Haryana

Karnal

CC/18/2022

Sanjiv Kumar - Complainant(s)

Versus

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

S.S. Moonak

25 Sep 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.18 of 2022

                                                        Date of instt 11.01.2022

                                                        Date of Decision:25.09.2024

 

Sanjiv Kumar, aged 40 years, son of Shri Jai Parkash, resident of house no.66, near Panchyat Bhawan, village Munak, District Karnal. Aadhar no.6637 7409 8374.

                                                                        …….Complainant.

                                              Versus

 

Star Health and Allied Insurance Company Limited, through its authorized person, SCF no.137, 2^nd floor, near ICICI Bank, Sector-13, Urban Estate, Karnal.

                                                                   …..Opposite Party.

 

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 S.S. Moonak, counsel for the complainant.

                 Shri A.K. Vohra, counsel for the OP.

 

                     (Neeru Agarwal, Member)

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 purchased a Mediclaim Insurance policy i.e. Family Health Optima Insurance Plan from the OP on 30.06.2014, vide policy no.P/211114/01/2020/003198 and customer code no.AA0002059464. The complainant himself, wife Smt. Rekha and daughters Vrinda and Aaradhya are covered under the said policy. The complainant paid a sum of Rs.15287/- as premium of the said policy. The sum assured was Rs.5,00,000/- and bonus benefit of Rs.2,25,000/- (limit of coverage Rs.7,25,000/-). The policy was valid from 06.07.2020 to midnight of 05.07.2021. On 02.05.2021, the complainant had Temperature, due to which the complainant took medicine from the doctor, thereafter he was taken to R.P.W. Hospital, Bastara, District Karnal for check up. The complainant was accompanied by his brother Parveen Kumar.The doctor prescribed some medicines which were taken by the complainant as advised. Thereafter, the sample was taken by the doctor of RPW Hospital, Bastara on 04.,05.2021, which was sent for covid-test to the KCGMCH Karnal. On examination, the sample was found to be Corona Positive as diagnosed, vide report dated 05.05.2021 received in 06.05.2021. The doctor on duty in RPW Hospital, Bastara after examination the report, prescribed certain medicines to the complainant. However, complainant had some problem in respiration system for that he was admitted in the said hospital on 07.05.2021. The brother of the complainant, named Parveen Kumar intimated the OP through his mobile on toll free number regarding the illness and hospitalization of the complainant. Due to Corona Positive, complainant was admitted in RPW Hospital, Bastara on 07.05.2021 and discharged on 03.06.2021. The complainant had spent a sum of Rs.4,00,000/- on his treatment, medicines, hospitalization, transportation etc. Thereafter, complainant submitted the claim form, original bills and other required documents to the OP for settlement of the claim but OP did not settle the claim and repudiated the same, vide letter dated 18.09.2021 on the false and frivolous ground. The complainant has given reply to the said letter to the OP and clarified the position, despite submitting reply/clarification, no response was given by the OP. The complainant had also submitted the letter/clarification duly signed by the Doctor R.I. Singh of the said hospital. Complainant requested the OP several time to settle the claim but OP did not pay any heed to the request of complainant and ultimately declined the request of complainant vide letter dated 23.11.2021. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence, complainant filed the present complaint seeking direction to the OP to pay Rs.4,00,000/-  alongwith interest @ 24% per annum from the date of treatment of complainant till its final realization and to Rs.50,000/- for mental pain, agony and harassment and litigation expenses.

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 the complainant purchased Family Health Optima Insurance Plan from the OP on 30.06.2024 after satisfying himself. The complainant, his wife and two dependent daughters were covered under the said policy. The sum assured was Rs.5,00,000/- and the policy in question was valid from 06.07.2020 to 05.07.2021. On receipt of claim intimation, the claim of the complainant was duly processed, considered on merits and same was not found payable due to the fact that the insured patient’s name was written in the series of April, 2021 and in IPD register, the date of admission is 07.04.2021, but date of admission in all hospital records is mentioned as 07.05.2021 as per documents and details available with the OP. The hospital is not functioning; in the indoor case records, the SPO2 level is tempered and over wring is noted by medical team of the OP. Thus, there is multiple discrepancies in the records which amounts to mis-representation of facts and as such the claim of the complainant is not admissible as per the terms and conditions of the above policy issued to the complainant. The claim of complainant was rightly repudiated by the OP, vide letter dated 23.11.2021. The insurance in question is based on utmost good faith and both the parties i.e. insured as well as the insurer are bound by the terms and conditions of the contract of insurance. In the 7^th year of the policy, the insured submitted claim for reimbursement of alleged treatment of Covid for Rs.3,86,530/-. On scrutiny of the claim documents, it is observed that:

.       As per the discharge summary for the period 07.05.2021 to 03.06.2021, the insured was conscious oriented and    afebrile and the SP02 is 88% at room temperature.

.        The insured patient’s name was written in the series of April, 2021 and in IPD register, the date of admission is     07.04.2021.

.       Whereas the date of admission in all the other hospital records it is mentioned as 07.05.2021.

.       As per investigation conducted by the OP, the hospital is not functioning.

.       That in the indoor case records, the SP02 level is tampered and overwriting is noted.

Thus, there are multiple discrepancies in the records which amount to misrepresentation of facts. As per condition no.6, the company shall not be liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be incorrect or false or such claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation whether by the insured person or by any other person acting on his behalf. Hence, the claim is not admissible as per the terms and conditions no.6 and thus claim was repudiated and the same was communicated to the insured, vide letter dated 23.11.2021. There is no deficiency in service and unfair trade practice 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 Covid-19 Test Report Ex.C2, copy of message/letter dated 07.05.2021 Ex.C3, copy of repudiation letters dated 18.09.2021 and 23.11.2021 Ex.C4 and Ex.C5, copy of claim form Ex.C6, copy of medical bills Ex.C7 to Ex.C26, copy of treatment record Ex.C27 to Ex.C29, copy of medical test report Ex.C30 to Ex.C33 and closed the evidence on 26.04.2023 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.OP1/A, copy of terms and conditions of the insurance policy Ex.O1, copy of policy schedule Ex.O2, copy of proposal form Ex.O3, copy of claim form Ex.O4, copy of discharge summary Ex.O5, copy of treatment record Ex.O6, copy of final bill Ex.O7, copy of repudiation letter dated 18.09.2021 Ex.O8, copy of certificate of treating doctor Ex.O9, copy of repudiation letter dated 23.11.2021 Ex.O10, copy of investigation report Ex.O11, copy of billing assessment sheet Ex.O12 and closed the evidence on 01.03.2024 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 was Rs.5,00,000/-. During the subsistence of the insurance policy, complainant had taken the treatment from Shri R.P.W. Hospital, Bastara, Karnal due to ‘Corona Positive’ and spent Rs.4,00,000/- on his treatment. Complainant lodged his claim with the OP and submitted all the required documents and also requested the OP for reimbursement of said amount, but OP did not pay the spent amount and repudiated the claim of complainant 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 OP issued a health insurance policy to the complainant, for covering complainant (self), his spouse and dependent children. Complainant lodged the claim for reimbursement. During scrutiny of the claim, OP observed various discrepancies in the documents submitted by the complainant. Thus, the claim of the complainant was rightly repudiated, vide letter dated 23.11.2021 by the OP 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 OP. It is also admitted that during the subsistence of insurance policy the complainant had taken treatment from RPW, Hospital, Bastara, District Karnal and spent an amount of Rs.3,86,530/- on his treatment. 

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.C5/Ex.O10 dated 23.11.2021 on the ground, which are reproduced as under:-

“Our medical team has perused your representation and the letter from the hospital and has noted the contents. The team which re-examined the claim records has observed that the insured patient’s name was written in the series of April, 2021 and in IPD register, the date of admission is 07.04.2021 but date of admission in all hospital records is mentioned as 07.05.2021; as per documents and details available with us, the hospital is not functioning; in the indoor case records, the SP02 level is tampered and over writing is noted.

Thus, there are multiple discrepancies in the records which amount to misrepresentation of facts. Hence, the claim is not admissible as per the terms and conditions of the above policy issued to you.

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

12.           The claim of the complainant has been repudiated by the OP on the abovesaid ground. The OP has alleged that various discrepancies were observed in the documents submitted by the complainant which amount to misrepresentation of facts. 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. OP has failed to explain that what discrepancies in the documents have been observed. There is only typical mistake in the month of admission of complainant. Complainant has taken the treatment in the month of May but due to typical error month of treatment has been written as April. Thus, OP cannot take the benefit of typical mistake. Rather, complainant has placed on file treatment record Ex.C27 to Ex.C29 and medical tests and reports Ex.C30 to Ex.C33, on perusal of said documents, no discrepancies appears. Complainant was hospitalized on 07.05.2021 for the treatment of severe Covid-19 infection/DM2/HTN and discharged on 03.06.2021.  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 OP 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 claimed Rs.4,00,000/- but as per claim form Ex.C6/Ex.O4 submitted with the OP, complainant has claimed Rs.3,86,530/- and the said amount neither denied nor rebutted by the OP.  Hence, the complainant is entitled for the amount of Rs.3,86,530/- 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 OP to pay Rs.3,86,530/- (Rs. three lakhs eighty six thousand five hundred thirty only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 23.11.2021 till its realization. We further direct the OP 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. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated: 25.09.2024   

                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Neeru Agarwal)         (Sarvjeet Kaur)

                   Member                          Member