Chandigarh

DF-I

CC/383/2023

BHAWNA GUPTA - Complainant(s)

Versus

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

JASKARAN SINGH

05 Jun 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/383/2023
Date of Institution	:	28/07/2023
Date of Decision	:	05/06/2024

Bhawna Gupta w/o Gaurav Gupta, aged 33 years, r/o flat No.602, Tower-5, Hero Homes, Sector-88, Mohali 160065.

… Complainant

V E R S U S

1. Star Health and Allied Insurance Company Limited, through its Manager/Authorised Signatory, having its branch office at SCO 5A, 2^nd Floor, Madhya Marg, Sector 7C, Chandigarh.
2. Gupta Nursing Home, situated at Naveen Colony, Naraingarh-134203, Ambala, through concerned Doctor/Authorised signatory.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

                                                                               

ARGUED BY	:	Sh.Gaurav Gupta, Advocate for complainant
	:	Sh.Vikramjeet Singh, Advocate for OP-1
	:	Sh.Abhinav Aggarwal, Advocate for OP-2 (OP-2 ex-parte)

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Bhawna Gupta, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that the complainant had been getting the health insurance policy from OP-1/ insurer for the last six years and the subject policy i.e. Family Health Optima Insurance Plan was obtained by the complainant, which was valid w.e.f. 8.7.2022 to 7.7.2023 (Ex.C-1) on payment of premium of ₹15,777/-. However, OP-1 never supplied the policy terms and conditions to the complainant.  On 23.10.2022, due to fever and sudden shortness of breath, complainant was hospitalized at Gupta Nursing Home, Naraingarh (hereinafter referred to as “Treating Hospital”) where she remained admitted from 23.10.2022 to 25.10.2022.  Intimation qua the hospitalisation was also given by the complainant to OP-1, which was duly acknowledged by OP-1 vide email dated 25.10.2022 (Ex.C-2).  Complainant was discharged from the Treating Hospital on 25.10.2022 and copy of discharge summary is Ex.C-3.  After getting discharged, complainant submitted the original documents alongwith claim form with OP-1 for processing the claim as she had spent an amount of ₹27,803/- for her treatment.  Copies of claim form, bills of treatment and medical examination bills are Ex.C-4 to Ex.C-12 and the receipt of the same was acknowledged by OP-1 vide email (Ex.C-13). However, vide email dated 22.11.2022 (Ex.C-14), OP-1 repudiated the genuine claim of the complainant on the ground that investigation and treatment of the insured patient are not transparently evident.  Despite of receiving the original documents qua the treatment of the complainant from the treating hospital/OP-2, OP-1/insurer has wrongly and arbitrarily repudiated the genuine claim of the complainant. Even the repudiation letter was also duly replied by the complainant vide email dated 25.11.2022 (Ex.C-15), but, with no success. In this manner, the aforesaid act of the OPs amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result. Hence, the present consumer complaint.
2. OP-1 resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, cause of action and concealment and misrepresentation of facts.  However, it is admitted that the complainant had purchased the subject policy from the answering OP, which was valid at the relevant time.  It is further alleged that the complainant/insured was hospitalized for AFI/LRTI at the Treating Hospital from 27.8.2021 to 31.8.2021 and as per the record submitted, there is tampering made in DOA (date of admission) in the discharge summary.  Not only this, the tampering was also noticed on ICP papers etc. and in this manner the investigation and treatment of the insured patient are not transparently evident and as per condition No.1 of the subject policy, if there is any misrepresentation by the insured person or any other person acting on his behalf, the company is not liable to make any payment. Moreover, there are certain expenses, regarding which the complainant has also made the claim, which are not covered under the subject policy and she is not entitled for the same.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. Though, pursuant to the notice issued, OP-2 put in appearance through counsel, but, as neither the reply and evidence were filed, within the stipulated period, nor anybody appeared on its behalf on the subsequent date, hence it was proceeded against ex-parte vide order dated 22.11.2023.
4. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, contesting 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 written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant, alongwith her husband and minor daughter, were insured under the subject policy (Ex.C-1), obtained from OP-1, which was valid w.e.f. 8.7.2022 to 7.7.2023 with basic floater sum insured of ₹10.00 lacs and the complainant/insured patient was admitted in the Treating Hospital and was diagnosed as “AFI/LRTI”, as is also evident from the discharge summary (Ex.C-3) and the claim lodged by the complainant has been repudiated by OP-1/insurer vide letter dated 22.11.2022 (Ex.C-14) on the ground that investigation and treatment of the insured patient are not transparently evident, the case is reduced to a narrow compass as it is to be determined if OP-1/insurer is unjustified in repudiating the genuine claim of the complainant on the said ground and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if OP-1/insurer is justified in repudiating the claim of the complainant and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of OP-1/insurer.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, medical record, having been relied upon by both the parties and the repudiation letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Ex.C-1 is copy of the subject policy, which clearly indicates that the same was valid w.e.f. 8.7.2022 to 7.7.2023 with basic floater sum insured of ₹10.00 lacs.
   4. As per the case of the complainant, she remained admitted in the Treating Hospital w.e.f.  23.10.2022 to 25.10.2022, as is also evident from the copy of discharge summary (Ex.C-3).  However, the case of the complainant has been resisted by OP-1/insurer on the ground that certain tamperings were noted on the medical record, having been relied upon by the complainant, as she was hospitalized for AFI/LRTI at the Treating Hospital w.e.f. 27.8.2021 to 31.8.2021. However, this defence of OP-1/insurer stands falsified from the medical record, having been produced and relied upon by OP-1, as OP-1 itself has proved the copy of discharge summary (Ex.R-5), having been issued by the Treating Hospital alongwith other medical record (Ex.R-6) ICP papers, which clearly indicates that the insured patient was admitted in the said hospital on 23.10.2022 and was discharged on 25.10.2022 and not remained admitted from 27.8.2021 to 31.8.2021, as is the defence of OP-1 set up in its written version.
   5. Not only this, even OP-1 has not made any investigation in order to ascertain the fact if the insured patient was ever admitted in the treating hospital w.e.f. 23.10.2022 to 25.10.2022 and the complainant has made any misrepresentation or tampering in the medical record as alleged in the written version. Though, in the discharge summary the date of admission has been overwritten, but, even the said overwriting has been duly initialed by the medical officer who issued the discharge summary with his stamp.  Even as per ICP papers (Ex.R-6) as well as repudiation letter (Ex.R-10), the date of admission is categorically mentioned as 23.10.2022.
   6. Moreover, the repudiation letter itself indicates that OP-1 has repudiated the claim of the complainant on flimsy grounds by not referring the facts indicating that the complainant has misrepresented the facts. The relevant portion of the repudiation letter is reproduced below for ready reference :-

“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 claims, as per the terms and conditions of the policy issued to you.

As per Condition No.1 of the policy issued to you, 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.”

 

7. Not only this, even the ground mentioned in repudiation letter, while repudiating the claim, the OPs have given reference of some investigation having been made by OP-1, but, no such investigation report has been proved or produced on record by it in order to prove that the complainant has misrepresented any fact qua her treatment. Hence, it is unsafe to hold that OP-1/ insurer was justified in repudiating the claim of complainant and the said act certainly amounts to deficiency in service and unfair trade practice on its part.
8. Now coming to the quantum of amount to be awarded in the instant case, the complainant has claimed an amount of ₹27,803/- by placing on record the medical bills (Ex.C-5 to C-10).  However, in the bill assessment sheet (Ex.R-11), OP-1 has assessed the medical expenses borne by the complainant to the tune of ₹24,077/- only by referring that an amount of ₹3,226/- is not payable, being not covered under the subject policy i.e. on account of mask, disposable, admission charges etc.  In this manner, as OP-1 itself has approved the claim to the tune of ₹24,077/- in pursuance to the terms and conditions of the subject policy, it is safe to hold that OP-1 is liable to pay the said amount to the complainant alongwith interest and compensation etc.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP-1 is directed as under :-

1. to pay ₹24,077/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 22.11.2022 onwards.
2. to pay ₹5,000/- 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 OP-1 within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Since no deficiency in service or unfair trade practice has been proved against OP-2, the consumer complaint against it stands dismissed with no order as to costs. 
7. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
8. Certified copies of this order be sent to the parties free of charge. The file be consigned.

05/06/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member