Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 457.
Instituted on : 15.10.2020.
Decided on : 03.01.2022.
Anoop Singh age 49 years, son of Sh. Om Parkash resident of Dalyan Pana village Dighal Tehsil Beri District Jhajjar.
..………..Complainant.
Vs.
- Star Health and Allied Insurance Co. Ltd., Ashoka Plaza, 3rd Floor, Delhi Road, Rohtak through its Branch Head.
- Star Health & Allied Insurance Company Limited, Regd. & Corporate Office: 1 New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034 through its Manager/Incharge.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR.TRIPTI PANNU, MEMBER.
Present: Sh.M.K.Munjal, Advocate for the complainant.
Sh. Gulshan chawla, Advocate for opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case that complainant had purchased Family health Optima Insurance-2017 policy no. P/211118/01/2021/003578 for the period from 21.07.2020 to 20077.2021. The complainant, his wife Monika and daughter Bhavya were covered under the said policy. The daughter of complainant suffered left shoulder injury on 02.08.2020 due to hitting by a cow and she was taken to Noble Heart & Super Speciality Hospital Rohtak on 07.08.2020 and after that she was got admitted in Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute on 27.08.2020 where she was operated upon and was discharged on 30.08.2020. An amount of Rs.285570/- was spent by the complainant on the treatment of his daughter. It is submitted that the cashless facility was denied to the complainant and as such the amount was paid by the complainant from his own pocket. The complainant submitted all the documents and bills to the opposite party for release of amount of claim but the opposite parties have not paid the amount of claim till today. Complainant made several requests to make the payment of amount of claim but opposite party has illegally withheld the claim amount of the complainant and rejected the same on or about 30.08.2020. The act of opposite party is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite parties may kindly be directed to pay the claim amount of Rs.285570/- alongwith interest, compensation and litigation expenses to the complainant as explained in relief clause.
2. On notice opposite parties appeared and filed their written reply submitting therein that complainant opted for Family Health Optima Insurance Plan and the policy was issued to the complainant accordingly. The daughter of complainant namely Bhavya on getting hospitalized on 29.08.2020 in Kokilaben Dhirubhai Ambani Hospital Mumbai raised a pre-authorization request on 29.08.2020 for availing cashless facility for the treatment of BANKARTS LESION LEFT SHOULDER and the same was lodged vide claim no.CL1/2020/211118/0267815. On scrutiny of documents it was observed that the insured patient-Bhavya was admitted in the hospital for treatment during the first 30 days from the date of commencement of the policy. As per consultation report dated 29.08.2020 from Dr. Dinshaw Pardiwala of Kokilaben Dhirubhai Ambani Hospital, Mumbai, that injury hit by bull 25 days back(As per para no.2 of the complaint, insured suffered injury on 02.08.2020) which is within 30 days from the commencement of the first policy. As per waiting period clause no.3.(i) of the policy, the claim is not admissible. It is further submitted that Pre-authorization or cashless treatment is the facility given by the applicant and does not amount to denial or refusal of the claim of the complainant. As per the policy conditions(5) denial of pre authorisation request is in no way construed as denial of treatment or denial coverage. The insured person can go ahead with the treatment, settle the Hospital bill and submit the claim for possible re-imbursement, which has not been done in present matter. That as on today, no claim alongwith original medical documents and bills have been submitted for settlement of claim on merits. Thus the complainant cannot comment upon the amount of expenses having being incurred on the treatment. Thus the complainant be directed to submit all the medical bills, Medical document, cash receipts from hospital, chemist, cash receipts from and reports for tests done, receipts from doctors, surgeons, anesthetist, certificate from attending doctor regarding the diagnosis, admission and discharge card and claim form for assessment of the claim on merits. The maximum quantum of liability under the terms of the policy will be ascertained on receipt of reimbursement documents. All the other contents of the complaint were stated to be wrong and denied and opposite parties prayed for dismissal of complaint with costs.
3. Both the parties led evidence in support of their case.
4. Ld. Counsel for the complainant in his evidence has tendered affidavits Ex.CW1/A, documents Ex.C1 to Ex.C39 and has closed his evidence on dated 01.07.2021. On the other hand, ld. Counsel for the opposite parties has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R9 and has closed his evidence on 23.07.2021.
5. We have heard ld. counsel for the parties and have gone through the material aspects of the case carefully.
6. In the present case, claim of the complainant has been repudiated by the opposite party on the ground that the insured patient-Bhavya was admitted in the hospital for treatment during the first 30 days from the date of commencement of the policy. As per consultation report dated 29.08.2020 from Dr. Dinshaw Pardiwala of Kokilaben Dhirubhai Ambani Hospital, Mumbai, that injury hit by bull 25 days back(As per para no.2 of the complaint, insured suffered injury on 02.08.2020) which is within 30 days from the commencement of the first policy. As per clause ‘waiting period’ no.3.(i) of the policy, the claim is not admissible. We have minutely perused the documents placed on record by both the parties. The complainant has placed on record a copy of policy Ex.C1. Ex.C2 is the letter issued by the insurance company to the complainant regarding the policy No. P/211118/01/2021/003578. Ex.C2 has 3 pages. On page no.2, the heading of the letter is :
Attached to and forming part of Policy No. P/211118/01/2021/003578
Sector Classification
Rural
We have also perused the policy placed on record by the insurance company as Ex.R3 , which is of 5 pages. On page no.2, the heading of the letter is:
Attached to and forming part of Policy No. P/211118/01/2021/003578
Sector Classification
Rural
But minute perusal of this document shows that the waiting period condition no.3(i) of the policy is mentioned in Ex.R3 but the same has not been mentioned in the document placed on record by the complainant upon page no.2 of policy letter Ex.C2. Meaning thereby a false and fabricated document has been prepared by the opposite party and less information has been provided to the complainant regarding the policy. Hence there is concealment of fact on the part of opposite party. We have again minutely perused the document Ex.R3, in which at page no.2, it is mentioned that: “Waiting periods- Clause 3(i) should read as follows and not as stated in the policy wordings “The company shall not be liable to make any payment under this policy if the hospitalization is directly or indirectly for any disease contracted by the insured person during the first 30 days from the commencement of this policy. However, if the hospitalization is for treatment of COVID 19, the waiting period is 15 days from the commencement date of this policy”. Perusal of this clause itself shows that this clause belongs to the disease suffered by the insured person within 30 days. But in the present case the insured was not hospitalized for any disease whereas she was hit by a bull and it was an accident. The insured was hospitalized due to injury of accident. Hence the alleged clause is not applicable on this case and the opposite parties are liable to pay the claim amount to the complainant. As per the complainant he had spent an amount of Rs.285570/- on the treatment of his daughter and to prove the same he has placed on record bill Ex.C9 to Ex.C16.
7. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite parties to pay Rs.285570/-(Rupees two lac eighty five thousand five hundred and seventy only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 15.10.2020 till its actual realization and shall also pay an amount of Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
03.01.2022.
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Nagender Singh Kadian, President
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Tripti Pannu, Member.
