Chandigarh

DF-I

CC/126/2024

ASHISH GARG - Complainant(s)

Versus

STAR HEALTH AND ALLIED INSURANCE COMPANY Limited - Opp.Party(s)

NAVKESH SINGH

05 Nov 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/126/2024
Date of Institution	:	04.03.2024
Date of Decision	:	5/11/2024

Ashish Garg son of Satishpal Garg, resident of House No.821, Sector 91, JLPL, SAS Nagar, Mohali.

.....Complainant

Versus

1.    Star Health and Allied Insurance Company Limited, Registered and Corporate Office 1, New Tank Street Valluvar, Kottam High Road, Nungambakkam, Chennai, through its Directors. Pin Code 600034.

2.    Star Health and Allied Insurance Company Limited, Registered and Corporate Office, Claim Department, No.15, Balaji Complex, Whites Lane, 1^st Floor, Royapeltah, Cheenai through Directors. Pin Code 600014.

3.    Star Health and Allied Insurance Company Limited, Branch Office, SCO 5A, 2nd Floor, Sector 7C, Madhya Marg, Chandigarh through its Manager. Pin Code 160019.

....Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Navkesh Singh, Advocate for complainant
	:	Ms.Surabhi Grover, Advocate for OPs.

Per Pawanjit Singh, President

1.         The present consumer complaint has been filed by complainant against the opposite parties (hereinafter referred to as the ‘OPs’).  The brief facts of the case are as under :-
   1. It transpires from the averments as projected in the consumer complaint that on 20.03.2020, the complainant purchased one Health Insurance Policy from the OPs, which was valid w.e.f. 21.03.2020 to 20.03.2020 (Annexure C-2) and the same was got renewed by the complainant from time to time and finally, the same was renewed w.e.f. 06.04.2023 to 05.04.2024 (hereinafter referred to as the ‘subject policy’) and the copy of the same is Annexure C-1. The complainant was not having any pre-existing disease at the time of obtaining the subject policy. However on 20.06.2023, the complainant suffered from pain, nausea and vomiting as a result of which he was admitted in the Shalby Multi Specialty Hospital, Phase-9, SAS Nagar, Mohali (hereinafter referred to as the ‘treating hospital’) where he was treated by Dr.Rahul Gupta and the copy of the admission summary is Annexure C-3. After conducting various tests and thorough check up, the complainant was found to be suffering from chronic pancreatitis and was advised operation for the same. The complainant was operated for the same and he incurred a sum of ₹85,559.04 on his treatment, vide bill dated 23.06.2023 (Annexure C-4) and he was discharged from the hospital satisfactorily (Annexure C-5). The complainant had informed the OPs about the said treatment and also submitted the claim form (Annexure C-6) but no action was taken by the OPs and, therefore, he sent an e-mail dated 13.09.2023 (Annexure C-7). However, vide e-mail dated 08.08.2023 (Annexure C-8), the OPs informed that the claim of the complainant had been repudiated as per the condition No.18 of the terms and conditions of the subject policy. The aforesaid act amounts to deficiency in service and unfair trade practice on the part of OPs. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
   2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, non-joinder of parties, jurisdiction and concealment of facts.  It is admitted that the subject policy was issued to the complainant and the same was valid at the relevant time of his treatment.  It is further alleged that as per specific condition No.18 of the subject policy, the insured shall obtain and furnish the company with all original bills, receipts and other documents which were required for dealing with the claim and as the complainant had not submitted the said documents despite repeated remainders, the request dated 20.06.2023 (Annexure OP-5) for cashless authorization at the treating hospital was not approved and the same was denied vide letter dated 21.06.2023 (Annexure OP-6). It is further admitted that the complainant had submitted the claim form (Annexure OP-7) and on 20.07.2023 (Annexure OP-8), the OPs asked the complainant to clarify about the letter of treating doctor, stating the exact cause and duration of pancreatitis, all prior Investigation report, consultation and hospitalization records for further evaluation and to clarify the exact duration of Hypertension and Diabetes Mellitus with all prior consultation papers but he has not given any clarification to the aforesaid queries and, as such the his claim was repudiated vide letter (Annexure OP-10). On merits, the facts as stated in the preliminary objections have been re-iterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
   3. Despite grant of numerous opportunities, no rejoinder was filed by the complainant to rebut the stand of the OPs.
2.        In order to prove their respective claims the parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3.        We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments on record.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had purchased the Health Insurance Policy from the OPs on 20.03.2020, as is also evident from Annexure C-2 and the same was renewed by the complainant from time to time and finally the subject policy was issued/renewed w.e.f. 21.03.2020 to 20.03.2020, as is also evident from Annexure C-1 and the complainant took the treatment from the treating hospital w.e.f. 20.06.2023 to 23.06.2023, as is also evident from the discharge summary (Annexure C-5) and the OPs firstly denied the cashless pre-authorization to the complainant, as is also evident from Annexure OP-6 and finally they repudiated the claim of the complainant vide repudiation letter dated 08.08.2023 (Annexure OP-10), the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in repudiating the genuine claim of the complainant by mis-interpreting the terms and conditions of the subject policy  and the complainant is entitled for the reliefs as prayed for, as is the case of the complainant, or if the OPs are justified in repudiating the claim of the complainant and the complaint of the complainant is liable to be dismissed, as is the defence of the OPs.
   2. In the back drop of the foregoing admitted and disputed facts on record, it is clear that the entire case of the parties is revolving around the terms and conditions of the Insurance Policy (Annexure OP-2 & OP-3), repudiation letter dated 08.08.2023 (Annexure C-8/OP-10) and the medical record of the complainant/insured (Annexure OP-11) and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of the repudiation letter dated 08.08.2023 (Annexure C-8/OP-10), clearly indicates that the claim of the complainant was repudiated as per the condition No.18 of the subject policy on the ground that various discrepancies in the documents were found. The relevant portion of the repudiation letter as well as the condition No.18 of the terms and conditions of the insurance policy are reproduced as under:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of ACUTE PANCREATITIS

We observe various discrepancies in the documents submitted to us. We find all the details regarding the investigation and treatment of the insured patient are not transparently evident. The full facts of the case may not have been presented to us. Therefore, we regret we are not in a position to admit your claim, as per Specific Condition No. 18 of the above policy issued to you.

We therefore regret to inform you that for the reasons stated above we are unable to settle your claim under the above policy and we hereby repudiate your claim.

The above decision has been taken as per the terms and conditions of the policy and based on the claim details/documents submitted.”

 

Condition No.18

 

 “18. The Insured Person/s shall obtain and furnish the Company with all 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”.

 

4. Perusal of the discharge summary (Annexure C-5) further indicates that the complainant was diagnosed with acute pancreatitis underlying chronic pancreatitis (etiology under evaluation) and the relevant portion of the discharge summary is reproduced below for ready reference:-

 “TYPE OF DISCHARGE: NORMAL

 

DIAGNOSIS:

ACUTE PANCREATITIS

UNDERLYING CHRONIC PANCREATITIS (ETIOLOGY UNDER EVALUATION)

PAST HISTORY:

OBESITY TDM

T2DM

HTN

CLINICAL SUMMARY:

33 YEARS OLD MALE PATIENT PRESENTED WITH CHIEF COMPLAINTS OF PAIN IN ABDOMEN, NAUSEA AND VOMITTING.

NOW PATEINT ADMITTED IN OUR SHALBY HOSPITAL FOR FURTHER MANAGEMENT AND EVALUATION.”

Thus one thing is clear from the discharge summary that though the insured/complainant was diagnosed with acute pancreatitis underlying chronic pancreatitis (etiology under evaluation), making it further clear that the medical officer has not given any specific finding that the insured/patient was having chronic pancreatitis especially when no reference has been given about the period from which he has been suffering. It is also not clear from the findings made by the Medical Officer that if the insured/patient had been suffering from chronic pancreatitis before the inception of the policy or during the currency of the subject policy.

5. Moreover, the entire medical record having been produced by the OPs nowhere indicate that if the insured/patient was suffering from chronic pancreatitis before the inception of the policy or during the currency of the subject policy. So far as the letter issued by the OPs asking the complainant to clarify the exact diagnosis, the medical documents etc. issued by the treating hospital are concerned, as the OPs have themselves collected and proved the medical record after obtaining the same from the treating hospital, which is also silent about the period of said disease or if he was suffering from the same before inception of policy, it is unsafe to hold that the complainant was having chronic pancreatitis. Hence, it is safe to hold that the OPs have repudiated the claim of the complainant on technical grounds, knowing fully well that they have failed to prove on record that the complainant was suffering from chronic pancreatitis.
6. In view of the aforesaid discussion, it is safe to hold that the complainant has successfully proved the cause of action set up in the consumer complaint and the present consumer complaint deserves to succeed.
7. Now coming to the quantum of relief, since the complainant has proved the bill summary dated 23.06.2023  (Annexure C-4) through which he paid the amount of ₹85,559/- to the treating hospital for his treatment, it is safe to hold that OP/insurer is liable to pay the said amount to the complainant alongwith interest and compensation etc. for the harassment caused.

4.        In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹85,559/- to the complainant alongwith interest @ 9% per annum (simple) from the date of payment to the treating hospital i.e. 23.06.2023 onwards.
2. to pay ₹10,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5.        This order be complied with by the OPs, within a period of 45 days from the date of receipt of certified copy thereof, failing which the amounts mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
6.        Pending miscellaneous application(s), if any, also stands disposed off.
7.        Certified copies of this order be sent to the parties free of charge. The file be consigned.

5/11/2024			[Pawanjit Singh] President
			[Surjeet Kaur] Member
			[Suresh Kumar Sardana] Member

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