Haryana

Karnal

CC/289/2018

Jagat Singh - Complainant(s)

Versus

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

Kulwant Singh Kadiyan

11 Nov 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 289 of 2018

                                                          Date of instt.29.10.2018

                                                          Date of Decision 11.11.2019

 

Jagat Singh son of Shri Ishwar Singh resident of V.P.O. Chandoli District Panipat now resident of House no.123 Ashoka Nursery, Karnal, age 42 years.

                                                 …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Co. Ltd. through its Manager, SCO 242, 1^st floor, Sector-12, Karnal.

2. Star Health and Allied Insurance Co. Ltd. through its Divisional Manager, Divisional Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034.

                                                                         …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

                Dr. Rekha Chaudhary…….Member

 

 Present:  Shri Kulwant Kadiyan Advocate for complainant.

                   Shri Naveen Khaterpal Advocate for opposite parties.

                 

                    (Jaswant Singh President)

 

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant had taken policy no.P/211124/01/2017/00004 under Family Health Optima Insurance Plan which was valid from 4.11.2016 to 3.11.2017 and paid premium of Rs.11880/- and for this year complainant also renewed the said policy by paying premium of Rs.15287/-, valid from 4.11.2017 to 03.11.2018. On 25.10.2017 the daughter of the complainant namely Riya fall down from the stairs at home in evening at about 3.45 p.m. Accordingly, she was taken to Ved Gupta Hospital, Barsat Road, Panipat where many tests and x-ray has been done by the doctors and doctor advised the complainant to came next day for further treatment. Thereafter, on 26.10.2017 when complainant alongwith her daughter visited to the doctor then he admitted the daughter of the complainant in the Hospital where she was remained indoor patient upto 28.10.2017 and complainant paid Rs.46421/-. Thereafter, complainant lodged claim, vide claim no.0398356 against the said policy and also submitted all relevant documents as per the demand of the OPs within time. Thereafter, various reminders and e-mail etc. sent by the complainant to release the claim amount of Rs.46421/- but OPs every time postpone the matter on one pretext or the other. Thereafter, the complainant again many times visited to the OPs and requested to release the claim amount but OPs always postponed the matter on one pretext or the other and lastly refused to release the claim of the complainant. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written version raising preliminary objections with regard to limitation; jurisdiction; complaint is bad for mis-joinder and non-joinder of necessary parties and concealment of true and material facts. On merits, it is pleaded that the insured availed Family Health Optima Insurance Plan covering Mr.Jagat Singh-self, Sunita-Spouse, Riya and Aryan-Dependant children for the sum insured of Rs.5,00,000/-, vide policy no.P/211124/01/2017/000004 for the period from 04.11.2016 to 03.11.2017. 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 the policy schedule. Moreover, it is clearly stated in the policy schedule “The Insurance under this policy is subject to conditions, clauses, warranties, exclusions etc., attached.” It is further pleaded that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the Proposal form. The insured patient Riya, was hospitalized at Dr. Ved Gupta Hospital for the treatment of B/B Fracture Right Forearm on 26.10.2017 and discharged on 29.10.2017 and submitted claim for Rs.46,421/-. Subsequently, the insured has submitted claim records for reimbursement of medical expenses. On scrutiny of the claim records, it is observed that:

        “As per the inpatient documents (Treatment Chart), the insured patient wanted to go home on 28.10.2017 at 8 p.m. after receiving IV antibiotics, he was then advised to report to the hospital on next day (29.10.2017) morning 6 a.m. which confirms there was no continuous hospitalization.

From the above findings, it is observed that there was no continuous impatient hospitalization. As per permeable of the policy:

        That if during the period stated in the schedule the insured Person shall contact any disease or suffer from any illness or sustain bodily injury through accident and of such disease or injury shall require the insured Person/s, upon the advice of a duly Qualified Physician/Medical Specialist/Medical Practioner or of duly Qualified Surgeon to incur Hospitalization expenses during the period stated in the schedule for medical/surgical treatment at any Nursing Home/Hospital in India as an in-patient, the company will indemnify the insured Person/s the amount of such expenses as are reasonably and necessarily incurred, upto the limits mentioned and/or compensate to an extent as agreed but not exceeding the limit of Coverage in aggregate in any one period stated in the schedule hereto.

In-patient means an Insured Person who is admitted to Hospital and stays there for a minimum period of 24 hours for the sole purpose of receiving treatment.

Further, the discharge summary and other medical documents shows continuous hospitalization, which shows discrepancy in the medical records. Thus, the claim is not payable as per the condition no.8.

The condition no.8, reads as follow

        “If there is any misrepresentation/non-disclosure of material facts 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 of the complainant was repudiated and the same was communicated to the insured vide letter dated 23.01.2018. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C27 and closed the evidence on 28.08.2019.

4.             On the other hand, OPs tendered into evidence affidavit of Rajiv Jain Ex.RW1/A and documents Ex.R1 to Ex.R10 and closed the evidence on 15.10.2019.

5.             We have heard the learned counsel of both the parties and perused the case file carefully and have also gone through the evidence led by the parties.

6.             The case of the complainant, in brief, is that complainant had taken policy no.P/211124/01/2017/00004 under Family Health Optima Insurance Plan, which was valid from 4.11.2016 to 3.11.2017 and complainant renewed the said policy, valid from 4.11.2017 to 03.11.2018. On 25.10.2017 the daughter of the complainant namely Riya fall down from the stairs and she was taken to Ved Gupta Hospital, Barsat Road, Panipat where many tests and x-ray has been done by the doctors. The daughter was admitted in the Hospital where she was remained indoor patient upto 28.10.2017 and complainant paid Rs.46421/-. Thereafter, complainant lodged claim with the OPs for reimbursement of claim amount OPs every time postpone the matter on one pretext or the other. Thereafter, the complainant again many times visited to the OPs and requested to release the claim amount but OPs always postponed the matter on one pretext or the other and lastly effused to release the claim of the complainant.

7.             The case of the OPs is that the complainant lodged a medical claim for reimbursement of the amount. The insured patient Riya, was hospitalized at Dr. Ved Gupta Hospital for the treatment of B/B Fracture Right Forearm on 26.10.2017 and discharged on 29.10.2017 and submitted claim for Rs.46,421/-. Subsequently, the insured has submitted claim records for reimbursement of medical expenses. On scrutiny of the claim records, it is observed that:

        “As per the inpatient documents (Treatment Chart), the insured patient wanted to go home on 28.10.2017 at 8 p.m. after receiving IV antibiotics, he was then advised to report to the hospital on next day (29.10.2017) morning 6 a.m. which confirms there was no continuous hospitalization.”

The discharge summary and other medical documents shows continuous hospitalization, which shows discrepancy in the medical records. Thus, the claim is not payable as per the condition no.8.

The condition no.8, reads as follow

        “If there is any misrepresentation/non-disclosure of material facts 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 of the complainant was repudiated and the same was communicated to the insured vide letter dated 23.01.2018.

8.             Admittedly, the complainant had purchased Family Health Optima Insurance Plan covering the complainant-self, Sunita Spouse, Riya (insured in the present claim) and Aryan for the Sum Insured of Rs.5,00,000/-. It is also admitted, insured Riya was hospitalized at Ved Gupta Hospital for a treatment on 26.10.2017 and discharge on 29.10.2017 and submitted the claim of Rs.46,421/-. The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.R7 on the ground that the insured-patient to home on 28.10.2017 at 8 p.m., which confirms there was  no continuous hospitalization and as per the terms and conditions of the policy Ex.R10, insured person who is admitted to Hospital and stays there for a maximum period of 24 hours for the sole purpose of receiving treatment.

9.             As per the terms and conditions of the policy Ex.R10, patient who was admitted in the hospital for the period of 24 hours or more than is only entitled for medical expenses. In the present case as per discharge summary the insured- patient got admitted in the hospital on 26.10.2017 and discharged on 29.10.2017. As per the version of the OP, the insured had gone home on 28.10.2017 at 8 p.m. and has reported on the next day (29.10.2017) morning, which confirms there was no continuous hospitalization. For the sake of argument, if the version of the OP, presumed to be true even after that the stay of the patient in the hospital comes out to b e  more than 24 hours as she admitted in the hospital on 26.10.2017 and had gone to home on 28.10.2017.

10.            In case New India Assurance Company Limited Versus Smt. Usha Yadav & Others 2008 (3) R.C.R. (Civil) III, the Hon’ble Punjab & Haryana High Court expressed its anguish and observed as follows:

“It seems that the Insurance Companies are only interest 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 adopted methods which could not be governed by the strict conditions contained in the policy.”

11.            It is also relevant to mention here that Section 19 of the General Insurance Business (Nationalization) Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of medical expenses reimbursement is utterly arbitrary on the ground that disease in question was pre-existing disease. It is mere an excuse to escape liability and is not bonafide intention of the insurance company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State ad public behaviour. Any policy in the realm of insurance company should be informed, fair and non-arbitrary. When the Insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice. So, we are of the confirmed view that the act of the OPs amount to deficiency in service and unfair trade practice. The claim of the complainant has proved the medical bills Ex.C5 to Ex.C26 amounting to Rs.46,421/-. Thus, the complainant is entitled the same alongwith compensation.

11.            Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.46,421/- to the complainant with interest @ 9% per annum from the date of repudiation till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment suffered by him and Rs.5500/- for the litigation expenses.  This order shall be complied with within 30 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:11.11.2019

                                                                    President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

 

 

                 (Dr. Rekha Chaudhary)

                        Member