Haryana

Karnal

CC/97/2019

Raghbir Singh - Complainant(s)

Versus

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

Sawan Gollen

15 Mar 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                         Complaint No.97 of 2019

                                                        Date of instt. 21.02.2019

                                                        Date of decision:15.03.2021

 

Raghbir Singh (aged 56 years), son of Shri Surta Ram, resident of village Kamalpur Dera, Tehsil Nigdhu, District Karnal.

 

…….Complainant.

 

                                              Versus

 

Star Health and Allied Insurance Company Limited, having its registered and corporate office 1, New Tank Street, Valluvar Kottam high Road, Nungambakkam, Chennai-600034 and having its Branch office at 2^nd floor, SCF 137, Sector 13, Urban Estate, near ICICI Bank, Karnal-132001 through its Branch Manager.

…..Opposite Party.

 

       Complaint u/s 12 of the Consumer Protection Act, 1986.              

Before   Sh. Jaswant Singh……President.       

      Sh.Vineet Kaushik ………..Member

              Dr. Rekha Chaudhary……Member

 

 Present   Shri Sawan Gallan counsel for complainant.

                Shri Naveen Khetarpal counsel for opposite party.

                               

                (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 obtained health policy bearing policy no.P-211114/01/2018/005237 from the opposite party (hereinafter referred to as OP), valid from 08.11.2017 to 07.11.2018 and paid the premium of Rs.21.240/-, for limit of coverage of Rs.3,00,000/-. After the expiry of one year the said policy renewed for the further period of one year w.e.f. 08.11.2018 to 07.11.2019. Initially, the complainant got some problem of high fever and he was taken to Amritdhara Hospital, ITI Chowk, Karnal and was checked up by  Dr. Ritesh Lal on 11.08.2018. Thereafter, he was diagnosed for the disease and he remained admitted in the hospital upto 14.08.2018. Complainant spent Rs.41,846/- on his treatment. After discharge from the hospital, complainant submitted the relevant documents i.e. receipt of medicines, doctor charges, Pathological tests etc. to the OP with the request to release the claim amounting to Rs.41,846/-. On being demanded, the complainant submitted the requisite documents in original with the OP. The claim application submitted by the complainant was duly entertained by the OP but OP did not intimate the complainant about the progress of his claim. Then the complainant contacted the officials of the OP time and again and requested for reimbursement of the claim but OP did not pay any heed to the request of complainant on one pretext or the other. Lastly, OP repudiated the claim of the complainant on the false and flimsy ground. In this way there was deficiency in service on the part of the OP. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OP, who appeared and filed written version raising preliminary objections with regard to maintainability; jurisdiction; mis-joinder and non-joinder of necessary parties; complainant is estopped by his own act and conduct from filing the present complaint and concealment of true and material facts. On merits, is pleaded that the insured has availed Star Cardiac Care Insurance Policy (Silver Plan), vide policy no.P/211114/01/2018/005237 for the period of 08.11.2017 to 07.11.2018 covering Mr. Raghbir Singh-self for the sum insured of Rs.3,00,000/-. 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. It is further pleaded that the insured patient got hospitalized on Amritdhara My Hospital-Rasulpur Kalan on 11.08.2018 towards the treatment CAD, POST PTCA, ATERAL FLUTTER with, CHF ACUTE FEBRILE ILLNESS. He has claimed an amount of Rs.41,846/-. On scrutiny of the claim documents it is observed that:

        “ As per the discharge summary dated 11.08.2018, the insured CAD,POST PTCA, ATERAL FLUTTER with, CHF ACUTE FEBRILE ILLNESS and administered with Antiarrhthymic, IV Fluids, IV Fluids, IV Antibiotics, IV PPI and IV antiemetic.

From the above findings, it is noted that the insured was administered with IV fluids and not underwent any surgery. As per the terms and conditions of the policy, the cardiac related complication that necessitated surgery is not payable and conservative management is not payable.

As per condition 2, Subject to limits indicated in the schedule, the Company will pay Under Silver Plan:- The expenses as listed under A to F above incurred as an inpatient for treatment in respect of all cardiac, related complications that necessitate surgery/intervention. Hence, the claim was repudiated and the same was communicated to the complainant, vide letter dated 25.10.2018. There is no deficiency in service on the part of the OP. 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.C1/A, insurance policy valid from 08.11.2018 to 07.11.2019 Ex.C1, insurance policy valid from 08.11.2017 to 07.11.2018 Ex.C2, Advance premium receipt Ex.C3, bills dated 14.08.2018 Ex.C4 and Ex.C5, My Pharmacy bill Ex.C6, discharge summary Ex.C7 and repudiation letter Ex.C8 and closed the evidence on 03.12.2019 by suffering separate statement.

4.             On the other hand, OP tendered into evidence affidavit of Rajiv Jain Chief Manager Ex.RW1/A, proposal form Ex.R1, letter to insured Ex.R2, copy of insurance policy Ex.R3, terms and conditions of the policy Ex.R4, claim form Ex.R5, discharge summary Ex.R6 and Ex.R7, claim form Ex.R8, calculation sheet Ex.R9 and repudiation letter Ex.R10 and closed the evidence on 25.01.2021 by suffering separate statement.

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

6.             Learned counsel of complainant argued that complainant obtained health policy from the OP and same was valid from 08.11.2017 to 07.11.2018 for limit of coverage of Rs.3,00,000/- thereafter, the said policy renewed for the further period of one year.  The complainant got some problem of high fever and he was taken to Amritdhara Hospital, ITI Chowk, Karnal and was checked up by the Doctor on 11.08.2018. Thereafter, he was diagnosed for the disease and he remained admitted in the hospital upto 14.08.2018. Complainant spent Rs.41,846/- on his treatment. After discharge from the hospital, complainant submitted the relevant documents with the OP, with the request to release the claim amounting to Rs.41,846/- but OP did not pay the same and repudiate the claim of the complainant without any reason.  Learned counsel of complainant further argued that no such terms and condition were intimated or communicated to the complainant by the OP, at the time of purchasing of insurance policy. Hence, prayed for allowing the complaint.

7.             Per contra, learned counsel of OP argued that the insured patient got hospitalized in Amritdhara Hospital Karnal on 11.08.2018 towards the treatment CAD, POST PTCA, ATERAL FLUTTER with, CHF ACUTE FEBRILE ILLNESS. He has claimed an amount of  Rs.41,846/-.  It is further argued that the insured was administered with IV fluids and not underwent any surgery. As per the terms and conditions of the policy, the cardiac related complication that necessitated surgery is not payable and conservative management is not payable. It is further argued that as per condition 2 the expenses as listed under A to F above incurred as an inpatient for treatment in respect of all cardiac, related complications that necessitate surgery/intervention. So, the claim of the complainant was rightly repudiated, vide letter dated 25.10.2018  and prayed for dismissal of the complaint.

8.             It is admitted fact that the complainant has obtained a Health policy. It is also an admitted fact that complainant was admitted in Amritdhara Hospital, Karnal during the subsistence of the insurance policy. Complainant spent Rs.41,846/- on his treatment. After discharge from the hospital complainant applied for reimbursement of the claim with the OP and completed all the formalities but OP did not pay the claim and repudiated the same, vide repudiation letter Ex.R10 on the ground that :-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of coronary artery disease (CAD), post PTCA, ateral flutter with chronic heart failure CHF).

As per the policy schedule the patient is covered under Silver Plan. It is observed from the medical records that the insured patient has undergone medical management for coronary artery disease, which is not payable as per Section-2 of the policy issued.”

Moreover, if this Commission came to the conclusion that complainant is entitled for mediclaim then is only entitled for Rs.36,272/- as per Ex.R9.

9.             OP has taken plea that the insured has availed Star Cardiac Care Insurance Policy (Silver Plan). The ailment of the complainant does not fulfill condition no.2 under the said policy. But as per version of the complainant, OPs had told the complainant that all the diseases were covered under the policy in question. No such terms and conditions were intimated or communicated to the complainant at the time of purchasing of insurance policy.

10.           As per version of the OPs, the terms and conditions were sent to the complainant alongwith policy. But the OPs have failed to produce on record any evidence that they have sent/communicated the same to the complainant at any stage. They further failed to produce any receipt/acknowledgement that the terms and conditions were sent/received by the complainant. Hence, the plea taken by the OPs has no force. In this regard, we relied upon New India Assurance Co. Ltd Versus Anil Manglunia 2016 (1) CPR 150 (NC),wherein Hon’ble National Commission held that OP failed to provide policy clause to the complainant and rejected genuine claim of the complainant. Hence, they do not find any merit in the revision petition and the same is hereby dismissed. We further relied upon Oriental Insurancce Co. Ltd Versus Naresh Sharma and others 2015 (2) PLR 75, wherein Hon’ble Punjab and Haryana High Court held that the exclusion clause has to be read to the benefit of patient in genuine circumstances. Where respondent was admitted in hospital suffering from headache, giddiness and hypertension, his claim cannot be rejected on the basis of exclusion clause.

11.           Furthermore, if the of terms and conditions were not provided to the complainant, then these are not applicable to the complainant. Since, the OPs have failed to prove the facts on record that the terms and conditions of the policy were sent and received by the complainant. A common person gets insurance for financial security for his health in good faith. Normally, he is not aware of the strict and complicated conditions and innocently believes in insurance policy. Hence, the repudiation of claim of the complainant is not justified in the eyes of law.             

12.           Keeping in view of the ratio of above judgments, facts and circumstances of the case, we are of the considered view that act of the OPs amount to deficiency in service.

16.           The complainant has claimed Rs.41,846/- but he has produced the bills Ex.C4 to Ex.C6, same is only of Rs.36,272/-. Thus, he is entitled for the same alongwith compensation and litigation expenses.

 17.          Thus, as a sequel to above discussion, we allow the present complaint and direct the OP to pay Rs.36,272/- to the complainant with interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OP to pay Rs.10,000/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expense. This order shall be complied 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: 15.03.2021                                                                    

                                                                      President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

 

 

 (Vineet Kaushik)               (Dr. Rekha Chaudhary)

      Member                               Member