DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/76/2023
Date of Institution: 27.06.2023
Date of Decision: 05.07.2024
Jeewan son of Sh. Balram resident of Street No. 06, Tapa Mandi Tehsil Tapa, District Barnala, Pin Code 148108.
…Complainant
Versus
1. Star Health and allied Insurance Company Limited through its Managing Directors registered address at Office No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai.
2. Mr. Ashwani Kumar, intermediary Star Health and allied Insurance Company Limited, Branch Office at SCO 133, 2nd Floor, above Tata Motor Finance, New Hotel Sweet Milan, Goniana Road, Bathinda, Pin Code 151001, Mobile Number 94179-71749.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Nitin Bansal Adv counsel for complainant.
Sh. Rohit Jain Adv counsel for opposite party No. 1.
Opposite party No. 2 deleted.
Quorum.-
1. Sh. Ashish Kumar Grover : President
2. Sh. Navdeep Kumar Garg : Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Star Health and allied Insurance Company Limited & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant purchased medical policy bearing No. P/211217/01/2023/001044 on dated 30.5.2022 from opposite parties for himself, his wife Priyanka and his sons Shivansh Garg and Raghav Garg. The above said policy was continued vide policy No. P/211217/01/2023/001044 on dated 30.5.2022 protected till 29.5.2023, covered an amount of Rs. 6.75 lacs for the whole family health and accident insurance for each member. It is further alleged that on 1.9.2022 the complainant complained of abdominal pain and they rushed to Malwa Hospital, Power House Road, Near Power Grid, Bathinda, for diagnose/checkup and there doctor admitted the complainant for the treatment of abdominal pain (Crohn Disease) and number of tests were conducted while treatment at Malwa Clinical Laboratory and the complainant got discharged on 3.9.2022 and during that period number of expenses occurred totaling Rs. 96,477/-. On 22.11.2022 the complainant wrote a letter to opposite party No. 1 to lodge claim of the complainant which the opposite party No. 1 rejected on 28.11.2022 on unjustified grounds and flatly refused to make payment. It is further alleged that the opposite party No. 1 did not pay any heed to reply and reinstitute the claim of the complainant. As such, the act and conduct of the opposite parties comes within the definition of the unfair trade practice as well as deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to release Rs. 96,477/- and directed the opposite party No. 1 to clear bill of medical treatment alongwith interest upto to date @12% per annum.
- To pay Rs. 1,00,000/- on account of compensation for causing mental harassment to the complainant.
- Further, to pay Rs. 5,000/- as litigation expenses.
3. The opposite party No. 2 was deleted from the arena of opposite parties vide order dated 12.7.2023 on the statement suffered by the Ld. Counsel for the complainant.
4. Upon notice of this complaint, the opposite party No. 1 appeared and filed written version by taking preliminary objections interalia on the grounds that the complainant has no locus-standi to file the present complaint. The present complaint is not legally maintainable in the present form. The complainant has not come with clean hands and suppressed the material facts from this Commission.
5. On merits, it is admitted that the complainant purchased medical policy bearing No. P/211217/01/2023/001044 on dated 30.5.2022 from opposite parties for himself, his wife Priyanka and his sons Shivansh Garg and Raghav Garg. It is also admitted that the above mentioned policy was continued vide policy No. P/211217/01/2023/001044 on 30.5.2022 protected till 29.5.2023 and covered for an amount of Rs. 5 lacs for whole family health and accident insurance for each member. It is further alleged that as per documents submitted by the complainant on 1.9.2022 the complainant complained of abdominal pain and they rushed to Malwa Hospital, Power House Road, Near Power Grid, Bathinda, for diagnose/checkup and there doctor admitted the complainant for the treatment of abdominal pain (Crohn Disease) and number of tests were conducted while treatment at Malwa Clinical Laboratory and the complainant got discharged on 3.9.2022 and during that period number of expenses occurred totaling Rs. 96,477/-. It is further admitted that on 22.11.2022 the complainant wrote a letter to opposite party No. 1 to lodge claim of the complainant. It is submitted that the opposite party No. 1 asked the complainant to produce/submit the requisite document demanded by the opposite party No. 1. It is denied that the opposite party No. 1 rejected the claim on 28.11.2022 on unjustified grounds and flatly refused to make the payment even after receiving the documents. It is also denied that opposite party No. 1 rejected the claim of complainant to make payment of pre and post hospitalization expenses incurred by complainant on 30.11.2022 on unjustified grounds. It is further 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. It is further alleged that on scrutiny of claim documents, query letter sent on 7.10.2022, 22.10.2022 and 6.11.2022 to furnish the following documents;-
1. Letter from the treating doctor stating that when was CROHNS DISEASES first diagnosed, its initial OPD consultation and its exact duration.
2. Previous history of hospitalization for the same ailment.
3. All past investigation records like COLONOSCOPY, ENDOSCOPY, USG reports for supporting diagnosis.
4. Discharge summary with definitive diagnosis and exact treatment procedure done (submitted one with no diagnosis).
5. Complete set of indoor case sheet papers with temperature chart.
6. All laboratory investigations done during current admission.
7. All follow up records.
But the complainant has not submitted the demanded document which amounts to non submission of required documents. Hence, the claim was rejected and conveyed to insured vide letter dated 28.11.2022. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
6. Ld. Counsel for complainant on 15.2.2024 suffered the statement that I do not want to file any rejoinder on behalf of complainant.
7. To prove the case the complainant tendered into evidence affidavit of complainant Ex.C-1, copy of policy Ex.C-2, copy of claim form Ex.C-3, copies of bills and medical reports Ex.C-4 (containing 53 pages), copy of repudiation letter Ex.C-5, copy of repudiation letter dated 30.11.2022 Ex.C-6 and closed the evidence.
8. To rebut the case the opposite party No. 1 tendered into evidence affidavit of Sumit Kumar Sharma Ex.O.P1/1, copy of proposal form Ex.OP1/2 (containing 4 pages), copy of policy Ex.O.P1/3 (containing 4 pages), copy of terms and conditions Ex.O.P1/4 (containing 6 pages), copy of field visit report Ex.O.P1/5 (containing 3 pages), copy of claim form Ex.O.P1/6 (containing 2 pages), copy of discharge card Ex.O.P1/7, copy of patient record Ex.O.P1/8 (containing 2 pages), copy of bill Ex.O.P1/9, copies of letter Ex.O.P1/10 to Ex.O.P1/12, copy of repudiation letter Ex.O.P13 (containing 3 pages) and closed the evidence.
9. We have heard the learned counsel for the parties and have gone through the record on the file.
10. It is admitted fact of the opposite parties that the complainant purchased medical policy bearing No. P/211217/01/2023/001044 on dated 30.5.2022 from opposite parties for himself, his wife Priyanka and his sons Shivansh Garg and Raghav Garg (Ex.C-2 & Ex. O.P1/3). It is also admitted that the above mentioned policy was continued vide policy No. P/211217/01/2023/001044 on 30.5.2022 protected till 29.5.2023 and covered for an amount of Rs. 5 lacs for whole family health and accident insurance for each member. It is further alleged that as per documents submitted by the complainant on 1.9.2022 the complainant complained of abdominal pain and they rushed to Malwa Hospital, Power House Road, Near Power Grid, Bathinda, for diagnose/checkup and there doctor admitted the complainant for the treatment of abdominal pain (Crohn Disease) and number of tests were conducted while treatment at Malwa Clinical Laboratory and the complainant got discharged on 3.9.2022 (Ex.O.P1/7). It is further admitted that on 22.11.2022 the complainant wrote a letter to opposite party No. 1 to lodge claim of the complainant.
11. Ld. Counsel for the complainant argued that the complainant has spent an amount of Rs. 96,477/- on the treatment. Ld. Counsel for the complainant further argued that the opposite party No. 1 rejected/repudiated the claim on 28.11.2022 on unjustified grounds and flatly refused to make the payment. It is further argued that the opposite party No. 1 did not pay any heed to reply and reinstitute the claim of the complainant, as such the act and conduct of the opposite parties comes within the definition of the unfair trade practice as well as deficiency in service.
12. Ld. Counsel for the opposite party No. 1 argued that the opposite party No. 1 asked the complainant to produce/submit the requisite document demanded by the opposite party No. 1. It is further argued that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. It is further argued that on scrutiny of claim documents, query letter sent on 7.10.2022, 22.10.2022 and 6.11.2022 to furnish the requisite documents as mentioned in the written version, but the complainant has not submitted the demanded document which amounts to non submission of required documents, hence the claim was rejected and conveyed to insured vide letter dated 28.11.2022.
13. On the perusal of the entire facts and evidence produced by both the parties it is established that the opposite party No. 1 has admitted the insurance policy and the insurance company also admitted that the complainant was got admitted in the alleged hospital and he has taken the treatment. Ld. Counsel for the complainant argued that as per policy benefits the complainant is entitled for pre-hospitalization bills of 60 days and post hospitalization bills of 90 days. Ld. Counsel for complainant further argued that after the completion of about 79 days of hospitalization the complainant immediately lodged the claim before the opposite party No. 1. The rejection ground of non submission of requisite documents is unjustified and the claim was rejected wrongly by the opposite party No. 1 vide letter dated 28.11.2022. The complainant has produced the claim form Ex.C-3 alongwith entire hospital bills, pharmacy bills and test reports and from which it is established that the complainant was got admitted in the hospital on 1.9.2022 and discharged on 3.9.2022 (as per Ex.O.P1/7). We have perused the above said bills placed on record by the complainant from which it is established that the complainant has spent an amount of Rs. 96,428/- on his treatment (as per Ex.C-4). However, the complainant has alleged in his complaint that he has spent an amount of Rs. 96,477/- on his treatment. Ld. Counsel for complainant further argued that the opposite party No. 1 has not supplied the terms and conditions of the policy. Ld. Counsel for the complainant further argued that the claim was wrongly repudiated on the false and baseless grounds. The opposite party No. 1 has failed to establish that the terms and conditions of the policy were supplied to the complainant with the insurance policy. The complainant has submitted all the documents in his evidence to prove the genuineness of the claim. Ld. Counsel for the complainant also relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims.
14. From the above discussion, it is proved that the claim of the complainant was repudiated by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties.
15. In view of the above discussion, the present complaint is partly allowed against the opposite party No. 1 and the opposite party No. 1 is directed to pay an amount of Rs. 96,428/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite party No. 1 is further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
5th Day of July, 2024
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
