Haryana

Karnal

CC/624/2023

Deepak Kakkar - Complainant(s)

Versus

Star Health And Allied Insurance Company Limited - Opp.Party(s)

Amit Sachdeva

21 Nov 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.624 of 2023

                                                        Date of instt 30.10.2023

                                                        Date of Decision: 21.11.2024

 

Deepak Kakkar, age 38 years, resident of house no.9, Chaman Garden, Railway Road, Karnal-132001.

 

                                                                        …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Company Ltd. having its office at SCF 137, Sector-13, near ICICI Bank, Urban Estate, Karnal-132001 through its Manager/authorized person.
2. Star Health and Allied Insurance Company Limited, registered office at-1-New Tank street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034 through its Managing Director/authorized person.

 

…..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

              Ms. Neeru Agarwal…….Member

      Ms. Sarvjeet Kaur…..Member

 

Argued by:  Shri Dheeraj Sachdeva, counsel for the complainant.

                    Shri Sarthak Singhal, counsel for the OPs.

                   

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that in the month of May 2014, an agent of OPs came to complainant and told about the health policy of OPs and also told that there are number of hospitals on the panel of OPs and in case of any medical emergency, proper care and treatment will be made available at the empanelled hospitals by the OPs. Under the influence of the agent of OPs, complainant purchased medical insurance policy from the OPs on 06.06.2014 and since then, the said medical health insurance policy is in continuation and the complainant is having valid medical insurance policy, vide policy no.P/211130/01/2023/000966. The premium of the said policy was Rs.20,580/- and the same was paid by complainant. The period of insurance is from 06.06.2022 to 05.06.2023. The said insurance plan was a package health plan for the complainant and his family vide plan namely Family Health Optima Insurance Plan. On 18.02.2023, Master Paras Kakkar the son of complainant, a beneficiary in the said policy was not feeling well and was having high fever and cough/cold. The complainant took his son to the Global Cradle hospital at Karnal. The doctor examined the complainant’s and prescribed the medicines for fever cough/cold and throat pain but the patient did not recover and the condition of the patient became worse day by day. On 20.02.2023, the doctor’s advised the complainant to get his son admitted for treatment. The son of complainant got admitted in the hospital. The complainant informed the OPs regarding the admission of his son. On 23.02.2023, the doctor discharged the son of complainant and also suggested some oral antibiotic with stable condition. The complainant has spent an amount of Rs.26,946/- on the treatment of his son. Complainant paid all the bills in the hospital from his own pocket as the said hospital is not empanelled hospital of the OPs. Thereafter, complainant lodged a claim with the OPs for reimbursement of the abovesaid amount but OPs did not pay the said amount and repudiated the claim of complainant, vide letter dated 27.03.2023 on the false and frivolous documents. It is further averred that in the month of August, complainant again submitted the claim form for the re-evaluation to the OPs company with all the necessary documents but OPs neither replied nor made genuine claim payment. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the complainant had taken a Family Health Optima Insurance Policy for a sum of Rs.10,00,000/- covering himself, his spouse and dependent child for the period 06.06.2022 to 05.06.2023. The policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy and the complainant had accepted the policy agreeing of being fully aware of such terms and conditions and has executed the proposal form and all 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 alongwith policy. Intimation regarding the admission of Paras Kakkar in the Global Cradle hospital for the period 20.02.2023 to 23.02.2023 was received and the reimbursement for medical expenses of “Age with Gastritis” was claimed. The medical team of the OPs had observed various discrepancies in the documents submitted by the complainant regarding the investigation and treatment of the insured patient and the full facts of the case were not presented and the hospital was not co-operating and moreover, the prescription etc. were stereotyped and there was multiple tempering and absence of duty staff signatures on the stereotyped documents and thus, the claim was not payable and the same was repudiated by the competent authority after considering all the relevant facts and after applying its mind as per condition no.18 of the policy of insurance. The intimation regarding the repudiation of claim was given to the complainant vide letter dated 27.03.2023 and thus, There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A,  copy of insurance policy Ex.C1, copy of treatment record Ex.C2, copy of bills of treatment and lab reports Ex.C3, copy of discharge summary Ex.C4, copy of final bills and payment receipts Ex.C5 to Ex.C7, copy of repudiation letter dated 27.03.2023 Ex.C8, copy of claim form Ex.C9, copy of medical card of Paras Kakkar Ex.C10, copy of aadhar card of Paras Kakkar Ex.C11 and closed the evidence on 18.04.2024 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma Ex.RW1/A, copy of proposal form Ex.R1, copy of policy schedule Ex.R2, copy of terms and conditions of the insurance policy Ex.R3, copy of claim form Ex.R4, copy of discharge summary Ex.R5, copy of final bill Ex.R6, copy of indoor case papers Ex.R7, copy of test reports Ex.R8, copy of repudiation letter dated 27.03.2023 Ex.R9 and closed the evidence on 08.08.2024 by suffering separate statement.

6.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant purchased a Health Insurance Policy from the OPs. The sum insured under the policy is Rs.10,00,000/-. During the subsistence of the insurance policy, the son of complainant had taken the treatment from Global Cradle Hospital, Karnal and spent Rs.26,946/- on his treatment. Complainant lodged a claim with the OPs and submitted all the required documents and requested for reimbursement of said amount, but OPs did not pay the claim amount and repudiated the claim of complainant on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that OPs issued a health insurance policy for the sum insured of Rs.10,00,000/- for covering complainant (self) and his spouse and dependent child. Complainant lodged the claim for reimbursement. OPs observed various discrepancies in the documents submitted by the complainant. Thus, the claim of the complainant has rightly been repudiated, vide letter dated 27.03.2023 and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant purchased Health Insurance Policy from the OPs. It is also admitted that during the subsistence of insurance policy, son of complainant has taken treatment from Global Cradle Hospital, Karnal and spent  Rs.26,946/-.

11.           The claim of the complainant has been repudiated by the OPs, vide letter Ex.C8/Ex.R9 dated 27.03.2023 on the ground, which are reproduced as under:-

“We processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of Age With Gastritis.

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 reason 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.”

12.           The claim of the complainant has been repudiated by the OPs on the abovesaid ground. The OPs have alleged that various discrepancies were observed in the documents submitted by the complainant and the treatment of the insured patient was not transparently evident. The onus to prove its version was relied upon the OPs but OPs have miserably failed to prove the same by leading any cogent and convincing evidence. OPs have failed to explain the discrepancies in the documents and as to why the treatment of the insured is not transparently evident. Rather, complainant has placed on file discharge summary Ex.C4/Ex.R5, on perusal of said summary, no discrepancies appears. Son of complainant was hospitalized on 20.02.2023 for the treatment of Acute Gastroenteritis with Dehydration with Walri? Multiple V.P.C. (Ventricular Premature Complexes)and discharged on 23.02.2023. Further, If there are any discrepancies in the record on the hands of the treating doctor for that complainant cannot be blamed. Moreover, it has become the routine practice of the insurance companies to reject the genuine claim on minor technicality.  Hence, the repudiation of the claim of complainant is unjustified, arbitrary and not tenable in the eyes of law.

13.           Furthermore, nowadays it has become a trend of insurance companies, they issue the policies by giving false assurances and when insured amount is claimed, they make such type of excuses. Thus, the denial of the claim of complainant is arbitrary and unjustified. In this regard, we place reliance on the judgment of Hon’ble Punjab and Haryana High Court titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, wherein the Hon’ble Punjab and Haryana High Court has held as under:-

“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. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

14.           Keeping in view that the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, the act of the OPs while repudiating the claim of complainant amounts to deficiency in services and unfair trade practice, which is otherwise proved genuine one.

 15.          The complainant has spent an amount of Rs.26,946/- on the treatment of his son and in this regard he has submitted the final bills and payment receipts Ex.C3 and Ex.C5 to Ex.C7, the said amount neither denied nor rebutted by the OPs.  Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental pain, agony harassment and litigation expenses etc.

16.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.26,946/- (Rs. twenty six thousand nine hundred forty six only) alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 27.03.2023 till its realization to the complainant. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs. 5500/- towards the litigation expenses. This order shall be complied within 45 days from the date of receipt of copy of the order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated: 21.11.2024    

                                                          President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Neeru Agarwal)         (Sarvjeet Kaur)

                   Member                          Member