BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAITHAL.
Complaint Case No.6 of 2019.
Date of institution: 04.01.2019.
Date of decision:11.02.2022.
Devi Dutt son of Sh. Ram Pal, resident of VPO Ramthali Kharkan, Tehsil Guhla, District Kaithal.
…Complainant.
Versus
- Star Health and Allied Insurance Company Limited, SCO No.70, 2nd floor, Opp. Tata Indico, New Leela Bhawan, Patiala, Punjab-147001 through its Branch Manager.
- Jai Chand Rai, Agent, Star Health and Allied Insurance Company Limited, Telephone Exchange Road, Cheeka, Tehsil Guhla, District Kaithal, Phone-9416655933.
….Respondents.
CORAM: DR. NEELIMA SHANGLA, PRESIDENT.
SMT. SUMAN RANA, MEMBER.
SH. RAJBIR SINGH, MEMBER.
Present: Sh. Surender Chugh, Advocate, for the complainant.
Sh. Ranvir Parashar, Advocate for the respondents.
ORDER
DR. NEELIMA SHANGLA, PRESIDENT
Devi Dutt-Complainant has filed this complaint under Section 12 of Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the respondents.
In nutshell, the facts of present case are that the complainant took Family Health Optima Insurance Plan bearing policy no.P/211115/01/2018/003389 insuring the complainant and his family with basic floater sum insured of Rs.5,00,000/- valid for the period w.e.f. 31.03.2018 to 30.03.2019 from the respondent No.1 through the respondent No.2. It is alleged that the child of complainant namely Lalit Sharma suffered with high fever with chills and rigors, poor appetite, throat pain and loose stools in the month of November, 2018 and admitted in Columbia Asia Hospital, Patiala on 29.11.2018 and remained admitted till 03.12.2018 and the respondent No.1 paid all the bills to the said hospital. The condition of Lalit Sharma did not improve in Asia Columbia Hospital, Patiala, hence, he was shifted in Dayanand Medical College & Hospital, Managing Society Ludhiana on 03.12.2018 vide admission no.2018080533 and he was discharged from the said hospital on 14.12.2018 but the respondent No.1 refused to pay the bills of the said hospital. The complainant was forced to pay Rs.1,53,274/- i.e. hospital bill of Rs.1,50,069/- and Rs.3205/- of pharmacy bills which was the duty of respondent No.1 and the complainant is entitled for the aforesaid amount alongwith interest. The complainant served legal notice to the respondents through his counsel and asked to pay the amount but the respondents informed that the claim of complainant has been rejected. So, it is a clear cut case of deficiency in service on the part of respondents and prayed for acceptance of complaint. Hence, this complaint.
2. Upon notice, the respondents appeared before this commission and contested the complaint by filing their written version raising preliminary objections with regard to locus-standi; maintainability; cause of action; that as per record submitted by the complainant the insured Lalit Sharma was treated by the doctors in Dayanand Medical College and Hospital, Ludhiana, hence, no part of cause of action has arisen at Kaithal; that the complainant has concealed the true and material facts from this Commission. The true facts are that the complainant purchased the policy in question valid for the period 31.03.2018 to 30.03.2019. It is submitted that as per record, the insured Lalit Sharma was admitted in the hospital on 03.12.2018 and was provisionally diagnosed for SYSTEM JUVENILE IDIOPATHIC ARTHRITIS (which is a 2 year exclusion)/FEVER and accordingly, the claim of complainant was approved for Rs.15,000/- on 04.12.2018 for the aforesaid treatment. The insured did not submit the claim for reimbursement alongwith the bills to process the claim. It is submitted that as per the condition No.3, the insured should submit the claim for reimbursement of medical expenses alongwith the documents i.e. claim form duly completed and signed, discharge summary, main hospital bill with break-up, investigation reports with X-ray film, MRI, USG, if any, medical bills/payment receipt with prescription and indoor case papers but the complainant did not submit the above-said documents and thus, there is no question of repudiation of such claim. There is no deficiency in service on the part of respondents. On merits, the objections raised in the preliminary objections are reiterated and so, prayed for dismissal of complaint.
3. The complainant tendered into evidence affidavit Ex.CW1/A and documents Annexure-C1 to Annexure-C17 and thereafter, closed the evidence.
4. On the other hand, the respondents tendered into evidence affidavit Ex.RW1/A and documents Annexure-R1 to Annexure-R13 and thereafter, closed the evidence.
5. We have heard the learned Counsel for both the parties and perused the record carefully.
6. Sh. Surender Chugh, Adv. for the complainant has stated that the complainant had taken Family Health Optima Insurance Plan bearing policy no.P/211115/01/2018/003389 insuring the complainant and his family with basic floater sum insured of Rs.5,00,000/- valid for the period w.e.f. 31.03.2018 to 30.03.2019 from the respondent No.1 through the respondent No.2. It has been further argued that the child of complainant namely Lalit Sharma suffered with high fever with chills and rigors, poor appetite, throat pain and loose stools in the month of November, 2018 and admitted in Columbia Asia Hospital, Patiala on 29.11.2018 and remained admitted till 03.12.2018. Respondent No.1-insurance company paid the bills of Rs.15,000/- (Annexure-C1) to the hospital Asia Columbia, Patiala through cashless policy but the health of Lalit Sharma was not recovered. Hence, he was referred to Dayanand Medical College & Hospital, Ludhiana on 03.12.2018 and remained admitted till 14.12.2018 and the bill amount of Rs.1,53,274/- was paid by the complainant.
7. Respondents raised the objection that Lalit Sharma was suffering from ARTHRITIS and he was treated for JUVENILE IDIOPATHIC ARTHRITIS which was not mentioned in his application form for seeking cashless insurance.
Rebutting his arguments, Sh. Surender Chugh, Adv. has stated that nowhere in the hospital of treatment and in the discharge summary, it has been mentioned that Lalit Sharma was given any medical treatment for ARTHRITIS. On the pathologic reports, nowhere mentioned regarding the disease ARTHRITIS. Meaning thereby, Lalit Sharma was treated for high fever with chills and rigors, poor appetite, throat pain and loose stools etc. In the medical discharge history and treatment history, there is not a single whisper that Lalit Sharma was treated for JUVENILE IDIOPATHIC ARTHRITIS.
Sh. Surender Chugh, Adv. for the complainant has stated that in order to avoid the payment of medical bill of Dayanand Medical College & Hospital, Ludhiana, the respondents have procured a bogus certificate from the Registrar, Dayanand Medical College & Hospital, Ludhiana in which one line is written “c/o SYSTEM JUVENILE IDIOPATHIC ARTHRITIS” but nowhere in the medical treatment or discharge history, the disease “SYSTEM JUVENILE IDIOPATHIC ARTHRITIS” is mentioned.
8. Thus, as a sequel of our aforesaid discussion, it is not proved on record that Lalit Sharma was suffering from the disease SYSTEM JUVENILE IDIOPATHIC ARTHRITIS rather he was treated for high fever with chills and rigors, poor appetite, throat pain and loose stools in Dayanand Medical College & Hospital, Ludhiana. Hence, this complaint is accepted with cost. Respondents are hereby directed to pay the amount of Rs.1,53,274/- i.e. hospital bills alongwith interest @ 6% p.a. from the date of payment till its realization within two months. The cost is assessed as Rs.11,000/- which will be paid by the respondents to the complainant. A copy of this order be sent to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
Dt.:11.02.2022.
(Dr. Neelima Shangla)
President.
(Rajbir Singh), (Suman Rana),
Member. Member.
Typed by: Sanjay Kumar, S.G.