BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 215 of 2018
Date of Institution : 21.08.2018
Date of Decision : 11.06.2019
Parveen Kumar aged 47 years son of Shri Krishan Kumar resident of House No.4, IInd Additional Mandi, Sirsa District Sirsa (Haryana)
……Complainant.
Versus.
- Star Health & Allied Insurance Company Ltd. Branch Office: Ground Floor, Opp. Shakti Motors, Near IDBI Bank, Sirsa, Tehsil & District Sirsa, through its Branch Manager.
- Star Health and Allied Insurance Company Limited Regd. Office: 1, New Tank Street, Valluyer Kottam High Road, Numgambakkam, Chennai-600034, through its 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. JBL Garg, 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 Family Health Optima Insurance Plan for himself, his wife Isha, Aarju daughter, Nancy daughter and Jatin Bansal son, vide policy No.P/2111119/01/2015/003252 for the period w.e.f. 21.03.2015 to 20.03.2016 with basic floater sum assured of Rs.5 lakhs and paid premium of Rs.13343/-. The policy was got renewed from 20.03.2010 to 20.03.2017, 21.03.2017 to 20.03.2018 and now from 21.03.2018 to 20.03.2019 and present policy bears No.P/21111/21/01/2018/004149. That the complainant fell ill in May, 2017 and was taken to Sir Ganga Ram Hospital where he was hospitalized and treated and spent Rs.2,24,587/- on his treatment. The complainant lodged claim with Ops and also deposited all the requisite documents besides completing all the formalities but the Ops have not settled the claim. He got served legal notice upon the Ops but to no effect. The act and conduct of the Ops clearly amounts to deficiency in service on their part. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement in which, it has been submitted that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. The complainant had submitted three claims vide three hospitalization vide claim No.CLI/2018/211121/0099875, CLI/2018/211121/0117889 and CLI/2018/211121/0230466 in the 3rd year of policy. The Ops had called for documents vide letters dated 17.08.2017 and even the complainant was requested number of times to submit the mandatory documents vide letters 01.09.2017, 16.09.2017 & 01.10.2017 but he had not submitted the same, therefore, the claim was closed vide letter dated 01.10.2017 and other claim was also closed on the same ground vide letter dated 19.11.2017. The repudiation has been made as per the terms and conditions of the policy as the complainant has failed to furnish the necessary documents to process the claim. Other pleas made in the complaint have been controverted and prayer for dismissal of the complaint has 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.CW1/A wherein he has reiterated all the averments made in his complaint. The complainant has also placed on record documents such as policy schedule Ex.C1, proposal form Ex.C2, policy schedule Ex.C3, Ex.C4, welcome letter for renewal of policy Ex.C5, policy schedule Ex.C6, treatment summary and bills issued by Sir Ganga Ram Hospital Ex.C7 to Ex.C23, legal notice Ex.C24, postal receipts Ex.C25 and Ex.C26 whereas the opposite parties have furnished affidavit of Sh. Rajiv Jain, Chief Manager as Ex.RW1 in which he has reiterated the averments of the written statement. The OPs have also furnished copies of documents such as preauthorization letter Ex.R1, policy schedule Ex.R2 to Ex.R5, Claim form Ex.R6 & Ex. C7, proposal form Ex.R8, terms and conditions Ex.R9 and reimbursement of medical claim Ex.R10.
6. Admittedly, the complainant had purchased medical claim policy from the Ops namely Family Health Optima Insurance Plan for himself, his wife Isha, Aarju daughter, Nancy daughter and Jatin Bansal son, vide policy No.P/2111119/01/2015/003252 for the period w.e.f. 21.03.2015 to 20.03.2016 with basic floater sum assured of Rs.5 lakhs and paid premium of Rs.13343/-. The policy was got renewed from 20.03.2010 to 20.03.2017, 21.03.2017 to 20.03.2018 and now from 21.03.2018 to 20.03.2019 and present policy bears No.P/b21111/21/01 /2018/004149. As per complainant, he fell ill in May, 2017 and was taken to Sir Ganga Ram Hospital where he was hospitalized and treated and spent Rs.2,24,587/- on his treatment. The claim was lodged with the Ops but the same was decided by the Ops despite legal serving of legal notice for the settlement of the claim. The perusal of the written statment of the Ops reveals that they have taken specific plea that the terms and conditions of the insurance policy were explained to the complainant. The insured had submitted three claims vide three hospitalization vide claim No.CLI/2018/211121/0099875, CLI/2018/211121/0117889 and CLI/2018/ 211121/0230466 in the 3rd year of policy.
1.Claim No.CLI/2018/211121/0099875:
The complainant/insured was admitted on 25.05.2017 at Sir Ganga Ram Hospital- New Delhi and submitted claim for Rs.1,01,423, records for reimbursement of medical expenses towards the treatment of right mid ureteric stone with proximal hydroureteronephrosis, left upper ureteric stricture and status post left Rirs. On scrutiny of the claim records, it is observed that:
As per discharge summary dated 03.06.2015 at RG stone and super specialty hospital, the insured patient was treated with left Renal & Upper Ureteric Calculi with DM and HTN with HbsAg positive (Old treated).
Thus, the respondent has called for the following documents vide letters dated 17.08.2017 which are mandatory to process the claim.
First consultation paper in which HbsAg was diagnosed and submit all past treatment taken details alongwith investigation report for the same.
Letter from treating doctor stating duration of DM and HTN alongwith consultation reports.
The answering respondent had requested number of times but the insured have not furnished the required documents and details even after repeated reminders dated 01.09.2017, 16.09.2017 & 01.10.2017.
As per condition No.4 of the policy, the insured person has to submit all the required documents and details called for by insurance company. Thus having no option, the claim was closed vid our leter dated 01.10.2017.
Claim No.CLI/2018/211121/0117889:
The insured/complainant was admitted on 06.06.2017 at Sir Ganga Ram Hospital- New Delhi and submitted claims records for reimbursement of medical expenses for Rs.36410/- and discharge on the same day towards the treatment of FUC B/L Ureteric Calculi. On scrutiny of the claim records, it is observed that the following documents are necessary to process the claim:
Discharge summary for the admission dated 09.08.2017 of Sir Ganga Ram Hospital.
Treatment undergone for Hepatitis B (Positive) medications taken from when the patient was diagnosed alongwith the relevant documents like investigations report and prescription/consultation papers for the same.
Hence, the answering respondent has called for the above documents vide letters dated 05.10.2017 which are mandatory to process the claim.
That answering respondents note that the insured have not furnished the required documents and details even after repeated reminders dated 20.10.2017, 04.11.2017.
Thus, having no option the claim was closed vide our letter dated 19.11.2017.
7. Due to non providing of required documents, the Ops had closed the claim vide letter dated 01.09.2017 , 01.10.2017 and 19.11.2017. The perusal of the evidence of the Ops reveals that they have tendered in evidence Ex.R1, the preauthorization requests form and the leter dated 09.08.2017 Ex.R1, the queries of pre-authorization by which the complainant was called upon to submit the discharge summary of RG stone hospital on 03.06.2015 patient is k/c/ohbsag positive treated, dm,htpertension, kindly send consultations, treatment details, discharge summary. Whereas the Ops have placed on record the report of RG stone super specialty hospital and also placed on record the prescription slips and treatment given by RG Stone Hospital, meaning thereby that this record was already in their possession. The reports of Sir Ganga Ram Hospital are also placed on record. So, it will be in the fitness of things, if the present complaint is allowed and the direction is to the Ops to re-open the claim file and settle and pay the claim to the complainant.
8. In view of the above discussion, we hereby allow the present complaint with a direction to the Ops to re-open the claim file and thereafter to settle and pay the claim of the complainant as per terms and conditions of the policy within 45 days of the receipt of the copy of this order. The Ops are further directed to pay Rs.3,000/- as compensation on account of harassment and Rs.2,000/- as litigation expenses to the complainant. A copy of this order be sent to both the parties free of costs. File be consigned to the record room.
Pronounced in open Forum. President,
Dated:11.06.2019. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member
DCDRF, Sirsa DCDRF, Sirsa
