is clearly stated in the policy that the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. Further, the insured preferred the claim in the 3rd year of the policy  for himself under claim No. 0742675 for his hospitalization from 16.10.2019 to 19.12.2019 in DMC and Hospital, Ludhiana for acute calculous cholecystitis and claimed Rs. 73,042/-. The insured requested a cashless of the medical expenses towards the treatment at DMC and Hospital, Ludhiana on 17.12.2019. It is observed from the pre-authorization report that the patient has pain in his abdomen for the past 10 days hence the onset of the said disease is during the break period of insurance and this was not disclosed at the time of renewal of policy hence cashless was repudiated on 17.12.2019. After that the insured submitted claim documents for reimbursement which was rejected vide letter dated 1.2.2020 on the ground that the insured is seeking reimbursement of hospitalization expenses for treatment of acute calculus cholecystitis. The said policy is renewed after a break of 10 days i.e. from 24.11.2019 to 4.12.2019 and as per condition No. 7 of the policy the company is not liable to protect the insured person between the policy expiry date and the date of payment of renewal premium. It is also observed from pre-authorization request form that the insured has complaint of pain in abdomen for the past 10 days which confirms that the said disease is during the break in policy period and insured patient is treated subsequently. Again the clarification request give by the insured stated that the duration has been wrongly stated by mistake but the corrected documents are not acceptable. Rest of contents of complaint are denied by the opposite parties and lastly prayed for the dismissal of the present complaint with costs. 

6. In support of his complaint, the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy schedule 2017-18 Ex.C-2, copy of ID cards Ex.C-3, copy of advance premium receipt dated 25.11.2017 Ex.C-4, copy of policy schedule 2018-19 Ex.C-5, copy of advance premium receipt dated 4.12.2018 Ex.C-6, copy of policy schedule 2019-20 Ex.C-7, copy of advance premium receipt dated 10.12.2019 Ex.C-8, copy of prescription slip of Mittal Hospital Ex.C-9, copy of receipt of Patiala Diagnostic Ex.C-10, copy of discharge summary Ex.C-11, copies of bills Ex.C-12 to Ex.C-15, copy of repudiation letter Ex.C-16, copy of terms and conditions Ex.C-17 and closed the evidence. 

7. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments also filed by both the parties. 

8. After hearing the arguments of the learned counsel for the parties and on the perusal of the documents on record and written arguments filed by both the parties, we found that the complainant has purchased insurance policy first time in the year 2017 and up to 2020 he renewed the same from the opposite parties. The opposite parties repudiated the claim of the complainant on the ground that the policy is renewed after a break period of 6 days i.e. from 4.12.2019 to 9.12.2019. But it is evident from the record that the complainant felt ill on 16.12.2019 and approached the Mittal Hospital, Barnala and the complainant had produced the prescription slip as Ex.C-9 and the doctor of the Mittal Hospital advised the complainant for ultrasound which was done on the same day by the complainant from Patiala Diagnostic Centre and Eye Clinic, Barnala and the complainant also produced the receipt of the fee paid to the said diagnostic centre as Ex.C-10. Thereafter, the complainant approached Dayanand Medical College and Hospital, Ludhiana on the same day i.e. 16.12.2019 and he remain admitted there till 20.12.2019. The discharge card is produced by the complainant as Ex.C-11. 

9. From the above said medical record it is established that the complainant felt ill within the validity period of the policy. The opposite parties have taken the plea that the insured patient has complained of  abdomen pain for the last 10 days which confirms that the said disease is during the break in the policy period and the insured patient is treated subsequently. But the complainant has produced the discharge card Ex.C-11 in which it is clear that the doctor wrongly mentioned  abdomen pain since 10 days and the Dr. Anubhav Gupta corrected the same by mentioning 10 hours and he also signed and stamped the discharge card. The same document has also been produced by the opposite parties in their evidence i.e. Ex.OPs-15. The plea taken by the insurance company is not adequate as the complainant is taking the policy in question from 2017 and in the present policy Ex.C-7 valid from 10.12.2019 to 9.12.2020 the opposite parties have provided the bonus in the coverage of the policy i.e. Rs. 1,05,000/- and the total sum assured amount is now exceeds from Rs. 3,00,000/- to Rs. 4,05,000/-. It is established from the above said act of the opposite parties that the policy of the complainant is in continuity. In this way by rejecting the claim of the complainant is clear cut deficiency in service and unfair trade practice on the part of the opposite parties.

10. The complainant has took the treatment from Dayanand Medical College and Hospital, Ludhiana and also produced the bill on the record as Ex.C-12 vide which has paid Rs. 55,424/-. He also produced the pharmacy bills Ex.C-13 to Ex.C-15 amounting of Rs. 4,243/- and copy of receipt Ex.C-10 of Patiala Diagnostic Centre and Eye Clinic, Barnala of Rs. 500/-. In this way, the complainant spent total amount of Rs. 60,167/- on his treatment.  

11. In view of the above discussion, present complaint is partly allowed and opposite parties are directed to pay Rs. 60,167/- to the complainant spent by the complainant on his treatment alongwith interest at the rate of 7% per annum from the date of filing of present complaint till actual realization. The opposite parties are also directed to pay Rs. 10,000/- to the complainant as compensation for mental tension and harassment and Rs. 5,500/- as litigation expenses. 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 February 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Urmila Kumari)

Member

 

(Navdeep Kumar Garg)

Member