| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C.No. 88 of 22-3-2022 Decided on : 18-5-2023 Hukam Chand Bansal S/o Shri Charanji Lal Bansal, R/o H. No.20941/5, Ajit Road, St.No.11/1, Near Baba Farid School, Bathinda, Punjab-151001. ........Complainant Versus Star Health and Allied Insurance Company Limited, Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034, through its CMD/MD/President/Chairman/GM/DM. Authorized Signatory/ Branch Manager/ Divisional Manager, Star Health And Allied Insurance Company Limited, SCF No.133, 2nd Floor, G.T. Road, Goniana Road, Bathinda-151001.
.......Opposite parties Complaint under Section 35 of the Consumer Protection Act, 2019 QUORUM Sh. Lalit Mohan Dogra, President Sh. Shivdev Singh, Member Present : For the complainant : Sh. Rajan Garg, Advocate. For opposite parties : Sh.Vinod Garg, Advocate. ORDER Lalit Mohan Dogra, President The complainant Hukam Chand Bansal (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 he purchased the Health Insurance Policy (Cashless/mediclaim policy) known as Hospitalisation Benefit Policy No.P/2111217/01/2021/007339 from the opposite parties through its Agent for a period from 31.03.2021 to 30.03.2022. Vide said policy, the complainant and his wife Pushpa Devi Bansal were insured for Rs.5,00,000/- each and complainant paid Rs.29,695/- as premium. The opposite parties issued only cover note along with Health Cards of the policy through e-mail and no terms and conditions were ever supplied to the complainant. It is alleged that all of a sudden firstly, wife of the complainant fell ill due to suffering from Dengue Fever and thereafter the complainant also fell ill due Dengue Fever and they remained admitted in New City Hospital, Bhagu Road, Bathinda. Wife of the complainant, namely, Pushpa Devi Bansal remained admitted from 19.10.2021 to 21.10.2021 and paid Rs.9500/- to the Hospital besides medicines of Rs.751/- on 19.10.2021, Rs. 209/- on 19.10.2021, Rs.683/- on 20.10.2021 and Rs.215/- on 21.10.2021 as well as charges of Labs separately. The complainant himself remained admitted in the said Hospital from 12.11.2021 to 14.11.2021 and paid Rs.7900/- as medical charges, Rs.850/- as Lab charges and Rs.500/- also as lab charges, besides making payment of medicines of Rs.689/- on 12.11.2021 and Rs.655/- on 13.11.2021. It is further alleged that the bills with regard to the complainant and his wife were submitted to opposite parties and opposite parties issued acknowledgement receipts dated 20.12.2021 through e-mail. The opposite parties vide letter dated 22.12.2021 through e-mail sought some additional documents from the complainant in respect of his wife, which were also submitted by the complainant and acknowledgement receipt dated 04.01.2022 through email was issued. It is also alleged that the opposite parties deposited the amount of Rs.7247/- in the account of complainant regarding reimbursement of the medical claim, but the claim in respect of wife of the complainant was rejected without any rhyme and reason on flimsy and imaginary grounds, which do not at all have any concern with the complainant. The opposite parties sent a letter dated 14.01.2022 through e-mail to the complainant stating that there is discrepancy in the record, which amounts to misrepresentation of facts and the amount already disbursed to the claimant be returned on the ground that the claim is not admissible as there is discrepancy in the records. The complainant alleged that besides the e-mail, complainant also received a letter/notice dated 10.01.2022 from the opposite parties through post to the effect that the Company may cancel the policy on the grounds of misrepresentation, fraud, moral hazard, non-disclosure of material fact, but the complainant duly replied the same through registered post and requested the opposite parties to make the reimbursement of the claim, but instead of that, opposite parties sent a letter through email dated 24.01.2022 to the effect that they had received complaint vide their reference and same is under their attention, but till date no response has been received by the complainant, which shows that the opposite parties are bent upon to swallow the hard earned amount of a senior citizen without any rhyme and reason and that too without any fault on the part of the complainant. It is further alleged that the opposite parties till today have not reimbursed the amount rather they are bent upon to cancel the policy in question without any rhyme or reason as well as any fault on the part of the complainant and intend to swallow the premium amount of Rs.29,695/- deposited by the claimant with the opposite parties. The complainant alleged that the opposite parties are creating hindrance without any logic and he claims that he is entitled to get compensation of Rs.50,000/- alongwith reimbursement of the claim amount. On this backdrop of facts, the complainant has prayed for directions to the opposite parties to make reimbursement of claim amount in respect to the medical expenses incurred on wife of complainant due to suffering from Dengue Fever with interest @ 18% p.a. from 20.12.2021 till payment and pay Rs.50,000/- as compensation. The opposite parties be also restrained from recovering medical reimbursement already made to complainant and also from cancelling the policy of the complainant besides any other additional or alternative relief. Upon notice, opposite party appeared through counsel and contested the complaint by filing written written reply raising legal objections that the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under the 'Act' and appropriate remedy, if any, lies only in the Civil Court. The complainant has concealed material facts and documents from this Commission as well as the opposite parties. The complainant has concealed the fact that the terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same were served to the complainant along with the Policy Schedule. It is clearly stated in the policy schedule that the insurance under this policy is subject to conditions, clauses, warranties exclusions etc., It has been pleaded that on scrutiny of claim documents, the opposite parties observed that the previous claim No. C1R/2022/211217/3613967 for the alleged treatment of Dengue Fever for Hukam Chand Bansal at New City Hospital for the admission dated 12- 11-2021 was settled by the opposite party. Again insured has submitted claim for his wife for same ailment at same hospital. Hence, to verify the genuinity of the claim, the opposite parties entrusted the claim for verification and it was found that receipt dated 21.10.2021 is numbered as 1274 but vide claim No. CIR/2022/211217/3613967 as per submitted receipt dated 14.11.2021 is numbered as 1028, thus the receipts are not in chronological order. (i.e documents fabricated for claim purpose). Similarly, the indoor case records and drug chart, vital chart is stereotyped manner and written in single handwriting and there is no IPD number, room category mentioned in the ICP. Further the medicine bill numbers are continuous for consecutive days; the Lab receipt dated on 21.10.2021 is numbered as 1273 but vide claim No. CIR/2022/211217/ 3613967 as per submitted lab receipt dated on 12.11.2021 is numbered as 1027. Even there is no ID in the report dated 19.10.2021 and 21.10.2021. Thus, there is discrepancy in the records which amounts to misrepresentation of facts. The opposite parties have further pleaded that as per 5, condition No. 6 of the policy, if there is any misrepresentation/ non-disclosure of material facts whether by the insured person or by any other person acting on his behalf, the company is not liable to make any payment in respect of any claim and policy becomes void. Hence the claim was repudiated vide letter dated 14.01.2022. The opposite parties have also pleaded that as per Condition No.10 of the policy, the Company may cancel this policy on the grounds of misrepresentation, fraud, moral hazard, non disclosure of material fact as declared in the proposal form and/or claim form at the time of claim and non co-operation of the insured by sending the insured 30 days notice by registered letter at the Insured person's last known address. Thus, the policy was cancelled via endorsement schedule dated 16.02.2022 with the prior notice dated 10/01/2022. Further legal objections are that the complaint is bad for non-joinder of necessary parties as the complainant has not impleaded Pushpa Devi Bansal actual patient and New City Hospital as party. The complainant has no locus standi to file the complaint for treatment and claim of Pushpa Devi Bansal. The complainant is not consumer and he has not furnished any certificate regarding reimbursement of medical bills from his employer as the complainant is a retired government employee. The complainant has no locus standi or cause of action and that the complaint is not maintainable in the present form and is liable to be dismissed. On merits, opposite parties have reiterated their version as pleaded in legal objections and detailed above. In the end, the opposite parties have prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his affidavit dated 17.5.2023 (Ex. C-15) and documents (Ex.C-1 to Ex.C-14). In order to rebut the evidence of complainant, the opposite parties have tendered into evidence affidavit of Jagjit Singh dated 16.2.2023 (Ex. OP-1/1) and documents (Ex. OP-1/2 to Ex.OP-1/22). The learned counsel for the complainant has argued that complainant had purchased Health Policy known as Hospitalization Benefit Policy from the opposite parties valid from 31-3-2021 to 30-3-2022 and complainant and his wife Pushpa Devi were insured upto Rs. 5,00,000/-each . It is further argued that opposite parties had only issued health cards of the policy to the complainant through e-mail and terms and conditions were never supplied to him. It is also alleged that wife of the complainant was admitted at New City Hospital, Bhagu Road, Bthinda for Dengue fever w.e.f. 19-10-2021 to 21-10-2021 and had to spent Rs. 9500/- for such hospitalization. It is further argued that thereafter complainant remained admitted in the same hospital for dengue fever w.e.f. 12-11-2021 to 14-11-2021 and had to spent Rs. 7900/-. The claim was lodged with the opposite parties and thereafter opposite parties deposited/paid the amount of Rs. 7247/- in the account of the complainant regarding reimbursement of medical claim, but claim of the wife of the complainant was rejected by the opposite parties on flimsly grounds. It is also argued that thereafter opposite parties cancelled the policy of insurance of the complainant without any notice and on complaint being filed by the complainant, the same was ordered to be restored vide endorsement schedule Ex. OP-1/22 upto 30-3-2022. It is further argued that opposite parties have wrongfully declined the reimbursement of medical bills of the wife of the complainant and illegally cancelled the policy of insurance and are further demanding Rs. 7247/- from the complainant, which amounts to deficiency in service. The learned counsel for the complainant further argued that during the pendency of present complaint, policy of insurance expired on 30-3-2022 and thereafter complainant has visited the opposite parties number of times for getting the insurance policy renewed but the opposite parties have refused to renew the policy with the excuse that since the original policy was already cancelled due to fraud, as such, policy of insurance cannot be renewed. The learned counsel for the complainant has also relied upon judgement of Hon'ble Supreme Court case titled as United India Insurance Company Vs. Manubhai Dharmasinhbhai Gajera reported in 2008(10) scc 404 wherein it was held by Hon'ble Supreme Court that renewal of medi-claim/health insurance policies issued by public sector insurance companies and renewal of mediclaim policy whether automatic on payment of amount of premium- PSU insurer being part of the State within the meaning of Article 12 of the Constitution and statutory creations, are required to act fairly and reasonable despite having the contractual power to cancel the policy at any time by sending the insured 30 days notice on refunding the premium pro-rata and despite their monopoly in the field of general insurance having being brought to an end. Binding effect of guidelines/directions issued by IRDA, Central Government and General Insurance Corporation, deifference in role and duties of PSU insurers from those of private insurers. Declration of Human Rights, 1948, Article 25 effect of held : (1) There is no automatic renewal where renewal is based on mutual consent. Medi-claim policy of a senior citizen would stand some what on a different footing. It will depend upon the contract entered into between the parties and the statutes operating in the field as also constitutional scheme. Contention that wherever renewal is subject to mutual consent to the parties, a State may at its whims and caprice refuse to renew. Such contention cannot be accepted. Though there is no legal right of automatic renewal but courts are required to strike a balance. It will depend upon the terms of the contract, the constitutional scheme and applicable statutory scheme. When a policy is cancelled the conditions precedent therefore must be fulfilled and some reasons therefore must be assigned.” Learned counsel for complinant also referred the case titled Biman Krishna Bose Vs. United India Insurance Co. Ltd., reported as 2001(4) RCR (Civil) 179, wherein Honb'le Supreme Court has held : Mediclaim insurance policy – Renewal of - restrospective renewal – Wrongful refusal of renewal of mediclain insurance policy. Renewal cannot be denied on the basis of exclusion clause of the policy qua pre-existing disease/injuries. The policy has to be renewed with retrospective effect on the same terms and conditions. Mere fact that some more installments also fell due, is also no ground to deny renewal. Company cannot take advantage of its own wrong. Once the mediclaim insurance policy is ordered to be renewed with retrospective effect, the company have to accept all the due installments and grant all the claims becoming due during the period the policy remained in abeyance on that account. The mischief and harm done to the insured must be remedied.” Another authority referred was of Hon'ble State Commission, Punjab, Chandigarh in the case titled Joginder Singh Vs. Oriental Insurance Co. Ltd., reported 2012(1) CLT 472 wherein it has been held : “Constitution of India 1950 Article 12 'State' – Definition and scope of mediclaim policy – Non-renewal. Appellant having medi-claim insurance policies from the respondents and being renewed every year – Non settlement of claim submitted in the year 2002 for Rs. 43,366/-. Subsequently appellant approached the District Forum. Complaint allowed. Respondents decline to accept amount of renewal of policy. Settled law by apex court that insurance company is considered to be a 'State' or other authority within meaning of Article 12 of the Constitution of India then the Insurance Company is bound to be fair and reasonable. The respondents are under legal obligation to renew the policy unless the exception circumstances of fraud etc., are proved. Directions issued to respondents to renew the medi-claim policy for the period. Hence, the appellant will lodge the insurance claim relating to that period supported by the documents and the respondent insurance company shall be bound to settle the claim within reasonable time. Appeal partly allowed.” On the other hand, learned counsel for the opposite parties argued that complainant concealed the fact that terms and conditions of the policy were explained to the complainant at the time of proposing the policy and the same were served to the complainant alongwith policy schedule. Moreover, it is clearly stated in the policy schedule that the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc., attached. The policy is contractual in nature and the claims arising there are subject to terms and conditions forming part of the policy. The complainant accepted the policy agreeing and being fully aware of such terms and conditions, executed the proposal form. It is further argued that on scrutiny of claim documents, the opposite parties observed that previous claim No. CIR/2022/211217/3613967 for the alleged treatment of dengue fever for Hukam Chand Bansal at New City Hospital for admission dated 12-11-2021 was settled by the opposite party and again insured submitted claim for his wife for the same ailment at same hopsital. Hence, to vertify the genuinity of the claim, the opposite parties entrusted the claim for verification and following findings were given : - Receipt dated 21.10.2021 is numbered as 1274 but vide claim No. CIR/2022/211217/3613967 as per submitted receipt dated 14.11.2021 is numbered as 1028, thus the receipts are not in chronological order. (i.e documents fabricated for claim purpose). - Similarly, the indoor case records and drug chart, vital chart is stereotyped manner and written in single handwriting and there is no IPD number, room category mentioned in the ICP. - Further the medicine bill numbers are continuous for consecutive days; the Lab receipt dated on 21.10.2021 is numbered as 1273 but vide claim No. CIR/2022/211217/ 3613967 as per submitted lab receipt dated on 12.11.2021 is numbered as 1027. - Even there is no ID in the report dated 19.10.2021 and 21.10.2021. From the above observations, there is discrepancy in the records which amounts to misrepresentation of fact. As per condition No. 5 & 6 of the policy, if there is any misrepresentation/non-disclosure of material facts whether by the insured person or by any other person acting on his behalf, the company is not liable to make any payment in respect of any claim and policy becomes void and accordingly, opposite parties have rightly repudiated the claim of the complainant. It is further argued by the learned counsel for the opposite parties that policy of insurance was also rightly cancelled. However, vide order dated 24-3-2022, opposite parties were restrained from cancelling the policy till further orders and as such, policy was again restored vide endorsement schedule Ex. OP-1/22 upto 30-3-2022. Counsel for the opposite parties has further argued that it is discretion of the opposite parties not to renew the policy as the complainant indulged in misrepresentation and indulged in fabrication of document for claim purposes in respect of treatment of dengue fever. It is further argued that since Pushpa Devi, wife of the complainant is not a party to the complaint, as such, claim qua Pushpa Devi should be dismissed. We have heard learned counsel for the parties and have gone through the record. It is admitted fact that opposite parties had issued policy of insurance Ex. C-1 as per which the complainant and his wife were insured upto Rs. 5,00,000/- each w.e.f. 31-3-2021 to 30-3-2022. It is further admitted fact that complainant and his wife suffered from dengue fever and remained admitted in City Hospital, Bathinda w.e.f. 12-11-2021 to 14-11-2021 and 19-10-2021 to 21-10-2021 respectively. Now the disputed question before this Commission is whether the opposite parties were having any right to repudiate the claim of the complainant and his wife for the treatment obtained by them in respect of dengue fever vide letter Ex. C-9. A perusal of repudiation letter Ex. C-9 shows that claim of the complainant and his wife was repudiated on the ground that receipt dated 21-10-2021 is numbered as 1274 whereas receipt dated 14-11-2021 is numbered as 1028 and as such, receipts are not in chronological order. It is further observed that in-door chart record and drug chart and vital chart is stereotyped manner and written in a single handwriting and there is no IPD number, room category mentioned. Even lab receipt dated 21-10-2021 is numbered as 1274 but the lab receipt dated 12-11-2021 is numbered as 1027. As such, discrepancy in the record amounts to misrepresentation of facts and policy was proposed to be cancelled by the opposite parties vide notice for cancellation of policy Ex. C-10. A perusal of file shows that complainant had replied notice for cancellation of policy wherein complainant had explained that receipts of bills of medicines and treatment chart were prepared by hospital and are hardly seen by the patient. It was the duty of the insurance company to have verified such facts regarding alleged discrepancy from the hospital, chemist and lab. This Commission is of the view that arguments submitted by the learned counsel for the complainant has force as it is none of the business of the complainant to verify whether the receipts and their numbers are in chronological order or not. If there was any discrepancy in the number of receipts, in that case, it was the duty of the opposite parties to have obtained explanation from the concerned hospital, lab, chemist shop, but in the present case, the opposite parties have not made any efforts to get any clarification regarding discrepancy from the hospital, lab and chemist shop meaning thereby that opposite parties were only interested in repudiating the claim of the complainant and his wife by finding faults in the number of receipts. Since the opposite parties have failed to get clarification from the hospital, lab and chemist shop regarding discrepancy in the number of receipts, if any, as such, act of the opposite parties of having repudiated claim of the complainant and his wife and cancellation of policy, amounts to deficiency in service. So far as question regarding maintainability of present complaint qua claim of Pusha Devi, wife of complainant is concerned, this Commission is of the view that since the complainant had purchased mediclaim policy for himself and his wife through one document by payment of premium, as such, complainant is fully competent to file complaint for himself and on behalf of his wife. Accordingly, present complaint is partly allowed with the following directions to the opposite parties :- i) To pay Rs. 8506/- on account of treatment obtained by Pushpa Devi, wife of complainant. ii) To withdraw notice served upon the complainant to return/refund the amount of Rs. 7247/- paid to complainant. iii) To renew the original policy of insurance Ex. OP-1/2 w.e.f. 1-4-2022 onwards in continuation of original policy of insurance with retrospective effect after receiving due premium from complainant. No order as to costs. The compliance of this order be made by the opposite parties within 45 days from the date of receipt of copy of this order. 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:- 18-05-2023 - (Lalit Mohan Dogra)
President (Shivdev Singh) Member
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