BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAPURTHALA.
Complaint No. 15 of 2023
Date of Instt. 16.03.2023
Date of Decision :04.12.2024
Vedanshi Arora aged about 3 years, minor daughter of Chander Shekher son of Sunil Arora, through her mother Neha Joshi@ Neha wife of Chander Shekher, being next friend and natural guardian, resident of H.No. 176/10, Street No.7, Mohalla Santpura, Kapurthala
…Complainant Versus
Star Health and Allied Insurance Company Limited, Branch Office, 3rd Floor, Nirmal Complex, EH-198, Civil Lines, G.T. Road, Jalandhar through its Branch Manager.
Star Health and Allied Insurance Company Limited, 15, Sri Balaji Complex, 1st Floor, Whites Lane, Royapetttha, Chennai, through its Regional Manager/ authorized Signatory.
Star Health and Allied Insurance Company Limited Regd. office, 1 New Tank Street, Valluvar Kottam High Road, Nengambakkam, Chennai through its M.D/ authorized Signatory.
Momi Hospital, Pvt. Limited, Kanjli Road, Kapurthala through its Dr. B.S. Momi.
...Opposite parties
Complaint under Section 35 of Consumer Protection Act
Quorum: Before: Sh. Rajesh Bhatia (President)
Mrs. Rajita Sareen (Member)
S. Kanwar Jaswant Singh (Member)
Present: Sh. Ajay Kumar, Advocate for the complainant.
Sh. A.K. Gandhi, Advocate for OPs No.1 to 3
None for OP No.4.
Order
Sh. Rajesh Bhatia (President)
1. The complainant has filed the present complaint under section 35 of Consumer Protection Act that Neha Joshi, the mother and natural guardian of the complainant is having Family Health Optima Insurance Plan vide insurance policy No.P/211215/01/2022/008479 for the period 25.02.2022 to 24.02.2023 since 2015 and renewed the same from time to time, from opposite parties and the complainant along with other family members are also covered under the said policy. The opposite parties had assured that the insurance policy covers all type of medical expenses on the treatment in case of any disease or accident. The opposite parties did not issue any terms and conditions of the policy. Rather only policy number was supplied/intimated. As per version of complainant, during the above said policy period, the complainant suddenly suffered with diarrhea, vomiting and severe dehydration and she was admitted in the hospital of opposite party No.4 on 17/8/2022 and was discharged on 20/8/2022 in the evening. The above said doctor intimated the opposite parties No. 1 to 3 by submitting claim form on behalf of complainant on 20/8/2022. The complainant submitted claim for reimbursement of medical expenditure Rs.14,707/- and submitted all original documents relating to treatment and medical bills to the opposite parties No.1 to 3 at their office at Jalandhar which were received by the officials of opposite parties No.1 to 3. Thereafter the complainant (through her mother) approached the opposite parties No. 1 to 3 at Jalandhar with the request to pay the claim and the opposite parties No. 1 to 3 obtained the signatures of the complainant on some blank printed forms with the assurance that the claim will be paid shortly but no payment was made rather the opposite parties kept on lingering on the matter on one pretext or the other. Thereafter the opposite parties No. 1 to 3 informed the complainant that there is tampering in the discharge slip and requested to submit clarification regarding tampering in the discharge slip from the Hospital concerned who is also opposite party No.4 in present complaint and the opposite party No.4 also submitted fresh discharge slip to the opposite party No.1 on 10/11/2022. The complainant repeatedly requested the opposite parties for the reimbursement of claim amount as the complainant has already submitted the documents to the opposite parties required for the settlement of the claim but the opposite parties wrongly and illegally repudiated the claim of the complainant on totally false grounds that there is tampering, vide letter dated 10/11/2022. The above said repudiation letter dated 10/11/2022 is totally illegal null and void and having no binding effect on the rights of the complainant as the complainant is entitled to reimbursement of her claim. Due to non-reimbursement and non payment of claim of the above said medical expenses of treatment of complainant by the opposite parties has caused mental, agony, pains and sufferings. Due to non payment of the claim amount, the complainant is suffering heavy damages on account of loss as well as she is suffering mental agony and pains for which the complainant has prayed for the compensation amount of Rs.20,000/- and interest @ 18% P.A. from the date of lodging of claim of Rs.14,707/- till payment calculated annually alongwith cost of Rs.5,000/- on account of expenses.
2. Notice of the complaint was issued to the opposite parties and opposite party appeared through counsel and filed its written reply by taking preliminary objections that the present Complaint is false, vexatious and has been filed with a malafide intention to harass the opposite parties No. 1 to 3 by misusing the process of law and to avail undue advantages. It is an attempt to waste the precious time of this Honorable Commission as no cause of action has arisen against the answering opposite parties No 1 to 3 and in favour of the Complainant, hence this complaint is liable to be dismissed. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. Moreover it is clearly stated in the policy schedule “THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSION ETC., ATTACHED”.
3. That the opposite parties No.1 to 3 have rightly Repudiated the claim of the complainant vide letter dated 10-11-2022 as the present case is a clear cut case of concealment of material facts and misrepresentation. Condition No.1 of the Policy 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”.
4. That the Complainant have not come before the Hon'ble Court with clean hands. It was within the knowledge of the Complainant that there is tampering in the record of the Hospital and the Complainant is trying to obtain the claim in question by using unlawful mean. As per version of the OP in their written statement that if the OPs No. 1 to 3 are liable to pay the claim in terms of the contract of insurance issued to the claimant-petitioner, it is respectfully submitted that the maximum quantum of liability under the terms of the policy shall be Rs.13,253/-.
5. Rejoinder not filed.
6. To prove his case, complainant submitted affidavit alongwith documents Ex. C1 to Ex. C9.
7. On the other hand, OPs No. 1 to 3 submitted affidavit Ex. OP/A alongwith documents Ex. OP/1 to Ex. OP/8.
8. We have heard the arguments of both the parties and also gone through the case file.
9. The opposite parties No. 1 to 3 have taken an objection that there is over writing on discharge summary dated 20/08/2024 and rejected the claim of complainant. That in present complaint, the opposite party No.4 i.e. hospital through Dr. B.S. Momi, who issued discharge slip to complainant for the treatment of her minor daughter Vedanshi and opposite party No.4 appeared before this Commission and filed it's written statement and admitted in it's written statement that the complainant was admitted in the hospital on 17/08/2024 and discharged on 20/08/2024.
10. The opposite parties No. 1 to 3 also stated in their written statement that the admission of complainant in the hospital of OP No.4 is matter of record. So after perusal of the case file, this Commission is of the view that there is deficiency in service on the part of opposite parties No.1 to 3 towards the complainant and the present complaint is partly allowed against the opposite parties No. 1 to 3. The opposite parties No. 1 to 3 are directed to pay the claim amount of Rs. 14,707/- alongwith interest @9% per annum from the date of filing of complaint till its realization. Further opposite parties No. 1 to 3 are directed to pay Rs. 5,000/- as compensation for harassment and Rs. 5,000/- as litigation expenses. There is no order against the opposite party No.4.
11. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated
Dated
04/12/2024
S. Kanwar Jaswant Singh Rajita Sareen Rajesh Bhatia
Member Member President
