BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 257 of 2018
Date of Institution : 22.10.2018
Date of Decision : 29.04.2019
Vijay Kumar aged about 47 years son of Shri Krishan Lal resident of House No.10, Opp.Saraswati High School, Ellenabad, District Sirsa (Haryana).
……Complainant.
Versus
- Star Health and Allied Insurance Company Limited, Branch Office : Ground Floor, Opp Shakti Motors, Near IDBI Bank, Sirsa, Tehsil & District Sirsa, through its Branch Manager.
- Star Health and Allied Insurance Company Ltd. Regd. Office : 1, New Tank Street, Valluyer Kottam High Road Numgambakkam Channai-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. Subash Chander, proxy counsel for Sh.Amit Goyal,
Advocate for the complainant.
Sh. Mukesh Saini, Advocate for opposite parties.
ORDER
The case of the complainant, in brief, is that the complainant purchased a Family Health Optima Insurance Plan policy No.P/211121/ 01/2018/001575, for himself, his wife Laxmi, sons Karan and Gaurav and daughter Nisha and paid the premium to the tune of Rs.23541/- for the period from 16.09.2017 to 15.09.2018. The policy was cashless policy and being basic floater was for sum insured of Rs.4 lakh only. On 31.12.2017, the complainant fell down from the motor cycle and suffered injuries on his foot. He was taken to Sanjivini Hospital, Sirsa where a fracture was diagnosed. The doctor had affixed screw to the fractured bone and he remained admitted in the hospital as indoor patient from 31.12.2017 to 04.01.2018. The complainant had spent Rs.90,968/- on his treatment. The policy was cashless but the Ops did not pay the said amount to the hospital, as a result thereof, the complainant lodged claim with Ops besides supplying all the requisite documents, but the Ops vide letter dated 01.01.2018 repudiated the claim on the ground that Document reviewed. As per provided document, patient has peri prosthetic fracture, which is the complication of previous fixation. Moreover, previous fracture and implant in situ is an endorsed PED, which is payable after 48 months from the date of inception of policy. The complainant requested the Ops to pay the amount spent by the complainant on his treatment but to avail. The act and conduct of the Ops clearly amounts to deficiency in service on their part.
2. On notice Ops appeared and filed their joint reply wherein it has been submitted that the terms and conditions of the policy were explained to the complainant at the time of proposing of policy and the insurance under this policy was subject to conditions, clauses, warranties, exclusions etc. The complainant had intimated the claim was reported in the 3rd month of the policy and the insured had not submitted claim for reimbursement. The insurance company has righty repudiated the claim on 01.01.2018, as the insured patient was treated for the pre-existing disease. The cashless approval was given by the insurance company only on a preliminary evaluation of documents submitted by treating hospital/insured and it is subject to review upon the receipt of further details/documents from the insured at any time. It has been further submitted that the cashless settlement/facility was not a part of contractual obligation as per the terms and conditions of the insurance policy contract. As per condition No.4, the insured person shall obtain and furnish the company with all the original bills, receipts and other documents upon which a claim is based and shall also give the company such additional information and assistance as the company may require in dealing with the claim. The documents to be submitted in support of the claim are as under:
For Reimbursement claims:
1.Claim Form duly completed and signed.
2.Discharge summary.
3.Main Hospital Bill with break up
4.Investigation Reports with x-ray film, MRI, USG, if any
5.Medical bills/payment receipt with prescription.
6. Indoor case papers.
Until and unless the documents are submitted, the insurance company is unable to process the claim. The complainant has not approached to this Forum with claim hands. Other contentions 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 perusal of the case file reveals that in order to prove his case, the complainant 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, rejection of pre authorization for cashless treatment, Ex.C2, proposal form Ex.C3,application Ex.C4, Permanent account number Ex.C5, aadhar card Ex.C6, cheque Ex.C7, receipts, tests and medical summary Ex.C8 to Ex.C22. On the other hand, 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 proposal form Ex.R1, policy schedule Ex.R2, terms and conditions of policy Ex.R3, OPD slip Ex.R4, rejection of pre-authorization for cashless treatment Ex.R5, request for cashless hospitalization for medical insurance policy Ex.R6 and query on pre authorization Ex.R7.
6. It is admitted fact that the complainant has purchased a Family Health Optima Insurance Plan from Ops for the period from 16.09.2017 to 15.09.2018 and got insured himself, his wife Smt.Laxmi, sons Karan and Gaurav and daughter Nisha for the basic floater sum insured Rs.4 lakh and paid a sum of Rs.23,541/- as premium. This policy was a cashless policy. The complainant categorically disclosed to the Ops about his previous injury and duly incorporated the details of his previous injuries i.e. in right leg and both arms rod placed and that now he is fit and fine. As per allegations of the complainant, on 31.12.2017, he fell down from his motor cycle as it slipped down and he suffered injuries on his foot. He was taken to Sanjivini Hospital, Sirsa and remained admitted there as indoor patient from 31.12.2017 to 04.01.2018 and spent on his treatment from his own pocket, as the cashless request was declined by the Ops on 01.01.2018 on the ground that the patient has peri prosthetic fracture, which is the complication of previous fixation. Moreover, previous fracture and implant in situ is an endorsed PED, which is payable after 48 months from the date of inception of policy.
7. As per contention of the learned counsel for the Ops that the complainant has not lodged any claim with the Ops and the same has not been repudiated so far and only the cashless request of the complainant was declined on 01.01.2018. It was the legal obligation of the complainant to lodge the claim alongwith the requisite documents, which he has not submitted. Though, learned counsel for the complainant has contended that the complainant has lodged the claim with the Op well in time alongwith all the requisite documents, but however, the perusal of the evidence of both the parties reveals that they have not placed on file any letter of repudiation. Meaning thereby that, the claim has not been settled by the Ops till date.
8. In view of the above discussion, we hereby allow the present complaint with a direction to the complainant to lodge the claim alognwith the requisite documents such as 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 within 15 days from the date of receipt of copy of order and thereafter, the Ops are directed to settle and pay the claim of the complainant, as per terms and conditions of the policy, within a period of 30 days. The Ops are further directed to pay interest @ 7 % per annum over the settled amount, if the orders are not complied within stipulated period of 30 days after receiving the requisite documents from the complainant. 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:29.04.2019. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member
DCDRF, Sirsa DCDRF, Sirsa
