Order by:

Sh.Amrinder Singh Sidhu, President

1.       Complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that on 26.02.2021, complainant No. 2 has taken the health insurance policy i.e. Star Comprehensive Insurance Policy bearing No. P/211222/01/2021/008218 from opposite party No.1, which covers complainants and their other family members. Complainant No. 2 is the policy holder of the said policy and complainant No.1 is beneficiary under the said policy. The complainant No.2 paid an amount of Rs.30,456/- for the period of 26.02.2021 to 25.02.2022. At the time of purchase of policy, the complainants disclosed all the facts to opposite parties regarding the health of the complainants and others. On 16.04.2021, the complainant No.1 suffered Noval Corona Virus (Covid-19) and has got admitted in Harbans Nursing & Maternity Hospital, Kot Ise Khan, Tehsil Dharamkot, District Moga where he was admitted w.e.f. 16.04.2021 to 27.04.2021 and Rs.1,96,709/- was incurred by the complainant for his treatment. Inspite of heaving a health policy with the opposite parties and inspite of filing claim the opposite parties have refused to make the payment to Harbans Nursing & Maternity Hospital, whereas all the documents were handed over by the complainant No. 2 to Harbans Nursing & Maternity Hospital regarding the insurance. When the complainant no.2 contacted the opposite party no.1, they told the complainant that due to some reason insurance company could not pay the claim of the complainants and assured that the insurance company will clear the claim after sometimes due to this, suddenly the complainants had to face the financial problem. Thereafter the complainant visited number of times in the office of the opposite party No. 1 and requested to make his genuine claim but all in vain. As per the terms and conditions of the policy, the opposite parties are liable to pay all the expenses, which was covered under the above said insurance policy but the opposite parties did not pay even a single penny to the complainants and refused to do the same. The complainants requested number of times to the opposite parties to admit their rightful claim and to pay the due amount as claimed above, but opposite party have failed to pay anything and to settle the other claim of the complainant. Complainants have also sent a legal notice to opposite parties, through their counsel, but the opposite parties did not reply to the same. Hence this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to the genuine claim of Rs.1,96,709/- alongwith interest @18% per annum till the date of payment on account of health policy.

b)      To pay an amount of Rs.5 Lacs as compensation on account of unfair trade practice, deficiency in service and harassment as well as mental agony.

c)       To pay an amount of Rs.2 Lacs to the complainant No. 1 as he is the beneficiary under the said policy and also Rs.21,000/- as litigation expenses, to the complainants.

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

2.       Opposite Parties appeared through counsel and contested the complaint by filing written version taking preliminary objections therein inter alia that the complaint being pre-mature, false, frivolous and without any cause of action is not maintainable. The insured was admitted and treated in an excluded, non covered and non empanelled hospital. Harbans Nursing & Maternity Hospital, Kot Ise Khan, District Moga is an excluder provider. The complainant has not come with clean hands. He has not disclosed the entire true facts. The complainant has also suppressed the material facts from this Commission as well as from the answering opposite party. No deficient services have been rendered to the complainant as alleged in the complaint. The complainant is estopped to file the present complaint by his own act and conduct. The complainant himself has not been cooperating with the answering opposite parties, as the complainant did not furnish the required information, record and documents etc. with the answering opposite party for the successful processing of the claim in question, inspite of repeated requests made by opposite and resultantly, the alleged claim file has been closed and the claim was rejected and repudiated, in the absence of required documents, as per terms and conditions of the insurance policy, which were explained to the complainant at the time of proposing policy and the same were served to the complainant along with policy schedule and it has been clearly mentioned in the policy schedule that "The Insurance under the policy is subject to Conditions, Clauses, Warranties, Exclusions, etc.". Further alleges that the Insurance policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the said policy. The complainant has accepted the policy agreeing and fully aware of such terms and conditions and had executed the proposal form. On merits, it is submitted that the present complaint pertains to insurance claim under Star Comprehensive Insurance Policy bearing No.P/211222/01/2021/008218 valid from 26.02.2021 to 25.02.2022 covering the Complainant no 2 self, and his wife Jaspal Kaur, and Dependant child Sukhamrit Singh complainant no.1 for a sum of Rs.5,00,000/-. However, it is submitted that 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 in case if any liability would arise against the answering Opposite Parties, then it would be subject to the terms and conditions of the insurance policy. As a matter of fact, the insured has preferred claim for reimbursement of medical expenses towards treatment of Covid-19. It has been observed from the submitted record that the insured patient was admitted and treated in an excluded non covered and non empanelled hospital or provider. And as per Exclusion clause No 11 the expenses incurred towards treatment in any hospital or by any medical practitioner or any other provider specifically excluded by the insurer and disclosed in its website/notified to the policy holders are not admissible. The reference may be made from the citations i.e. (1) Shri Virendra Kumar Kashyap vs Director ESIC Law finder Doc id 878325 and (2) Platinum Nursing Home vs Gurwinder Kaur 2016 (3)CPJ31. Moreover, it was requested by the Opposite Party Insurance company to the Insured to furnish the ABG analysis report and it was not submitted by the insured and in the absence of required information and documents the Opposite Party Company was unable to process the claim. As per Policy Condition No V (2) The insured has to submit all the required documents and details called for by the Insurer.  Further alleges that the submitted indoor case record and the vital chart for the date 16.04.2021 to 27.04.2021 from 10 a.m to 8 p.m is in stereotype manner and written in single hand writing. Thus, there is discrepancy in the record which amounts to misrepresentation of facts and as per policy terms and conditions, if there is any misrepresentation whether by the insured person or any other person acting on behalf of insured, the company will not be liable to make any payment in respect of any claim. Hence, in the above said circumstances with due application of mind, the claim was rejected and conveyed to the insured vide letter dated 09.10.2021. Thus, from the above said circumstances, it is crystal clear that the complainant himself has been careless and dis-interested in the processing and settlement of the alleged claim and did not furnish the details etc to the company. The answering Insurance Company is not at any default for the repudiation of the claim and no deficient services has been rendered as alleged by the complainant. Further as per the Final Bill, the amount claimed is Rs.1,96,709/- for 12 days. Excluding CT (Rs.3,500/-) and high end drug Remdesivir (Rs.28,800/-), the hospital has charged Rs.1,64,409/- for 12 days. However, as per the GIC guidelines, hospital rates per day for severe sickness for Non NABH hospital is Rs.8,000/- only, which is inclusive of consultation, nursing charges, room stay and meals, COVID testing, Monitoring & investigation- Biochem & Imaging, Physiotherapy, PPE, Drugs & Medical Consumables, BWM and other protective gear, bed side procedures and Exclusive of Interventional procedures, High end drugs like immunoglobulins, meropenem, etc, High end investigations like CT and MRI etc, dead body storage, treatment of any co morbid conditions. Further alleges that the insurance policy issued to the complainant under which the dispute has been raised is governed by limits of liability as per its clauses. Remaining facts mentioned in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove his case, complainants tendered in evidence affidavit of complainant no.2 Ex.C1 along with copies of documents Ex.C2 to Ex.C29.

4.       To rebut the evidence of complainant, Opposite Parties tendered in evidence affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1,2/A alongwith copies of documents Ex.OP1,2/1 to Ex.OP1,2/15.

5.       During the course of arguments, Ld. counsel for both the parties have mainly reiterated the same facts as narrated in the complaint as well as written reply. The case of the complainant is that on 26.02.2021, complainant No. 2 has taken the health insurance policy i.e. Star Comprehensive Insurance Policy bearing No. P/211222/01/2021/008218 from opposite party No.1, which covers complainants and their other family members. Complainant No. 2 is the policy holder of the said policy and complainant No.1 is beneficiary under the said policy. The complainant No.2 paid an amount of Rs.30,456/- for the period of 26.02.2021 to 25.02.2022. On 16.04.2021, the complainant No.1 suffered Noval Corona Virus (Covid-19) and has got admitted in Harbans Nursing & Maternity Hospital, Kot Ise Khan, Tehsil Dharamkot, District Moga where he was admitted w.e.f. 16.04.2021 to 27.04.2021 and Rs.1,96,709/- was incurred by the complainant for his treatment. Thereafter complainant lodged the claim with opposite parties, but the opposite parties rejected the claim of the complainant. Ld. counsel for the opposite parties repelled the aforesaid contention of ld. counsel for the complainant on the ground that the insured was admitted and treated in an excluded, non covered and non empanelled hospital. Harbans Nursing & Maternity Hospital, Kot Ise Khan, District Moga is an excluder provider. It has been observed from the submitted record that the insured patient was admitted and treated in an excluded non covered and non empanelled hospital or provider and as per Exclusion clause No 11 the expenses incurred towards treatment in any hospital or by any medical practitioner or any other provider specifically excluded by the insurer.

6.       It is not disputed that complainant No. 2 has taken the health insurance policy i.e. Star Comprehensive Insurance Policy bearing No. P/211222/01/2021/008218 from opposite party No.1, which covers complainants and their other family members. Complainant No. 2 is the policy holder of the said policy and complainant No.1 is beneficiary under the said policy. Complainant No.1 suffered Noval Corona Virus (Covid-19) and has got admitted in Harbans Nursing & Maternity Hospital, Kot Ise Khan, Tehsil Dharamkot, District Moga where he was admitted w.e.f. 16.04.2021 to 27.04.2021 and Rs.1,96,709/- was incurred  on the treatment is also not disputed. The main dispute between the parties is that complainant no.1 got treatment from non network / non listed hospital provided by the opposite party that’s why claim was denied. It is not the case of the Opposite Parties that the treating hospital from where the policy holder Sukhamrit Singh took treatment has charged more than the empanelled hospital.  Moreover , the rejection of claim on the ground that policy holder got the treatment from non listed hospitals is totally arbitrary. Sometime it is not possible for the policy holder to approach the listed hospitals due to any reasons.

7.       It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the Doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated. Specialty Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment. Can it be said that taking treatment in Specialty Hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. In the facts of the present case, it cannot be denied that Sukhamrit Singh policy holder was admitted in Harbans Nursing & Maternity Hospital, Kot Ise Khan, Tehsil Dharamkot, District Moga in emergency conditions due to Noval Corona Virus (Covid-19). Moreover, the law does not require that prior permission has to be taken in such situation where the survival of the person is the prime consideration. Once, it is established, the claim cannot be denied on technical grounds. Clearly, in the present case, by taking a very inhuman approach, the Opposite Parties have denied the grant of medical reimbursement to the Complainants and   forcing them to approach this District Commission. To support her version, the Complainant has relied upon the judgement of  Hon’ble Supreme Court of India in case titled  Shiva Kant Jha Vs. Union of India in Civil Writ Petition No. 694 of 2015, decided on 13.04.201. 

8.       The other plea taken by the opposite parties is that the complainant did not furnish the required information, record and documents etc. with the opposite parties for the successful processing of the claim in question, inspite of repeated requests made by opposite and resultantly, the alleged claim file has been closed and the claim was rejected and repudiated. The demands of aforesaid documents demanded by the Opposite Parties are merely a ground to repudiate the claim of the complainant. It is not very uncommon that the insurance companies would issue repeated advertisement in the newspaper and through electronic media, highlighting many financial and other benefits, inviting general public to go for insurance policies. However, whenever any claim, including most genuine claim is put by the insured for disbursement of the due amount most of the insurance companies would start finding fault with the insured on one pretext or the other, raising even the technical and totally unwarranted objections. That is how, this kind of approach adopted by the insurance companies, gives rise to wholly unwarranted and avoidable litigation.

9.       In view of the above discussion, we hold that the Opposite Party-Insurance Company have wrongly and illegally rejected the claim of the complainant.

10.     Now come to the quantum of amount claimed by complainants. The complainants have claimed the amount of Rs.1,96,709/-. However, vide Ex.OP1, 2/15 the Opposite Parties have approved Rs.1,85,006/- only. The details of the amount which was claimed by complainant and the amount approved by the Opposite Parties after deducting non-payable amount is mentioned in the table below:-

11.     In view of the aforesaid facts and circumstances of the case,  we partly allow the complaint of the Complainants and direct the Opposite Party-Insurance Company to make the payment of  Rs.1,85,006/- (Rupees One Lac Eighty Five Thousand Six only) to complainant as approved by them vide Ex.OP1, 2/15 with regard to the treatment taken by complainant no.1. The compliance of this order be made by the Opposite Parties within 60 days from the date of receipt of copy of this order, failing which the complainants shall be at liberty to get the order enforced through the indulgence of this District Consumer Commission.  Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced in Open Commission.