Order by:

Smt.Priti Malhotra, President

1.           The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that complainant has purchased policy bearing no.P/211222/01/2021/005763 from Opposite Party No.1 which was valid from 06.12.2021 to 05.12.2022. During the said policy, unfortunately complainant suffered Stomach infection and admitted in Sham Nursing Home and Heart Centre, Railway Road, Moga on 11.07.2022 and was discharged on 14.07.2022. The complainant has to pay a sum of Rs.27800/- to the hospital and Rs.3079/- were spent on medicines. The complainant timely performed all the formalities relating to the claim and submitted all the documents required by the Opposite Parties, but despite that Opposite Parties have not paid the medical and other bills covered under the said policy of the complainant and rejected the claim of the complainant on the ground that the said hospital is an excluded provider hospital. Moreover, no information was given by the Opposite Parties that the said hospital has been excluded. At the time of filing of proposal form, the complainant it was assured that complainant get his treatment from any hospital. Due to the wrongful acts on the part of the Opposite Parties complainant suffered mental tension and agony. Opposite Parties were asked many time to admit the rightful claim, but they refused to do so. Hence this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay an amount of Rs.30,879/- alongwith interest thereon @ 2% per month.

b)      To pay an amount of R.50,000/- as compensation on account of mental tension, harassment and agony.

c)       To pay an amount of Rs.15000/- as litigation expenses.

d)      And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Parties on the ground that as per insurance policy terms and conditions and as per Exclusion Clause no.11, the Opposite Parties-insurance company is not liable to make payment under the policy in respect of the expenses incurred for the treatment at the hospital, which is an Excluded Provider Hospital. The present complaint pertains to insurance claim under Family Health Optima Insurance Plan Policy bearing no.P/211222/01/2022/007303 valid from 06.12.2021 to 05.12.2022 covering the complainant self and his spouse Priya Bansal and Prisha and Amber Bansal for a sum of Rs.5,00,000/-. The aforesaid insurance policy was issued to the insured by the answering Opposite Parties subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of the contract. Moreover, the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same were served to the complainant along with policy schedule. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Therefore it is submitted that in case if any liability would arise against the answering Opposite Party, then it would be subject to the terms and conditions of the insurance policy. Further alleged that the insured submitted the claim documents for the reimbursement of medical expenses towards the treatment of AGE (Acute Gastroenteritis) for hospitalization from 11.07.2022 to 14.07.2022 at Sham Nursing Home & Heart Centre, Moga. On scrutiny of claim documents the medical team of the answering Opposite Parties observed that the patient was admitted and treated in an excluded provider hospital. Based on these findings, the claim was repudiated vide letter dated 07.08.2022 as according to the Exclusion Clause no.11 of the policy the claim for the medical expenses incurred in the said excluded hospital are not payable. Moreover, the insured has intimated the claim on 02.08.2022 i.e. few days after the discharge and the excluded email was sent to the insured on the same day of intimation. Hence the claim was finally rejected and it was conveyed to insured. The instant complaint is neither maintainable in law nor on facts. No deficient services have been rendered by the answering Opposite Parties as alleged by the complainant. The claim in question was duly entertain, inquired into and after due application of mind the alleged claim has been repudiated on the basis of terms and conditions of insurance policy. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove his case, complainant tendered in evidence his affidavit Ex.CW1/A alongwith copies of documents Ex.C1 to Ex.C10.

4.       To rebut the evidence of the complainant, Opposite Parties tendered in evidence affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd.  Ex.OP/1, 2/A along with copies of documents to Ex.OP1, 2/1 to OP1, 2/12.

5.       We have heard the counsel for the complainant and gone through the documents placed on record.

6.       It is not disputed that complainant purchased policy bearing no.P/211222/01/2022/007303 for the period 06.12.2021 to 05.12.2022 from Opposite Parties. It is also not disputed that during the said policy, complainant suffered Stomach infection and admitted in Sham Nursing Home and Heart Centre, Railway Road, Moga on 11.07.2022 and was discharged on 14.07.2022. It is the grouse of the complainant that his genuine claim has wrongly been repudiated by the Opposite Parties, whereas the stand of the Opposite Parties are that complainant get his treatment from the hospital which is not empanelled and thus, claim is not payable as per policy terms and conditions. We are not convinced with the stand of Opposite Parties and are of the concerted view that the Opposite Parties have wrongly repudiated the genuine claim of the complainant for the reasons recorded hereunder. 

7.       At the first instance, it has been observed that the complainant never been supplied with the policy terms and conditions and also revealing the alleged list of empanelled hospital; as the record in this context has not been made part of the file for the reasons best known to the Opposite Parties. Thus, in the absence of any information qua the empanelled hospital under the policy in question it could not be expected from the insured to be aware to approach the alleged empanelled hospital, if any.

8.       Above all even if for the sake of arguments, it is presumed that the complainant was aware about the empanelled hospital even then, it is not expected from any insured/patient been encounted with the emergency will first look for any empanelled hospital to meet out the emergency. We are of the considered view that in the given circumstances the best option available with the patient/insured concerned is to land up to the nearest hospital to meet out the emergency. So, the rejection of the claim on this frivolous ground seems to be unjustified.

9.       For the opinion above, we are guided by the latest pronouncement of the Apex Court titled as Shiva Kant Jha Versus Union of India, Writ Petition (Civil) No.694 of 2015 decided on 13.08.2018. Further it is to add that it has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insurance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company.

Since, it is proved on record that no terms and conditions of the policy in question have been supplied to the complainant, thus the repudiation of the claim on the basis of unsupplied terms and conditions is unjustified.

10.     Vide instant complaint, the complainant has claimed the amount of Rs.30,879/- for his treatment and to prove this amount, he placed on record final bill Ex.C2, which shows that during the admission in the hospital he spent the amount of Rs.27,800/-, besides this he spent Rs.800/- vide Ex.C3, Rs.360/- vide bill Ex.C4, Rs.100/- vide bill Ex.C5, Rs.730/- vide bill Ex.C6, Rs.730/- vide bill Ex.C7, Rs.359 vide bill Ex.C8 totaling Rs.30,879/-. Hence we allow the same.

11.     From the discussion above, the repudiation made by the opposite party-Insurance Company regarding genuine claim of the complainant is unjustified and amounts to deficient services. Thus, we partly allow the complaint of the complaint and direct the Opposite Party to pay a sum of Rs.30,879/- (Rupees Thirty Thousand Eight Hundred Seventy Nine only) incurred by the complainant on his treatment. Opposite Party is also directed to pay compository amount of Rs.10,000/- (Rupees Ten Thousand only) towards compensation and litigation costs to the complainant. The compliance of this order be made by the Opposite Party within 45 days from the date of receipt of copy of this order, failing which, the Opposite Parties are further burdened with additional amount of Rs.20,000/- (Rupees Twenty Thousand only) to be paid to the complainant in addition to the awarded amount. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission