Haryana

Karnal

CC/108/2023

Gulshan Kumar - Complainant(s)

Versus

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

Shubham Kalia

02 May 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 108 of 2023

                                                        Date of instt.13.02.2023

                                                        Date of Decision:02.05.2024

 

Gulshan Kumar aged about 52 years son of Shri Darshan Lal, resident of Trivedi Camp, Mubarakapur, S.A.S. Nagar (Mohali), Punjab. Aadhar no.653549054895.

 

                                               …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Co. Ltd. # SCF-137, 2^nd floor, near ICICI Bank, Sector-13, Urban Estate, Karnal-132001, through its Branch Manager.

 

2. Star Health and Allied Insurance Co. Ltd. # no.15, Sri Balaji Complex 1^st floor, whites Lane, Royapettah, Chennai-600014 through its M.D./CEO/Authorized Signatory.

 

…..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Dr.  Suman Singh…..Member

 

 Argued by: Shri Shubham Kalia, counsel for the complainant.

                    Shri Rajesh Kumar 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 July, 2022, complainant had purchased/renewed a health insurance policy from the OPs, vide policy no.P/211114/01/2023/005321 by paying premium of Rs.19,017/-. The product name Medi Classic Insurance Policy (individual)  revised 2022 and said insurance policy commenced from 27.07.2022 upto 26.07.2023. In the said insurance policy the basic sum assured is Rs.5,00,000/-. Prior to purchasing the said policy, the complainant had also purchased a health insurance policy no.P/211114/01/2022/003755 from the OPs and the said policy commenced from 05.07.2021 upto 04.07.2022. In the month of July 2022, the complainant had suffered from Acute chest pain and thereafter complainant was admitted in Amcare, Super-Specialty Hospital, VIP Road, Zirakpur, Punjab for his treatment, where the concerned doctor diagnosed him with ACS unstable angina and admitted the complainant on 28.07.2022 and was discharged on 30.07.2022. The complainant has spent an amount of Rs.1,45,000/- on his treatment. After discharge from the hospital, complainant lodged a claim with the OPs for reimbursement of the said amount and also completed all the formalities as required by the OPs. Thereafter, complainant visited the office of OPs several times and requested to settle his claim but OPs did not bother to the request of complainant and lastly vide letter dated 25.11.2022 repudiated the claim of complainant on the false and frivolous ground that there are various discrepancies in the documents submitted by the complainant. Then complainant sent a legal notice dated 24.01.2023 to the OPs but it also did not yield any result. 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 written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the complainant had availed the Medi Classic Insurance Policy from the OPs for a sum of Rs.5,00,000/- and the said policy was valid from 27.07.2022 to 26.07.2023. The terms and conditions of the policy were explained to the complainant at the time of proposing the policy and the same was served to the complainant alongwith policy schedule. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. It is further pleaded that the complainant was admitted in Amcare Medical & Research Pvt. Ltd. Zirakpur and remained there for the period 28.07.2022 to 30.07.2022 and he was diagnosed as ACS Unstable Angina and a claim of Rs.1,47,630/- was submitted. The insured had requested for cashless medical expenses towards the treatment of chest pain/ACS Unstable Angina on 28.07.2022 but the cashless was rejected on 29.07.2022 as the OPs were not able to ascertain the duration of the disease based on the documents/details submitted by the hospital and had asked the complainant to submit the claim for reimbursement after discharge from the hospital. The complainant had submitted the bill for reimbursement and on scrutiny of the claim documents, it was observed that there were various discrepancies in the documents submitted to the OP and it was found that the investigation and treatment of the insured patient are not transparently evident and the full facts of the case have not been presented to the OPs. Therefore, the claim was not payable and the same was denied as per the terms and conditions of the policy of insurance. As per 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. Hence, the claim was rejected and the rejection was duly conveyed to the complainant, vide letter dated 25.11.2022. 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.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy dated 05.07.2021 Ex.C1, copy of customer identity card Ex.C2, copy of tax invoice Ex.C3, copy of health insurance policy dated 27.07.2022 Ex.C4, copy of tax invoice dated 27.07.2022 Ex.C5, copy of repudiation letter dated 25.11.2022 Ex.C6, copy of Amcare Hospital Final Bill Ex.C7, copy of Amcare Hospital discharge summary Ex.C8, copy of legal notice Ex.C9, postal receipts Ex.C10 and Ex.C11 and closed the evidence on 05.05.2023 by suffering separate statement.

4.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.OP1/A, copy of proposal form Ex.R1, copy of insurance policy Ex.R2, copy of policy schedule Ex.R3, copy of cashless authorization request Ex.R4, copy of query on authorization for cashless treatment Ex.R5 and Ex.R6, copy of denial of pre-authorization request for cashless treatment Ex.R7, copy of insurance policy dated 28.07.2022 Ex.R8, copy of letter dated 09.08.2022 regarding authorization to Star Health and Allied Insurance Co. Ltd. alongwith discharge summary Ex.R9, copy of final bill Ex.R10, copy of letter dated 25.08.2022 regarding requirement of additional documents/information Ex.R11, copy of reminders dated 09.09.2022 and 24.09.2022 Ex.R12 and Ex.R13, copy of letter dated 09.10.2022 Ex.R14, copy of repudiation letter dated 25.11.2022 Ex.R15, copy of bill assessment sheet Ex.R16 and closed the evidence on 14.09.2023 by suffering separate statement.

5.             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.

6.             Learned counsel for the complainant, while reiterating the contents of complaint, has vehemently argued that complainant purchased a Medi Classic Insurance Policy for a sum of Rs.5,00,000/- from the OPs. In the month of July 2022, the complainant had suffered from ACS Unstable Angina due to Acute chest pain and was got admitted in the Amcare, Super-Specialty Hospital, Zirakpur, Punjab for his treatment.  The complainant spent an amount of Rs.1,45,000/- on his treatment. The complainant submitted the claim with the OPs for pre-authorization and lateron for reimbursement of the 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.

7.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that the complainant was admitted in Amcare Medical & Research Pvt. Ltd. Zirakpur and was diagnosed as ACS Unstable Angina and the insured had requested for cashless medical expenses but the cashless request was rejected on 29.07.2022 and asked the complainant to submit the claim for reimbursement after discharge from the hospital. The complainant had submitted the claim with the OPs for reimbursement but the claim was not payable as there were various discrepancies in the documents submitted by the complainant. So, the claim of complainant was rightly rejected by the OPs and lastly prayed for dismissal of the complaint.

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

9.             Admittedly, complainant had availed Medi Classic Insurance Policy from the OPs for the sum of Rs.5,00,000/-. It is also admitted that during the subsistence of the insurance policy the complainant was hospitalized in Amcare Super Specialty Hospital, Zirakpur and spent Rs.1,45,000/- on his treatment.

10.           The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.C6/Ex.R15 dated 25.11.2022 on the grounds, which are reproduced as under:-

“We have processed the claim records relating to the complainant seeking reimbursement of hospitalization expenses for treatment of ACS Unstable Angina.

We observes 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.”

 

11.           The claim of the complainant has been repudiated by the OPs on the aforesaid grounds. The onus to prove its version was relied upon the OPs, but OPs has miserably failed to prove the same by leading any cogent and convincing evidence. OPs have failed to prove the discrepancies in the documents/medical records as alleged by them. Moreover, on perusal of the medical records placed on file by the parties, there appears to be no discrepancies in the said records. It appears that OPs have rejected the claim of complainant on the basis of presumption and assumption, which is not admissible in the eyes of law.

12.           During the course of arguments, OPs have relied upon letter Ex.R11 dated 25.08.2022 (subject: requirement of additional documents/information), 1^st Reminder Ex.R12 dated 09.09.2022, 2^nd reminder Ex.R13 dated 24.09.2022 and letter of rejection of Reimbursement claim Ex.R14 dated 09.10.2022, but OPs have not discussed about the alleged documents in its written version. There is no proof on the file that above letters have been delivered to the complainant. Meaning, thereby, all the alleged letters/reminders have been prepared lateron by the OPs, just to delay the claim and to harass the complainant. Furthermore, OPs have alleged that treatment of the insured are not transparently evident but they have failed to prove the same by leading any cogent and convincing evidence. Thus, plea taken by the OPs has no force.

13.  

“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, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OPs while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

15.           The complainant has spent Rs.1,45,000/- on his treatment and in this regard he has placed on file the medical bills Ex.C7. The said bill has been admitted by the OPs. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental 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.1,45,000/- (Rs. one lakhs forty five thousand only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e.25.11.2022 till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.
Announced

Dated: 02.05.2024 

  President,       

District Consumer Disputes

Redressal Commission, Karnal.

 

                  (Vineet Kaushik)              (Dr. Suman Singh)      

                      Member                             Member