Haryana

Karnal

CC/502/2022

Sandeep Khatkar - Complainant(s)

Versus

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

Balwan Singh Dhaunchak

10 Jun 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.502 of 2022

                                                        Date of instt.29.08.2022

                                                        Date of Decision:10.06.2024

 

Sandeep Khatkar, aged 40 years, son of late Shri Jagbir Singh, resident of late Shri Jagbir Singh, resident of house no.1893, Ground floor, sector-6, Housing Board Colony, Karnal. Mobile no.8901121664.

 

                                                                   …….Complainant.

                                              Versus

 

Star Health and Allied Insurance Co. Ltd. SCF-137, 2^nd floor, above ICICI Bank, Sector-13, Urban Estate, Karnal.

                                                                   …..Opposite Party.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Dr.  Suman Singh…..Member

 

 Argued by: Shri Balwan Singh, counsel  for the complainant.

                    Shri Mohit Goyal, counsel for the OP.

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant had taken Family Health Optima Insurance Plan with the Basic floater sum insured of Rs.3,00,000/-plus Bonus Rs.30,000/-, total limit of coverage Rs.3,30,000/- with recharge benefit of Rs.75,000/-, covering therein complainant self, his wife Nirmal, daughter Diksha and son Daksh from the OP, vide policy no.P/211130/01/2022/001174, valid from 22.06.2021 to 21.06.2022, by paying a premium of Rs.11,889/- on 22.06.2021. The minor daughter of complainant Diksha was got tested for covid on 02.02.2022 being ill with the Dr. Sudershan Kumar of Nishant Clinic. Sample of the same was received by the Kalpana Chawla Government Medical College Hospital, Karnal on 02.02.2022 and sample testing was done on 03.02.2022 and with result negative by RTPCR. Further test were conducted by  City Clinical Laboratory inside Nishant Clinic for ALB, Sugar, RBCS, Pus Cell all resulting nil. Her Covid Antigen test was conducted at Amritdhara Hospital, Karnal with the result negative. Further on 03.02.2022 tests were conducted in City Clinical Laboratory inside Nishant Clinic, Karnal for Himogram, RBC indices, Platelets indices, widal test, S Typhi o, Styphi H, S Paratyphi AH, S Paratyhio BH, S Billrubin (Total) and S Billrubin (Direct), SGOT and SGPT. Lateron, she was admitted in Happy Family Hospital, behind community centre, sector 6, Karnal on 03.02.2022 and discharged on 06.02.2022. The complainant has spent an amount of Rs.19,784/- on the treatment of her daughter. Complainant lodged the claim with the OP  and submitted all the required documents  and also requested for reimbursement of the said amount but OP did not pay any heed to the request of complainant and lingered the matter on one pretext or the other and lastly repudiated the claim of the complainant, vide letter dated 18.04.2022 on the false and frivolous ground. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence this complaint.

2.             On notice, OP 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 OP issued a Family Health Optima Insurance Plan, vide policy no.P/211130/01/2022/001174 for the period of 22.06.2021 to 21.06.2022 covering risk of insured Mr. Sandeep Khatkar-self, Nirmal Spouse, Deeksha and Daksh-dependent children, for the sum insured Rs.3,00,000/-. The complainant submitted a claim with the OP with regard to hospitalization of her daughter Diksha at Happy Family Hospital, Karnal towards the treatment of Enteric Fever from 03.02.2022 to 06.02.2022. On perusal of submitted records, then medical team was of the opinion that:

.       The insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted.

.       Moreover, the documents are stereotyped manner and also tampering is noted in the ICP. Thus there is discrepancy in the records which amounts to misrepresentation of facts.

As per terms and conditions of the policy issued, if there is any misrepresentation 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, claim was rejected, vide letter dated 12.03.2022. OP has received the letter dated 12.04.2022 alongwith a letter dated 05.04.2022 issued by the above hospital, in response to the letter dated 12.03.2022, seeking reconsideration of the claim. The medical team has perused the representation and the letter from the hospital and has noted the contents. The team which re-examined the claim records and observed that

.       As per the discharge summary, time of admission is 7.40 p.m. and temperature is mentioned as 102 F while as per TPR chart on 03.02.2022 at 8.00 p.m., temperature is mentioned as 98.6 and also in the temperature chart, twice 100f is noted and both are tampered.

.       Thus, there is discrepancy in the records which amounts to misrepresentation of facts.

As per terms and conditions of the policy, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, company is not liable to make any payment in respect of claim. Moreover, the medical team was of the opinion that the hospitalization is not warranted for the above diagnosis. Therefore, the OPs are unable to consider the representation of complainant and informed the complainant, vide letter dated 18.04.2022 that repudiation of claim is in order. 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.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy Ex.C1, copy of ID card of Sandeep Khatkar and Deeksha Ex.C2, copy of repudiation letter dated 18.04.2022 Ex.C3, copy of claim form Ex.C4, copy of treatment record Ex.C5, copies of medical bills Ex.C6, copy of aadhar card of Sandeep Khatkar Ex.C7 and closed the evidence on 18.07.2023 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Sumit Kumar Sharma Ex.OPW1/A, copy of insurance policy Ex.OP1, copy of terms and conditions of insurance policy Ex.OP2, copy of proposal form Ex.OP3, copy of claim form Ex.OP4, copy of discharge summary Ex.OP5, copy of Monitoring Chart Ex.OP6, copy of medical report Ex.OP7, copy of final bill Ex.OP8, copy of repudiation letter Ex.OP8, copy of assessment sheet Ex.OP9 and closed the evidence on 18.04.2024 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 the complainant, while reiterating the contents of complaint, has vehemently argued that complainant purchased a health insurance policy from the OP covering his family. On 02.02.2022 the daughter of complainant Diksha was diagnosed for Enteric Fever due to which he was admitted in Happy Faimly, Hospital, Karnal and was discharged on 06.02.2022. The complainant spent Rs.19,784/- for the treatment of his daughter. After discharge from the hospital, complainant lodged the claim with the OP for reimbursement of the said amount but OP did not pay the claim and repudiated the same on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that the argued that the claim of the complainant was duly processed and the same was not found payable on the ground that the hospitalization of the insured patient is not warranted for the diagnose taken by the insured and the tampering noted in the ICP and there are discrepancies in the records which amounts to misrepresentation of facts and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, complainant purchased a health insurance policy from the OP, covering the risk of complainant Nirmal-Spouse,  Diksha and Daksh Dependent children. It is also admitted the daughter of complainant admitted in the Happy Family Hospital, Karnal during the subsistence of the insurance policy.

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.C3 dated 18.04.2022 on the ground, which is reproduced as under:-

“The team which re-examined the claim records has observed that as per the discharge summary, time of admission is 7.40 p.m. and temperature is mentioned as 102 F while as per TPR chart on 03.02.2022 at 8.00 p.m., temperature is mentioned as 98.6 and also in the temperature chart, twice 100 f is noted and both are tempered. Thus, there is discrepancy in the records which amounts to misrepresentation of facts.

As per terms and conditions of the policy issued to you, if there is any misrepresentation 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.

Moreover, out medical team is of the opinion that the hospitalization is not warranted for the above diagnoses.

We are therefore unable to consider your representation favourably and we inform you that repudiation of your claim is in order”.

12.           The claim of the insured has been repudiated by the OP on the aforesaid ground. The onus to prove its version was relied upon the OP but OP has miserably failed to prove the same by leading any cogent and convincing evidence. The claim of the insured has been repudiated by the OP on the ground that there were multiple tampering in the medical record and hospitalization of the insured patient was not warranted. If there is any tampering upon the medical record, it was on the hand of the treated doctor and complainant cannot blamed for that. Moreover, on perusal of the medical record, there is no such type of tampering for which the claim of the complainant was required to be repudiated. Further, it is the treated doctor who has to decide whether the hospitalization of the patient is required or not. Thus, the repudiation of the claim of insured is only on the basis of presumption and assumption, which is not admissible in the eyes of law.

13. Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, 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, the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, we are of the considered view that the act of the OP while repudiating the claim of the complainant amounts to deficiency and unfair trade practice, which is otherwise proved genuine one. 

15.           The complainant spent Rs.19,784/- on the treatment of his daughter and in this regard he has placed on record claim form Ex.C4/Ex.OP4 alongwith medical bills. The sum insured is Rs.3,00,000/-. The said bill neither denied nor rebutted by the OP. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

16.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.19,784/-(Rs. nineteen thousand seven hundred eighty four only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of claim i.e. 18.04.2022 till its realization. We further direct the OP to pay Rs.10,000/- to the complainant on account of mental agony and harassment and Rs.5500/- towards the litigation expenses.  This order shall be complied with 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:10.06.2024

                                                                 President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Suman Singh)

                          Member                          Member