Haryana

Karnal

CC/141/2022

Pushkar - Complainant(s)

Versus

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

Balinder Sandhu

28 Nov 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.141 of 2022

                                                        Date of instt 21.03.2022

                                                        Date of Decision: 28.11.2024

 

Pushkar minor son of Satyawan, resident of house no.36-B, Gali no.3, Basant Vihar, Karnal, through his mother Smt. Kamal Devi as his natural guardian and next friend of minor who has got no adverse interest to that of minor. Aadhar no.2453 1102 7913.

 

                                                                        …….Complainant.

                                              Versus

 

1.  Star Health and Allied Insurance Company Limited registered  and corporate office 1, new Tank street, Valluvar Kotlum High Road,  Nungambakkarm Chennai, 600034 through its authorized person.
2. Star Health and Allied Insurance Company Ltd. SCF 137 Sector 13 Market, Karnal through its 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 Balinder Sandhu, 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 the father of complainant namely Satyawan purchased a Family Health Optima Insurance Policy from OPs, vide policy no.P/211114/01/2022/010644 dated 01.12.2021, valid from 01.12.2021 to 30.11.2022. As per terms and conditions of the policy, all family members of Satyawan are covered under this policy and OPs are liable to pay the compensation to the complainant also being his son. On 26.02.2022 at about 7 a.m., the complainant was standing near Partap Public School Sector-6, Karnal in the meanwhile a car came in wrong side and hit the complainant and he met with an accident. After the accident, he was taken to Amritdhara hospital, Karnal where he remained admitted from 26.02.2022 to 03.03.2022. The intimation was sent to the OPs. A sum of Rs.2,72,352/- has been spent by the father of complainant on his treatment.  Thereafter, complainant lodged the claim, vide claim no.CIR/2022/211114/3919501 with the OPs and submitted all the required documents for reimbursement of the said amount but till today OPs have not paid the same to the complainant and repudiated the claim of complainant, vide letter dated 02.03.2022 on the false and frivolous ground. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence complainant filed the present complaint seeking direction to the OPs to pay Rs.2,72,352/- alongwith interest @ 24% per annum and to pay Rs.50,000/- on account of deficiency in service and causing the mental pain, agony and harassment as well as financial loss and any other relief to which this Commission deems fit may also be granted to the complainant.

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 availed Family Health Optima Insurance Plan covering Mr. Satyawan (self), Mrs. Kamal Devi(spouse), Pushkar and Mehak-dependent children for sum of Rs.10,00,000/-, vide policy no.P/211114/01/2022/010644 for the policy period 01.12.2021 to 30.11.2022, which is continuation since 30.11.2015 from Star Health and ported to Religare and thereafter again ported to Star Health again on 01.12.2020. The complainant raised the cashless request for hospitalization on 27.02.2022 in Amrtidhara Hospital Pvt. Ltd. towards the treatment of Roadside accident. On scrutiny of the pre-authorization documents, the opponent has initially approved an amount of Rs.50,000/- on 28.02.2022 based on pre-auth request and other documents submitted. On receipt of addition documents it is noted that

.               Discrepancy is observed in the circumstances of the injury

.               As per the parent details-Roadside accident hit by the car but as per the letter from the insured’s sister Mehak (age 16) (which is mentioned as brother in rejection letter)-patient was hit by a car while driving the scooter.

.               Moreover, as per the policy information sent to the hospital, the age of injured is 18 years, but as per the policy and medical records age of complainant is 14 years with above facts and discrepancy claim not admissible.

OPs are, therefore, unable to approve the claim and the authorization already given for cashless treatment of the above diagnosed disease stands withdrawn vide letter dated 02.03.2022. The insured sent a reconsideration stating that the claim should be verified again, since the earlier investigator has collected wrong investigation and said that his son was standing near a scooty and a car hit him. Thus, the claim was investigated again and the insured was ready to give information to the investigator, however based on the ICP collected by the investigator it is noted that:

.       As per the ICP collected by the investigator, the insured has complaints of RSA (by bike).

.       As per the information given by the sister of patient, the insured was driving the scooter and was hit by a car.

.       The insured is a minor and to prevent the legal action the insured         age is mentioned as 18 in policy information form.

.       As per the allegation of the complainant that if a car hit Pushkar, why the complaint is not filed against the car owner.

It is further pleaded that the complainant incurred an amount of Rs.2,72,352/- on his treatment. The cashless request of the complainant was rejected. However, complainant has not submitted any claim for reimbursement of the medical expenses. 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 aadhar card of Kamal Devi Ex.C1, copy of rejection letter dated 02.03.2022 Ex.C2, copy of admission form Ex.C3, copy of physical examination report Ex.C4, copy of critical care flow sheet Ex.C5, copies of medical bills Ex.C6 to Ex.C9, copy of discharge summary Ex.C10, copy of aadhar card of Puskhar Ex.C11, copy of customer ID cards Ex.C12 to Ex.C16 and closed the evidence on 09.12.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of affidavit of Sumit Kumar Sharma Ex.OPW1/A, copy of terms and conditions of the policy Ex.R1, copy of policy schedule Ex.R2, copy of proposal form Ex.R3, copy of portability form alongwith declaration Ex.R4, copy of authorization request Ex.R5, copy of field visit report Ex.R6, copy of cashless authorization letter dated 28.02.2022 Ex.R7, copy of statement given by the insured sister Ex.R8, copy of Police Information Form Ex.R9, copy of Urine Examination Report dated 27.02.2022 Ex.R10, copy of Head Report dated 26.02.2022 Ex.R11, copy of NCCT Face Report dated 26.02.2022 Ex.R12, copy of Critical Care Flow Sheet Ex.R13, copy of rejection and withdrawal of approval letters dated 02.03.2022 Ex.R14 and closed the evidence on 17.10.2023 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 the father of complainant  purchased Health Insurance Policy from the OPs for the sum insured of Rs.10,00,000/-. During the subsistence of the policy, complainant has taken the treatment from Amritdhara Hospital, Karnal and spent an amount of Rs.2,72,352/-.  Complainant lodged a claim with the OPs for reimbursement of the said amount and submitted all the required documents to settle the claim, but OPs did not pay the claim amount and repudiated the claim of complainants 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 Mr. Satyawan (self), his spouse and dependent children Pushkar (complainant) and Mehak. Complainant got admitted in Amritdhara Hospital in a roadside accident case. On investigation of the pre-authorization request, OPs observed various discrepancies in the documents submitted by the complainant’s father.  Thereafter, complainant never submitted the claim for reimbursement. Hence, the complaint is premature and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, Satyawan father of complainant purchased a Family Health Optima Insurance Plan from the OPs. It is also admitted that during the subsistence of insurance policy the insured (complainant) has taken treatment from Amritdhara Hospital, Karnal and spent an amount of Rs.2,72,352/- on his treatment. 

11.           The cashless claim of the complainant has been denied by the OPs, vide letter Ex.C2/Ex.R4 dated 02.03.2022 on the ground, which are reproduced as under:-

“We have approved an amount of Rs.50,000/- on 28.02.202 for the treatment of above diagnosed disease of the insured patient based on the pre-auth request and other documents submitted by the hospital.

As per the submitted details discrepancy in the circumstances of the injury as per the parents details roadside accident hit by the car but as per the letter from the insured brother insured patient was driving the bike hit and fall moreover as per the FIR copy age of injured is 18 years but as per the policy and medical records age of insured is 13 years with above facts and discrepancy claim not admissible.

We are, therefore, unable to approve the claim and authorization already given for cashless treatment of the above diagnosed case stands withdrawn.

Our decision to reject the claim and to withdraw the approval already given for cashless treatment has been taken in accordance with the terms and conditions of the policy issued to you. In case you are not satisfied with the above decision, you may represent to our Grievance Department.”

 

12.           The cashless claim of the complainant has been denied by the OPs on the abovesaid ground. In the said denial letter OPs has alleged that as per the parents details, the roadside accident hit by car but as per letter submit by sister of the complainant, complainant was driving the bike at the time of accident. OPs further alleged that as per FIR, the age of complainant is 18 years but as per the policy and medical record, the age of the patient is 13 years. OPs have failed to examine/tender the affidavit of sister of complainant and also failed to place on file copy of FIR wherein the age of the complainant has allegedly been mentioned 18 years.  The OPs have observed above mentioned discrepancies in the record.  Admittedly, as per the insurance policy and medical record, the age of complainant was 14 years at the time of accident. The abovesaid discrepancies are nothing and have observed only for denial the claim of complainant.

13.           OPs have also alleged that complainant has not submitted the claim for reimbursement. Complainant has alleged that he has submitted the claim for reimbursement alongwith documents. To prove his version, complainant has mentioned the claim no. CIR/2022/211114/3919501, vide which he has submitted the claim with the OPs. Hence, it has been proved from the said claim number that complainant has submitted the claim and OPs have intentionally denied the same just to escape from their liability. Hence, the said plea taken by the OPs has no force. Moreover, it has become the routine practice of the insurance companies to reject the genuine claim on minor technicality. 

14.           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”.

15.           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 denying the claim of complainant amounts to deficiency in services and unfair trade practice, which is otherwise proved genuine one.

16.           The complainant has spent an amount of Rs.2,72,352/- on his treatment and in this regard he has submitted the medical bills Ex.C6 to Ex.C9, the said amount neither denied nor rebutted by the OPs. Hence, the complainant is entitled for the amount of Rs.2,72,352/- alongwith interest, compensation for mental pain, agony harassment and litigation expenses etc.

17.           As per copy of aadhar card Ex.C11 and copy of insurance policy Ex.R2, the date of birth of the complainant is 20.01.2008. As per medical records, the complainant was 14 years old at the time of accident. Hence, in view of the above documents, the complainant is still minor.

18.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.2,72,352/- (Rs. two lakhs seventy two thousand three hundred fifty two only) to the complainant alongwith interest @ 9% per annum from the date of filing the complaint 21.03.2022 till its realization. We further direct the OPs to pay Rs.25,000/- 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.  It is made clear all the awarded amount shall be deposited in Nationalized Bank in the shape of FDR till complainant attains the age of majority. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated: 28.11.2024    

                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Neeru Agarwal)         (Sarvjeet Kaur)

                   Member                          Member