Haryana

Karnal

CC/243/2020

Neelam Rani - Complainant(s)

Versus

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

Pradeep Kapoor

28 Feb 2024

ORDER

BEFORE THE PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION KARNAL.

                                                Complaint No.243 of 2020

                                                Date of Inst: 10.07.2020

                                                Date of Decision: 28.02.2024

 

Neelam Rani wife of late Shri Judge Kumar, resident of H.No.495/18, Avtar Singh Colony, Near Vijay Gupta Hospital, Karnal.

…….  Complainant

Versus

1.     Star Health and Allied Insurance Company Limited, Branch Office: 2^nd Floor, SCF-137, Sector-13, Urban Estate, Karnal, through its authorized signatory.

2.     Star health and Allied Institute Company Limited, office at 23, Ist Floor, Himalaya House, Kasturba Gandhi Marg, New Delhi, Pin Code 110001.

                                                                 …… Opposite parties

Complaint Under Section 12 of Consumer Protection Act, 1986 as amdned upto date.

 

Before:    Shri Jaswant Singh…………President

                Sh.Vineet Kaushik……….Member

                Dr.Suman Singth…………Member

 

Argued by: Shri Pardeep Kapoor, counsel for complainant.

                 Shri Mohit Goyal, counsel for OPs.

 

                (Jaswant Singh President)

 

ORDER:

                The complainant has filed the present complaint under Section 12 of Consumer Protection Act, 1986 (now amended under Section 35 of Consumer Protection Act, 2019) against the Opposite parties (hereinafter referred as the ‘Ops’) on the averments that complainant got a health insurance policy cover for herself and his family member which includes her husband from the agent of OP on 23.03.2014 vide policy No.P/211114/01/2014/001979 after paying full premium amount to the OPs. At the time of taking the policy, a full body checkup as well as medical tests were conducted by the agents of OPs and after finding both the insured fit and to the satisfaction level of company, the abovesaid policy was got issued by the OPs. After completion of one year, the same policy was got renewed. In the month of September, 2018, the husband of complainant got high fever and accordingly, he was admitted to Sanjiv Bansal Cygnus Hospital, Karnal on 20.09.2018 and later discharged on 23.09.2018. The complainant got lodged claim in this regard. Thereafter, again in the month of December, 2018, the husband of complainant due to his ill health admitted in Sanjiv Bansal Cygnus Hospital and was regularly taking treatment as well  as medicines. The condition of husband was not improving accordingly, he was shifted to Apollo Hospital, Delhi on 07.01.2019 and after taking complete treatment from the said hospital, he was discharged on 17.01.2019. Since, it was told by Cygnus Hospital that intimation in this regard have already been communicated to the OPs so complainant spent Rs.4,53,286/- on the said treatment with the hope that the money will be reimbursed. The husband of complainant again admitted in Sanjiv Bansal Cygnus Hospital on 19.01.2019 and was discharged on 21.01.2019 after paying full bill amount to the hospital concerned. Unfortunately, on dated 25.01.2019, husband of complainant got expired leaving behind the complainant and her two major sons. An amount of Rs.7,82,244/- was spent on the treatment of husband of complainant, the original bills are in the possession of complainant. Complainant and her husband duly insured from the OPs vide the policy aforesaid and proper intimation was sent to the OPs about the treatment by complainant as well as authorities of Cygnus Hospital, Karnal and the complainant approached the OPs but OPs paid no need to the genuine request of complainant. A legal notice was also issued to the OPs with the request to make the payment of Rs.7,82,244/- within a period of 15 days from the date of notice but despite the notice, the OPs failed to make the payment. Hence, the present complaint.

2.             On notice, OPs appeared and filed their joint written version and raised preliminary objections regarding maintainability, etc. On merits, it is pleaded that the policy is contractual in nature and claims arising therein are subject to 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 company’s liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured per family mentioned in the schedule. The OPs already settled two cashless claims of the complainant one for an amount of Rs.1,10,416/- and another for Rs.31,350/-. The ailment occurred due to consumption of alcohol is not payable as per exclusion No.4 of the policy terms and conditions. As per the complainant, an amount of Rs.7,82,244/-, Rs.4,53,286/- and Rs.31,350/- spent for treatment, however, the complainant neither submitted bills nor submitted claim documents for the same. 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 complainant has tendered into evidence her affidavit Ex.CW1/A, copies of insurance policies Ex.C1 to Ex.C5, copies of medical bills Ex.C6 to Ex.C27, copy of treatment bill of Apollo Hospital Ex.C28 and copy of death certificate Ex.C29 and closed the evidence on 09.03.2022 by suffering separate statement.

5.             Learned counsel for OPs tendered into evidence affidavit of Shri Rajeev Jain, Chief Manager as Ex.OPW1/A, copy of policy schedule Ex.OP1, copy of terms and conditions Ex.OP2, copy of pre-authorzation request Ex.OP3, copy of pre-authorization request Ex.OP4, copy of progress sheet Ex.OP5, copy of query on pre authorization Ex.OP6, copy of rejection of pre-authorization for cashless treatment Ex.OP7, copy of request for cashless Ex.OP8, copy of authorization Ex.OP9, copy of query on pre authorization Ex.OP10, copy of denial of pre authorization Ex.OP11, copy of progress sheet Ex.OP12, copy of USG Abdomen Ex.OP13, copy of reimbursement of medical claim Ex.OP14, copies of reminders Ex.OP15 to Ex.OP17, copy of authorization for cashless treatment Ex.OP18,  copy of authorization for encashment of amount Ex.OP19, copy of bill Ex.OP20, copy of proposal form Ex.OP21  and closed the evidence on 13.0.2023 by suffering separate  statement.

6.             We have heard the learned counsel of 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 got a health insurance policy cover for herself and his family member. The husband of the complainant fell ill and remained admitted in Sanjiv Bansal Cygnus Hospital, Karnal and thereafter in Apollo Hospital, Delhi and spent Rs.4,53,286/- and an amount of Rs.7,82,244/-. The complainant has sent the intimation to the OPs about the treatment taken by her husband and submitted the claim form for reimbursement but OPs paid no heed to the genuine request of complainant 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 the complainant has neither intimated with regard to admission in the hospital of the insured nor submitted the claim form and without submitting the claim form, the claim cannot be settled. Thus, the present complaint is pre-mature and lastly prayed for dismissal of complaint.

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

10.           The OP has alleged that the complainant neither intimated the OP with regard to death of the insured nor has submitted the claim form for reimbursement of medical bills of her husband.

11.           Now, firstly, we decide, whether the present complaint is pre-mature or not?

12.           The onus to prove her version with regard to submission of claim form with the OP was relied upon the complainant but the complainant has miserably failed to prove her version by leading cogent and convincing evidence. The complainant has relied upon the documents Ex.C1 to Ex.C29. The said documents are relating to the policy, medical bills and death certificate of the insured. There is nothing on file from which can be proved that the complainant had ever intimated or submitted the claim form with the OPs. Without submitting the claim form, the claim of the complainant cannot be decided by the OPs.  The complainant has not disclosed anywhere in the pleadings, the date and month of submission of the claim form. Hence, the version of complainant goes unproved. Thus, the present complaint is pre-mature at this stage. 

13.           In view of the above observation, we dispose of the present complaint being pre-mature with the liberty to the complainant to submit the claim form with the OPs, if so desired, and on receipt of claim form, OPs are directed to settle the claim of the complainant within 30 days. No order as to costs. This order shall be complied with accordingly. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated:28.02.2024

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Suman Singh)   

      Member                       Member