DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.

 

Complaint Case No : CC/190/2019

Date of Institution : 01.11.2019

Date of Decision : 28.01.2020

Walaiti Ram son of Sh. Niranjan Lal, H. No. B-533, Pharwahi Bazaar, W. No. 18, Barnala, District Barnala. …Complainant

Versus

1. Star Health and Allied Insurance Company Ltd., SCO  133, 2nd Floor, Above Tata Motor Finance, Near Hotel Sweet Milan, Goniana Road, Bathinda. 

2. Dr. Pardeep Sharma Hospital, K.C. Road, Barnala through Dr. Pardeep Sharma. 

…Opposite Parties

Complaint Under Section 12 of the Consumer Protection Act, 1986.

Present: Sh. Chamkaur Singh counsel for the complainant.

Opposite party No. 1 exparte. 

Sh. Yashpal Joshi counsel for opposite party No. 2. 

Quorum.-

1. Sh. Kuljit Singh : President

2. Sh. Tejinder Singh Bhangu : Member

(ORDER BY KULJIT SINGH, PRESIDENT):

    The complainant namely Walaiti Ram has filed the present complaint under the Consumer Protection Act as amended up to date  (hereinafter referred as Act) against Star Health and Allied Insurance Company Limited, Bathinda and another. (hereinafter referred as opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that he was insured with opposite party No. 1 by way of Family Health Optima Policy for Rs. 10,00,000/- vide policy No. P/211217/ 01/2018/001670 which was renewed vide endorsement No. P/211217/01/ 2019/002985 for the period from 29.3.2019 to 28.3.2020 and premium of Rs. 25,158/- was charged from the complainant.

3. It is further alleged that the complainant met with an accident on 29.3.2019 and admitted in Dr. Pardeep Sharma Hospital and he was diagnosed to be having fracture femur. The doctor conducted various tests and after arranging implants conducted surgery on 30.3.2019. The complainant was discharged on 4.4.2019 and total expenditure of the treatment was Rs. 72,302/-. The intimation of claim was given to opposite party No. 1 and sales Manager of opposite party No. 1 collected the necessary papers from the complainant and assured that the claim will be paid in few days. The complainant was shocked to received a letter dated 10.6.2019 from the opposite party No. 1 vide which they repudiated the claim of the complainant on the ground that it is observed from the discharges card of the above hospital that the insured patient was admitted on 29.3.2019 and discharged on 4.4.2019 but the indoor case records are started on 30.3.2019 and submitted indoor case records are incomplete. Thus there is discrepancy in the submitted claim documents which amount to misrepresentation and as per condition No. 6 repudiate the claim of the complainant. 

4. It is further alleged that the complainant again vide letter dated 7.8.2019 requested the opposite party No. 1 that all papers issued by the doctor provided to the opposite party No. 2 so decision of repudiation be reconsidered but complainant has not received any reply from the opposite party No. 1. The act and conduct of the opposite party No. 1 is unfair trade practice and deficiency in service on their part. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite party may be directed to pay the claim of the complainant amounting to Rs. 72,302/- alongwith interest at the rate of 12% from the date of filing of claim till realization.  

2) To pay Rs. 50,000/- as compensation on account of mental agony and harassment.

3) To pay Rs. 11,000/- as litigation expenses.  

4) Any other relief this Forum deems fit. 

5. The opposite party No. 1 not appeared before this Forum despite service through RC AD on 6.11.2019 so the opposite party No. 1 was proceeded against exparte vide order dated 10.12.2019. 

6. Upon notice of complaint, opposite party No. 2 filed written reply taking preliminary objections on the grounds that the present complaint is bad for non joinder and mis joinder of necessary parties. 

7. On merits, the opposite party No. 2 admitted that complainant was insured with opposite party No. 1 and he met with an accident on 29.3.2019 and immediately take to the answering opposite party hospital. It is also admitted that surgery on the complainant was conducted on 30.3.2019 and he was discharged from the hospital on 4.4.2019 and expenditure of the treatment was Rs. 72,302/-. It is further submitted that the answering opposite party maintained the record carefully and there is no deficiency on his part. It is also submitted by the opposite party No. 1 that he supplied the requisite documents to the opposite party No. 1. Lastly, he prayed for the dismissal of the present complaint against the answering opposite party. 

8. In support of his complaint, the complainant tendered into evidence copy of insurance policy Ex.C-1, copy of discharge card Ex.C-2, copy of treatment chart Ex.C-3, copy of medical record Ex.C-4, copy of claim processing sheet Ex.C-5, copy of certificate of letter dated 10.6.2019 of repudiation of claim Ex.C-6, copy of letter dated 7.8.2019 Ex.C-7, copies of bills Ex.C-8 to Ex.C-18, affidavit of complainant Ex.C-19 and closed the evidence.

9. To rebut the case of the complainant, the opposite party No. 2 tendered in evidence affidavit of Dr. Karan Sharma Ex.OP-2/1, copy of OPD slip Ex.OP-2/2, copy of report of lab Ex.OP-2/3, copy of intake and output of complainant Ex.OP-2/4, copy of treatment chart Ex.OP-2/5, copy of consent form Ex.OP-2/6 and closed the evidence.

10. We have heard the learned counsel for the parties and have gone through the record. Written arguments also filed by the complainant and opposite party No. 2.

11. It is admitted fact between the complainant and the opposite party No. 2 that complainant was insured with opposite party No. 1 vide policy Ex.C-1 for sum assured of Rs. 10,00,000/- from 29.3.2019 to 28.3.2020. It is also admitted by the opposite party No. 2 that complainant met with accident on 29.3.2019 and admission in his hospital on the same day and discharged on 4.4.2019 having expenditure of Rs. 72,302/- on his treatment. 

12. From copy of letter dated 10.6.2019 written by the opposite party No. 1 to the complainant it is proved on the file that the opposite party No. 1 repudiated the claim of the complainant only on the ground that it is observed from the discharge card of the hospital that the insured patient was admitted on 29.3.2019 and discharged on 4.4.2019 but the indoor case records are started on 30.3.2019 and submitted indoor case records are incomplete and there is discrepancy in the submitted claim documents which amounts to misrepresentation so as per condition No. 6 as there is misrepresentation in the claim so the same was repudiated. 

13. Dr. Karan Sharma Proprietor of opposite party No. 1 in his affidavit Ex.OP-2/1 duly deposed in para No. 1 of this affidavit that the complainant got admitted in his hospital on 29.3.2019 and discharged on 4.4.2019 and total expenditure of his treatment was Rs. 72,302/- which was paid by him to the hospital of the deponent. He also filed copy of OPD slip Ex.OP-2/2, copy of lab test report dated 29.3.2019 Ex.OP-2/3, copy of intake and output record Ex.OP-2/4 and copy of treatment chart Ex.OP-2/5 and these documents proved on the file beyond any doubt that the complainant was admitted in the hospital on 29.3.2019 and his record of treatment also started from 29.3.2019. Even his consent form Ex.OP-2/6 also signed on 29.3.2019. The complainant also filed copy of discharge card Ex.C-2, copy of treatment chart Ex.C-3, copy of OPD slip Ex.C-4, copies of bills Ex.C-10, Ex.C-12 and Ex.C-18 and copy of lab test report Ex.C-11 also proved on the file that complainant was admitted in the hospital on 29.3.2019 and record of his treatment also started from 29.3.2019. In this way, the opposite party No. 1 repudiated the claim of the complainant on false and baseless ground. The opposite party No. 1 further not appeared before this Forum to rebut the claim of the complainant and to prove the ground vide which they repudiated the claim of the complainant, so the repudiation of the claim by the opposite party No. 1 on false and baseless ground is clear cut deficiency in service and unfair trade practice on the part of the opposite party No. 1. 

14. The Hon'ble Punjab and Haryana High Court at Chandigarh in case titled New India Assurance Company Limited Versus Smt. Usha Yadav and others 2008(3) RCR (Civil) Page-111 held as under.-

“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs. 5,000/- for luxury litigation being rich.”

This citation is also fully applicable to the facts of present case as in the present matter also the opposite party No. 1 earned premium of Rs. 25,158/- from the complainant but at the time when complainant lodged insurance claim then opposite party No. 1 repudiated the claim of the complainant on baseless ground, so the opposite party No. 1 is liable to pay the claim of the complainant. Further, as in the present case also insurance company repudiated the claim of the complainant unnecessarily without any strong grounds despite his repeated requests which is clear cut deficiency in service and unfair trade practice on their part. 

15. In view of the above discussion and citation of the Hon'ble Punjab and Haryana High Court at Chandigarh, present complaint is allowed against the opposite party No. 1. Accordingly, the opposite party  No. 1 is directed to pay Rs. 72,302/- to the complainant which was expended by him on his treatment vide bills Ex.C-8 to Ex.C-18, alongwith interest at the rate of 6% per annum from the date of filing of the present complaint till actual realization. The opposite party No. 1 is also directed to pay Rs. 3,000/- to the complainant as consolidated amount of compensation on account of mental tension, harassment and litigation expenses. The opposite party No. 1 is also directed to deposit Rs. 3,000/- as costs in the Consumer Legal Aid Account maintained by this Forum. Compliance of this order be made within the period of 30 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 FORUM:

  28h Day of January 2020

 

 

            (Kuljit Singh)

            President

 

            (Tejinder Singh Bhangu)

Member