Haryana

Karnal

CC/56/2024

Mohinder Kumar Saluja - Complainant(s)

Versus

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

Kartik Jindal

17 Sep 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No.56 of 2024

                                                        Date of instt. 29.01.2024

                                                        Date of Decision: 17.09.2024

 

Mohinder Kumar Saluja son of Shri Hari Chand, resident of house no.43, old Ramesh Nagar, Karnal. Aged 54 years, aadhar card no.6463 7112 6276. Mobile no.98962 56009.

                                                                        …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Company Limited, SCF no.137, Sector-13, near ICICI Bank, Karnal through its Branch Manager.
2. Star Health and Allied Insurance Company Limited, no.15, Sri Balaji Complex, first floor whites Lane, Royapettah, Chennai-PIN-600014 through its Branch office SCF no.137, Sector-13, near ICICI Bank, Karnal through its Branch Manager.

 

…..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 Kartik Jindal, counsel for the complainant.

                    Shri Naveen Khetarpal, 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 complainant and his family members purchased the mediclaim policy no.P/211114/01/2024/008837 on 18.10.2023. The abovesaid policy is valid from 18.10.2023 to midnight of 17.10.2024. The basic floater sum insured is Rs.10,00,000/-. The complainant is an old customer of the OPs as he purchased the policy on 18.10.2013. On 15.11.2023, complainant visited Shri Ram Chand Memorial Hospital Pvt. Ltd. Karnal on account of fever and severe pain in the body, particularly in the joints. In this regard, the doctor concerned issued an OPD card and also prescribed the required medicines. The complainant could not bear the pain even after taking the medicine which were prescribed by the doctors. Due to unbearable pain and fever, the complainant visited the said hospital on 16.11.2023 and remained admitted upto 20.11.2023. The intimation was given to the OPs regarding admission of complainant. After discharge from the hospital, complainant visited in the said treatment for follow up treatment.  Complainant spent an amount of Rs.57,557/- on his treatment in the said hospital. Complainant submitted a claim form alongwith required documents with the OPs for reimbursement of the abovesaid amount but OPs did not pay the said amount despite of repeated requests and visits. Lastly, OPs refused to pay the claim amount and repudiated the claim of complainant on the false and frivolous ground. Thereafter, complainant sent various emails to the OPs for reconsideration of the claim of complainant but OPs did not consider the request of complainant and rejected the claim of complainant. 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 objection with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that complainant availed the Star Health Assure Insurance Policy through Branch Office covering Mohinder Kumar Saluja-self, Monika Kumar-Spouse, Taksh Saluja and Kunjan-dependent child for sum insured of Rs.10,00,000/-, vide policy no.P/211114/01/2024/008837, valid from 18.10.2023 to 17.10.2024. 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 has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. The insured has submitted the reimbursement of the medical expenses towards the treatment AFI at Shri Ram Chand Memorial Hospital on 16.11.2023 to 20.11.2023. After scrutiny of documents, various discrepancies were observed in the documents submitted to OPs. OPs company find all the details regarding the investigation and treatment of the insured patient is not transparently evident. The full facts of the case may not have been presented to OPs Company. Therefore, OPs company not in a position to admit claim of the complainant, as per specific condition no.18, of the above policy issued to insured. Hence, being not maintainable, as per terms and conditions of the policy, the claim was rejected and conveyed to insured, vide letter dated 20.12.2023, which was communicated to the complainant. 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 list of receipts Ex.C1, copy of insurance policy Ex.C2, copy of claim registration intimation Ex.C3, copy of claim form Ex.C4, copy of repudiation letter dated 20.12.2023 Ex.C5, copy of application dated 23.12.2023 for reconsider the claim Ex.C6, copy of letter of hospital dated 22.12.2023 Ex.C7, copy of reply of reconsider the claim dated 15.01.2024 Ex.C8, copy of email ID dated 23.12.2023 Ex.C9, copy of reply of mail dated 08.01.2024 Ex.C10, copy of reply of mail dated 29.12.2023 Ex.C11, copies of bills dated 20.11.2023, 24.11.2023 and 01.12.2023 Ex.C12 to Ex.C14, copies of IPD and OPD receipts Ex.C15 to Ex.C19, copy of investigation report Ex.C20, pharmacy receipts Ex.C21 to Ex.C29, OPD slips dated 15.11.2023, 24.11.2023 and 1.12.2023 Ex.C30 to Ex.C32, copy of IPD slip Ex.C33, copy of discharge slip dated 20.11.2023 Ex.C34, copy of investigation report Ex.C35 to Ex.C43, copy of terms and conditions of the insurance policy Ex.C44, copy of aadhar card Ex.C45 and closed the evidence on 07.05.2024 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 Part-A Ex.R4, copy of discharge summary Ex.R5, copy of IPD final bills detail Ex.R6, copy of tests report Ex.R7, copy of TPR chart Ex.R8, copy of repudiation letter dated 20.12.2023 Ex.R9 and closed the evidence on 10.07.2024 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, complainant had taken the treatment from Shri Ram Chand Memorial Hospital Private Ltd. Karnal and spent Rs.57,557/- on his treatment. Complainant lodged a claim with the OPs and submitted all the required documents and also requested the OPs for reimbursement of said amount, but OPs did not pay the spent amount and repudiated the claim the 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), his spouse and dependent children. Complainant lodged the claim for reimbursement. OPs observed various discrepancies in the documents submitted by the complainant. Thus, the claim of the complainant was rightly repudiated, vide letter dated 20.12.2023 by the OPs 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 the complainant had taken treatment from Shri Ram Chand Memorial Hospital, Pvt. Ltd., Karnal and spent an amount of Rs.57,557/- on his treatment.  

11.           The claim of the complainant has been repudiated by the OPs, vide letters Ex.C5/Ex.R9 dated 20.12.2023 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 AFI.

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 is 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 that what discrepancies in the documents and why the treatment of the insured are not transparently evident. Rather, complainant has placed on file treatment record Ex.C33, discharge/DOPR/LAMA Referral Ex.C34, on perusal of said documents, no discrepancies appears. Complainant was hospitalized on 16.11.2023 for the treatment of Acute Febrile illness with body and severe joint pain and discharged on 20.11.2023. Further, If there are any discrepancies in the record on the hands of the treating doctor for that complainant cannot be blamed. Moreover, nowadays, 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, now a days 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.57,557/- on his treatment and in this regard has submitted the list of receipts Ex.C1, IPD final bill details Ex.C12 and bills Ex.C13 to Ex.C29, the said amount neither denied nor rebutted by the OPs.  Hence, the complainant is entitled for the amount of Rs.57,557/- 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.57,557/- (Rs. fifty seven thousand five hundred fifty seven only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 20.12.2023 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 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: 17.09.2024   

                                                                    President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Neeru Agarwal)         (Sarvjeet Kaur)

                   Member                          Member