| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C.No.323 of 06.10.2022 Decided on : 10-07-2024 Balwinder Kaur W/o Sukhvinder Singh R/o H.No 20039/12, Jujhar Singh Nagar, Bathinda. ........Complainant Versus Star Health and Allied Insurance Company Limited, Registered Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakam, Chennai-600034, through its MD/Chairman/CMD/GM/Authorized Signatory. Star Health and Allied Insurance Company Limited, having its Branch Office at Sirki Bazaar, Bathinda, through Branch Manager/Authorized Signatory Bathinda.
.......Opposite parties Complaint under Section 35 of the Consumer Protection Act, 2019 QUORUM Smt.Priti Malhotra, President Smt.Sharda Attri, Member Present : For the complainant : Sh.Amit Gupta, Advocate. For opposite parties : Sh.Vinod Garg, Advocate. ORDER Priti Malhotra, President The complainant Balwinder Kaur (here-in-after referred to as complainant) has filed this complaint U/s 35 of Consumer Protection Act, 2019 (here-in after referred to as 'Act') before this Commission against Star Health and Allied Insurance Company Limited and another (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that on the assurance of opposite party No.2, she purchased one policy bearing No.P/211218/1/2021/012003 under cashless “family health optima insurance plan” for the period from 16.1.2020 to 15.1.2021 and It was again renewed vide renewal endorsement No.P/211218/01/2021/012003 from 16.1.2021 to 15.1.2022 and thereafter again, it was renewed from 16.1.2022 to 15.1.2023 vide policy bearing No.2/211218/01/2022/013251. The sum assured was of Rs.5 lakhs and limit of coverage was Rs 6,75,000/-. The policy or its terms and conditions were never issued to the complainant, rather a covernote was given to her. Opposite parties promised that the policy covers all types of diseases, accident and surgical procedures. It is alleged that the complainant all of a sudden became ill with symptoms of fever, nausea and vomiting. She was got admitted on 21.5.2022 in Vincare Hospital, 100 Ft Road Opposite Petrol Pump, Bathinda. She was diagnosed with infection in her body and kidneys. So, she remained admitted there for 2 days under treatment and spent Rs.37,743/-. She neither got any relief from pain nor her infection was reduced, so she got discharge for further treatment at DMCH Ludhiana on 23.5.2022. On the advise of the doctor of DMC, she got admitted in DMC Hospital Ludhiana. The tests were conducted including her biopsy. She was diagnosed with the problem of LUPUS NEPHRITIS or SLE (Systemic Lupus Erythematosus) and she remained there upto 2.6.2022. After discharge from the hospital, she submitted the bill of Rs.37,743/- of Vincare Hospital and Rs.85,031/- of DMC Ludhiana to opposite parties for making payment, but they accepted the claim of Rs.8478/- out of Rs.85,031/- of DMC claim and nothing has been given against bill of Vincare Hospital of Rs.37,743/-. Opposite parties did not explain the reason for repudiation of genuine claims of the complainant. They disallowed all the claims illegally and without any reason and even no reasoning has been mentioned in intimation No.CIR/2023/211218/0226294 dated 12.8.2022. It is further alleged that the complainant submitted the application including claim form, admission slip, medical record and medicine bills for payment, but on 12.8.2022, opposite parties repudiated the total claim and passed only a meager amount of Rs.8478/- against total amount of Rs.1,22,774/-. On this backdrop of facts, the complainant has prayed for directions to opposite parties to make the payment of Rs.1,14,296/- with 18% interest from 21.5.2022 till payment and to pay Rs.1 lakh as compensation. Upon notice, opposite parties appeared through counsel and contested the complaint by filing written version and raising legal objections that the intricate questions of law and facts are involved in the complaint. They require voluminous documents and evidence for determination. It is not possible in the summary procedure under 'Act' and appropriate remedy, if any, lies only in the civil court. The complainant has concealed the material facts and documents from this Forum and opposite parties. As such, she is not entitled to any relief. She has concealed the fact that the terms and conditions of the policy were explained to her at the time of proposing the policy and same was supplied to her alongwith policy schedule. It is clearly stated in the policy schedule 'The insurance under this policy is subject to Conditions, Clauses, Warranties, Exclusion etc.'. Further legal objections are that the complainant availed 'FAMILY HEALTH OPTIMA Policy' with sum assured of Rs.5,00,000/- with date of policy inception 16.1.2020 for the period from 16.1.2022 to 15.1.2023 for self and Avneet Singh dependent child for sum assured of Rs.5,00,000/- vide policy No.P/211218/01/2022/013251 and policy No. P/211218/01/2020/009333 valid from 16.1.2020 to 15.1.2021 and policy No.P/211218/01/2021/012003 valid from 16.1.2021 to 15.1.2022. The insured preferred claims in 3rd year of the policy. The complaint is about two claims i.e. CIR/2023/211218/0210580 and CIR/2023/211218/0226294 for Vincare Hospital and DMC respectively For Rs.37,743/- and Rs.85,031/- (Rs.56,928/- in claim form). From submitted records, it has been observed that there is no IP/UHID number in the final bill and discharge summary. There is no hospital header in the final bill and there is no hospital seal and sign. As such, there are discrepancies in the records. It amounts to misrepresentation of fact. As per Condition No.1 of the policy issued to the complainant, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim. As such, claim was rejected vide letter dated 17.8.2022. Regarding 2nd hospitalization at DMC Hospital. The insured Balwinder Kaur was hospitalized at DMC on 25.5.2022 to 2.6.2022 for the treatment of LUPUS NEPHRITIS. She submitted the documents for reimbursement. Based on the submitted reimbursement documents, the claim was processed and an amount of Rs.8478/- was approved and paid to her through NEFT-N 229222080999455 dated 17.8.2022. Further, on reconsideration request from insured, claim was again reviewed and an amount of Rs.23,456/- was approved and paid to her through NEFT- N292222169503829 dated 19.10.2022. It is further pleaded that the reason for deduction during hospitalization period are: As per the other Excluded Expenses of the Policy, the charges pertaining to lab charges, no detail was given, hence disallowed. For Misc. Charges, Nephrology Not payable, so Rs.16,330/- are not payable. As per the other Excluded Expenses of the Policy, the charges pertaining to consumables, IV Cannula, IV set, NACL 0.9% vein guard, disposable not payable of Rs.4383/-. As per the other excluded expenses of the policy, the charges towards admission fee are not payable, pathology no break up was given, hence only 80% payable and an amount of Rs.4274/- was deducted. Rs.19,142/- was deducted as per assessment made according to claim form that may be considered if the amount mentioned above in claim form is clarified. Hospital discount of Rs.8968/- is given by the hospital is not payable. Hence maximum payable amounts of Rs.31,934/- (8478/- + 23,456/-) are already paid to the insured. Thus, total amount is Rs.85,031/-, deduction is of Rs.53,097/- and total payable amount was Rs.31,934/- that has already been paid. In the complaint, insured only accepted the receipt of claim amount of Rs.8478/- only, but Rs.23,456/- was also approved and paid to her through NEFT dated 19.10.2022 vide N292222169503829 and no more amount is payable as per terms and conditions of the policy. As per 2000(1) CLT 33 SC, burden of proving deficiency is on the person who alleges it. It is settled law that the insurance policy is a contract between the parties and both the parties are bound by the terms and conditions thereof. Further the terms and conditions of the policy have to be construed/interpreted strictly in determining the rights and liabilities of the parties. The complainant has no locus-standi or cause-of-action to file the complaint against opposite parties. The complaint is not maintainable in the present form and it is liable to be dismissed. On merits, opposite parties have reiterated their version as taken in the legal objections as detailed above and controverted all other averments of the complainant and prayed for dismissal of complaint. In support of her complaint, the complainant has tendered into evidence her affidavit dated 6.10.2022, (Ex.C1) and documents, (Ex.C2 to Ex.C19). In order to rebut the evidence of complainant, opposite parties have tendered into evidence documents, (Ex.OP 1/1 to Ex.OP 1/16). We have heard learned counsel for the parties and gone through the file carefully. Learned counsel for parties have reiterated their stand as taken in their respective pleadings as detailed above. We have given careful consideration to these submissions. Admitted facts are that the complainant obtained policy 'family health optima insurance plan' in the year 2021 and got it renewed regularly and now, policy bearing No.P/211218/01/2022/013251 for the period from 16.1.2022 to midnight of 15.1.2023 for sum assured of Rs.5 lakhs, (Ex.C3). It is proved on record that during the above coverage period, she fell ill and she got admitted in Vincare Hospital, Bathinda on 21.5.2022. She was diagnosed with infection in her body and kidneys and she spent Rs.37,743/- on her treatment. Further proved on record that when she could not recover with the treatment given at Vincare Hospital, Bathinda. Thereafter she got admitted in DMCH Ludhiana and she was diagnosed there with the problem of LUPUS NEPHRITIS or SLE (Systemic Lupus Erythematosus) and she spent Rs.85,031/- on her treatment. It is proved on record that the complainant submitted both the claims with opposite parties with bill of Rs.37,743/- of Vincare Hospital and Rs.85,031/- of DMC Hospital Ludhiana, but they released the claim amount of Rs.8478/- out of Rs.85,031/- of DMC claim and they did not release any amount against bill of Vincare Hospital of Rs.37,743/-. Later on, opposite parties have also released an amount of Rs.23,456/- to the complainant against claim of Rs.85,031/-. Counsel for complainant has also admitted this amount vide suffering separate statement on 8.5.2024. In this way, opposite parties have released only Rs.31,934/- (Rs.8478/- + Rs.23,456/-= Rs.31,934/-) out of Rs.1,22,774/- and remaining claim amount of Rs.90,840/- (Rs.1,22,774/- minus Rs.31,934/-=Rs.90,840/-) is still pending against them. Opposite parties have repudiated the first claim amount vide letter dated 17.8.2022, (Ex.OP1/8). The relevant portion of this letter is as under:- “It is observed from the submitted medical records that there is no IP/UHID number in the final bill and discharge summary; there is no hospital header in the final bill and there is no hospital seal and sign. Thus, there are discrepancies in the records which amount to misrepresentation of fact.” Opposite parties have also repudiated the second claim amount with the remarks, (Ex.C19).The relevant portion of this remarks is as under:- “Lab Charges No Detail Hence Disallowed...///Misc charges, Nephrology not payable; Consumables, IV CANNULA, IV SET, NACL 0.9% VEIN GUARD, DISPOSABLE NOT PAYABLE.” We are of the considered opinion that by paying an amount of Rs.8478/- out of total claim of Rs.85,031/-, it is quite clear that opposite parties admitted qua the hospitalization and treatment availed by the complainant, but they declined the major part of the claims on account of some technical hitches which in our opinion are not sustainable in the light of the evidence placed on record by the complainant. The documents placed on record pertaining to two hospitalization periods are in order and well stamped. Thus, the objection/rejection of the claim on those grounds is not legal and genuine. The discrepancies as alleged in the written version do not correspond with the stand/ground taken in the rejection letter dated 17.8.2022 in dispute. Also no specific clauses are being mentioned vide which the alleged deductions have been made. Neither there is any proof regarding the supply of terms and conditions of the policy in question. As there is no legal justification for the deductions made, thus amount of both the claims being genuine is payable. In view of what has been discussed above, present complaint is partly allowed with Rs.7000/- as cost and compensation against opposite parties. Opposite parties are directed to pay remaining claim amount of Rs.90,840/- to the complainant after verifying her medical bills in question. The compliance of this order be made within 45 days from the date of receipt of copy of this order. In case of non-compliance of the order within the stipulated period, thereafter opposite parties will be liable to pay additional cost of Rs.5000/- to the complainant. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room. Announced 10-07-2024 - (Priti Malhotra)
President (Sharda Attri) Member
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