Chandigarh

DF-II

CC/359/2020

Anju Garg - Complainant(s)

Versus

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

Nitin Jain & G.S. Randhawa

17 Jun 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	359 of 2020
Date  of  Institution	:	20.08.2020
Date   of   Decision	:	17.06.2021

 

 

 

 

1]  Anju Garg wife of Sh.Rajiv Kumar,

2]  Rajiv Kumar son of Sh.Jai Bhagwan,

Both residents of House No.166, Sector 38-A, Chandigarh.

             …..Complainant

Versus

Star Health and Allied Insurance company Limited, having its Registered and Corporate Office at : #1, New Tank Street, Valluvar Kottam High Road, Nungambakkam Chennai 600034, Tamil Nadu & one of its Branch Office at : SCO 236, 2^nd Floor, Sector 20, Panchkula 134109 through its Managing Director

    ….. Opposite Party 

 

BEFORE:  SH.RAJAN DEWAN             PRESIDENT

         SH.B.M.SHARMA                     MEMBER 

                   SMT.PRITI MALHOTRA             MEMBER

                                                               

 

 

Argued by :-  Sh.Nitin Jain, Adv. for the complainant.

                 Sh.Sahil Abhi, Adv. for the OP

 

 

PER B.M.SHARMA, MEMBER

 

         Briefly stated, the complainants obtained Family Health Optima Insurance Plan from OP effective from 31.10.2018 to 30.10.2019 by paying premium of Rs.15,257/- (Ann.C-1).  The said policy was renewed further for another year effective from 31.10.2019 to 30.10.2020 having sum assured of Rs.3.75 lacs (Ann.C-2).  It is stated that during the currency of said policy, complainant No.1 Anju Garg had burnt her right shoulder while making tea from the flame of the gas on 14.6.2020.  She visited Emergency Ward of Max Super Speciality Hospital, Phase-6, Mohali, where she was given dressing.  It is averred that on 15.6.2020, the complainant NO.1 again visited the said Hospital, where the consulting Dr.Rishi Dhawan recommended surgery.  It is also averred that the said Hospital intimated the Insurer/OP about the necessity of performing a surgery upon complainant No.1-Anju Garg on account of burn injuries she had suffered in the incident and thereafter, the complainant No.2 received a message from OP on 15.6.2020 approving the cashless claim of Rs.50,000/- (Ann.C-3). Thereafter, the complainant No.1 remained admitted in the said from 17.6.2020 to 24.6.2020 and underwent surgery namely ‘Tangential Excision and Grafting’ (Ann.C-4). However, the OP though initially approved cashless claim, but subsequently vide communication dated 24.6.2020 (Ann.C-5) rejected the complete claim of the complainants and also withdrew earlier approval.  Ultimately, the complainants had to arrange the money and paid an amount of Rs.2,20,042/- to the said hospital for the said treatment till 1.7.2020 (Ann.C-6 to C-11). It is stated that apart from this, since the insurance policy covered post hospitalization bill for a period of 90 days, the complainants also incurred expenses under said period for follow-up treatment and dressing of the surgical wound to the tune of Rs.15,760/- (Ann.C-12 to C-19).  It is stated that the OP has not paid any amount to the complainant due under the claim.  It is also alleged that rejection of the claim by OP for treatment of burn injuries on the ground of non-disclosure of alleged seizure disorder is illegal and amounts to deficiency in service.  Hence, this compliant has been filed.

 

2]       The OP has filed reply and while admitting the factual matrix of the case about issuance of the policy in question and treatment taken by the complainant No.1 during policy period, stated that the complainant No.1 Mrs.Anju Garg was hospitalized at Max Hospital Mohali on 15.6.2020 for the treatment of burns (flame burn right shoulder) and said hospital on behalf of complainant No.1 raised a request for pre authorization for cashless treatment.  It is stated that as per submitted cashless document by the said hospital on behalf of complainant No.1, an amount of Rs.50,000/- was initially approved on 15.6.2020, but later on the said pre-authorization was withdrawn vide letter dated 24.6.2020 stating that as per the discharge summary (preliminary summary), the complainant No.1 is known case of hypothyroidism for 5 years and is on a regular medication and is also a known case seizure disorder and was on treatment for last 25 years (Ann.OP-4).  It is submitted that the complainant being a known case of seizure, failed to submit the medication details and past history and instead submitted a revised discharge summary in which the date from which she was under medication was removed. It is also submitted that the said documents are material documents and are essential and required by OP for further processing and as such the earlier authorization of Rs.50,000/- was withdrawn and the claim was denied and repudiated and communicated to treating hospital as well as complainants vide letter dated 24.6.2020.  It is pleaded that the complainant has not submitted any claim form along with bills for reimbursement to the OP.  It is pleaded that the complainant No.1 has suppressed & concealed material information about her health and treatment being taken by her prior to inception of policy and therefore, the claim was rightly repudiated. Denying rest of the allegations, the OP has prayed for dismissal of the complaint.

3]       Replication has also been filed by the complainants thereby reiterating the assertions as made in the complaint and controverting that of the reply filed by OP.

4]       Parties led evidence in support of their contention.

5]       We have heard the ld.Counsel for the parties and have gone through entire documents on record.

6]      The thorough perusal of documents placed on record, clearly shows that the Opposite Party has wrongly & unjustifiably repudiated the genuine claim of the complainant.

         It is farfetched an assumption that the accident of the patient/complainant No.1 can be attributed to the hypothyroidism, which has no relation whatsoever with the circumstances as detailed by the complainants in the complaint. The treatment taken by complainant No.1 for burn injuries has nothing to do with her alleged hypothyroidism ailment. Therefore, the repudiation of claim is without any justification, which amounts to gross deficiency in service on the part of Opposite Party causing harassment to her. 

7]       In the light of above observations, we are of the considered view that the deficiency in service is established on the part of Opposite Party. Hence, the present complaint deserves to succeed against the Opposite Party.  Accordingly, the complaint stands allowed with direction to Opposite Party to reimburse to the complainant No.1 an amount of Rs.2,20,042/- incurred by her on the treatment, along with interest @9% p.a. from the date of filing this complaint i.e. 20.8.2020 till realisation. The OP is also directed to pay to the complainant No.1 a compository amount of Rs.15,000/- which includes compensation for the harassment as well as litigation expenses.

         The above said order shall be complied with by the Opposite Party within a period of 30 days from the date of receipt of its copy, failing which it shall be liable to pay penal cost of Rs.10,000/- apart from the above relief. 

        The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced                                                             

17^th June, 2021                                                         sd/-

                                      (RAJAN DEWAN)

PRESIDENT

 

Sd/-

(PRITI MALHOTRA)

MEMBER

 

 

Sd/-

 (B.M.SHARMA)

MEMBER