BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 182 of 2018
Date of Institution : 06.06.2018
Date of Decision : 09.04.2019
Deepak Gupta aged 36 years son of Onkar Mal Gupta, resident of Behind Talwar Nursing Home, Court Colony, Hisar Road, Sirsa District Sirsa.
……Complainant.
Versus
- Star Health & Allied Insurance Co. Ltd., Ground Floor Rathore Towers, Near Hotel Mehal, Dabwali Road, Sirsa District Sirsa through its Branch Manager.
- Star Health & Allied Insurance Co.Ltd. No.15, Sri Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai-600014, through its General Manager/authorized signatory.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA………………. ……PRESIDENT.
SH. ISSAM SINGH SAGWAL ………MEMBER.
MRS. SUKHDEEP KAUR……………..MEMBER.
Present: Sh. P.K.Berwal, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
The case of the complainant, in brief, is that the complainant purchased a policy No.P211121/01/2018/001515, for himself, his wife Vicky Gupta and daughter Richa Gupta for a sum insured of Rs.3,00,000/- vide receipt No.1379001876 dated 12.09.2017 and paid premium of Rs.10059/- vide receipt No.1379001876 dated 12.09.2017. The policy was having validity from 14.09.2017 to 13.09.2018. On 27.10.2017, daughter of the complainant fell ill and was admitted in Janta Maternity and General Hospital, Sirsa, where the doctor after examination found that she was suffering from Brochial Asthma/APD/AC Gastritis/URTI. She remained under treatment upto 31.10.2017 and the complainant had spent Rs.12,239/- on the hospitalization. He lodged claim with Ops vide application No.CLI/2018/201121/0400256 and also supplied all the requisite documents but the Ops have repudiated the claim vide letter dated 29.12.2017 on the ground that It is observed from the submitted medical records that the insured patient is aferbrile and vitals are stable; all the investigations report are within normal limits. Our medical team is of the opinion that the insured patient could have been treated as an outpatient and hospitalization is not warranted. It has been further averred that the Ops have wrongly and illegally repudiated the claim despite the fact that his daughter was got admitted in the hospital as per advice of the doctor. The complainant got served legal notice upon the Ops but to no avail. The act and conduct of the Ops clearly amounts to deficiency in service and unfair trade practice on their part. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement taking certain preliminary objections. It is submitted that true facts of the case are that the insured availed Family Health Optima Insurance Policy vide policy No.P/211121/01/2018/001515 for the period 14.09.2017 to 13.09.2018 covering Deepak Gupta-self, Mrs.Vicky Gupta- spouse and Ms.Richa Gupta, dependent children, for the sum insured of Rs.3,00,000/-. The insured got admitted in Janta Maternity & General Hospital, Musahab Wala on 27.10.2017 and remained admitted there till 30.10.2017 and also submitted claim for Rs.11,439/- for the treatment of Brochial Asthma/APD/AC Gastritis/ URTI. It has been further submitted that the insured patient is afebrile and vitals are stable; all the investigations reports are within normal limits. Thus, the insured patient could have been treated as an outpatient. As per Exclusion No.19 of the policy, the charges incurred on diagnostics that are not consistent with the treatment for which, the insured is admitted in the hospital/nursing home. Admission primarily for diagnostic purpose with no positive existence of sickness/disease/ailment/injury and no further treatment is indicated. It has been further submitted that neither the complainant has locus standi and cause of action to file the present complaint nor he has filed the present complaint with clean hands. The complainant does not fall within the ambit of consumer and there is no deficiency in service and unfair trade practice on the part of Ops. Other contentions have been controverted and prayer for dismissal of the complaint has been been made.
3. Thereafter, both the parties have led their respective evidence.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. The complainant in order to prove his case has furnished his affidavit Ex.C1 wherein he has reiterated all the averments made in his complaint. The complainant has also placed on record copies of documents such as copy of policy Ex.C2, repudiation letter Ex.C3, discharge card Ex.C4, indoor patient card Ex.C5, treatment summary Ex.C6, Ex.C7, bills of hospital, path labs, medicines Ex.C8 to Ex.C17, Ex.C17A, report Ex.C18, legal notices Ex.C19, Ex.C20, postal receipts Ex.C20A, Ex.C21, treatment summary Ex.C22, Ex.C23, advance receipt Ex.C24, insurance plan Ex.C25, prescription slip Ex.C26, legal notices Ex.C27, Ex.C29 and postal receipts Ex.C28 and Ex.C30. On the other hand, the Ops have tendered affidavit of Sh.Rajiv Jain, Ex.RW1 wherein he has reiterated the facts as mentioned in the reply. The Ops have also tendered customer information sheet/terms and condition Ex.R1, thanks letter on renewal of policy issued to the complainant by the Ops Ex.R2, policy schedule Ex.R3, schedule Ex.R4, Ex.R5, proposal form Ex.R6, Ex.R7, repudiation letter Ex.R8, claim form Part A Ex.R9 and treatment summary Ex.R10.
6. Admittedly, the complainant has purchased a policy bearing No.P/211121/01/2018/001515 vide receipt No.1379001876 dated 12.09.2017 and paid Rs.10059/- as insurance premium to the Ops, for the period from 14.09.2017 to 13.09.2018, which was covering complainant, his wife Vicky Gupta and his daughter Richa Gupta. On 27.10.2017, the daughter of the complainant namely Richa Gupta suddenly suffered from serious illness and due to this, she was admitted in Janta Maternity and General Hospital, Sirsa where the doctor examined her and found that she is suffering from Bronchial Asthma/APD/AC Gastritis/URTI. The complainant had lodged the claim and also submitted the necessary documents with Ops, but however, the claim of the complainant was repudiated by the Ops vide letter dated 29.12.2017 on the ground that It is observed from the submitted medical records that the insured patient is afebrile and vitals are stable; all the investigations reports are within normal limits. Our medical team is of the opinion that the insured patient could have been treated as an outpatient and hospitalization is not warranted.
7. The perusal of the evidence of the Ops reveals that the Ops have only furnished the affidavit of Sh.Rajiv Jain, Chief Manager of the Ops/insurance company, who has deposed in terms of pleas taken in the written statement but he has not uttered a single word that how he found the opinion that no hospitalization was required for the insured Richa Gupta. The Ops have also neither placed on file any record of the TPA, nor any opinion of the expert doctor, who examined the reports of insured. It was need of the patient, who was suffering at the time when she got admission in the hospital and she remained there for such a period and it was not the observer who has to observe that whether any admission is required or not. Since, the Ops have failed to place on record any opinion of the expert nor has furnished affidavit of any such expert, who has examined and investigated the reports of the insured Richa Gupta, on the basis of which she had been given the treatment by the doctor, therefore, the pleas of the Ops appears to be devoid of merit and the Ops have arbitrarily and illegally rejected the claim of the complainant.
8. In view of the above discussion, we hereby allow the present complaint with a direction to the Ops to settle and pay the claim, in accordance with law, within a period of 30 days from the date of receipt of the copy of this order. The Ops are further directed to pay interest @ 7 % per annum from the date of lodging the claim till its realization. The Ops are further directed to pay Rs.3,000/- to the complainant as composite compensation for harassment and litigation expenses. A copy of this order be sent to both the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:09.04.2019. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member
DCDRF, Sirsa DCDRF, Sirsa
