Haryana

Karnal

CC/609/2022

Satish Kumar - Complainant(s)

Versus

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

Mohit Sacheva

26 Mar 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 609 of 2022

                                                        Date of instt.31.10.2022

                                                        Date of Decision:26.03.2024

 

Satish Kumar son of Shri Inder Pal, resident of house no.61, Gali no.1, Friends Colony, Kaithal Road, Karnal.

 

                                               …….Complainant.

                                              Versus

 

Star Health and Allied Insurance Company Limited, SCF-137, 2^nd floor, Sector-13, Urban Estate, near ICICI Bank, Karnal through its Branch Manager..

       

                                                                 …..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 Mohit Sachdeva, counsel for the complainant.

                    Shri Gaurav Gupta, 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 purchased a health insurance policy bearing no.P/211114/01/2022/009878, valid from 02.01.2022 to 01.01.2023 from the OP. The complainant and his family were insured in the said policy. On 28.03.2022, the son of complainant namely Krish Allang was diagnosed Viral Hepatitis, due to which he was admitted in Virk Hospital, Karnal. The son of complainant was got admitted on 28.03.2022 in the said hospital and was discharge on 02.04.2022. The intimation regarding the admission was duly given to the OP and the surveyor of the OP also  visited the hospital. The complainant had spent Rs.34,267/- for the treatment of his son. On 06.04.2022, all the original documents regarding the treatment and claim were submitted with the OP. The complainant received a letter dated 25.04.2022 from the OP whereby the claim of the complainant has been repudiated on the false and frivolous ground. The complainant applied for re-consideration of the claim alongwith the certificate of the Virk Hospital dated 27.04.2022 but OP did not consider the claim of complainant and again repudiated the same. Then complainant sent a legal notice dated 24.08.2022 but it also did not yield any result. 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; jurisdiction and concealment of true and material facts. On merits, it is pleaded that complainant availed the Star Group Health Insurance Policy-Gold (for bank customers) covering Mr. Satish Kumar-self and Davinder Kaur-Spouse, Krish Allang-Dependent child for sum insured Rs.3,00,000/-, vide policy no.P/211114/01/ 2022/009878, valid from 02.01.2022 to 01.01.2023. The terms and conditions of the policy were explained to the complainant and same was served to the complainant alongwith the policy schedule. Complainant has submitted the reimbursement of the medical expenses towards the treatment Viral Hepatitis at Virk Hospital Private Limited-Karnal of hospitalization from 28.03.2022 to 02.04.2022. On perusal of record, it is observed from the discharge summary that the patient was admitted in the hospital with the complaint of fever on and off, pallor (discoloration) + over face, icterus, decreased appetite and all vital are normal at the time of admission. (Normal PR:20/mm, BP:118/70 mmhg, PR: 20/mm, Temp: 98.6 degree f chest-B/L Air Entry+ Abdomen-PA Soft CVS-SIS2+CNS-Concious/Oriented SP02-96% On Room Air). On verifying the various documents in support of the claim, it is noted that the hospitalization of the insured patient is not warranted for the above diagnosis. Moreover, multiple tampering noted in the Vital Chart submitted. Hence, the claim was repudiated on the ground of that the hospitalization was not warranted for the above claim and misrepresentation of the documents submitted by the complainant. It is further pleaded that OP has received the insured letter dated nil alongwith the medical certificate dated 27.04.2022 issued by Dr. Netarpal Rawal, in response to letter dated 25.04.2022, seeking re-consideration of the claim and the same was reviewed and replied vide letter dated 25.04.2022 stating that the hospitalization of the insured patient is not warranted for the above diagnoses. Moreover, multiple tampering noted in the indore case records. Hence, claim was again repudiated and conveyed to insured, vide letter dated 07.05.2022. 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 discharge summary Ex.C1, copy of claim form Ex.C2, copy of repudiation letter dated 25.04.2022 Ex.C3, copy of reconsideration letter dated 27.04.2022 Ex.C4, copy of certificate of Virk Hospital dated 27.04.2022 C5, copy of repudiation letter dated 07.05.2022 Ex.C6, copy of certificate of Virk Hospital dated 09.08.2022 Ex.C7, copy of email dated 12.08.2022 Ex.C8, copy of legal notice dated 24.08.2022 Ex.C9 and closed the evidence on 05.06.2023 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.RW1/A, copy of proposal form Ex.R1, copy of portability form Ex.R2, copy of policy schedule Ex.R3, copy of terms and conditions of the policy Ex.R4, copy of claim form Ex.R5, copy of discharge summary dated 02.04.2022 Ex.R6, copy of Indore case papers Ex.R7, copy of final bill Ex.R8, copy of repudiation letters dated 25.04.2022 and 07.05.2022 Ex.R9, copy of billing assessment sheet Ex.R10 and closed the evidence on 12.09.2023 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 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 28.03.2022, the son of complainant Krish Allang was diagnosed for Viral Hepatitis due to which he was admitted in Virk Hospital, Karnal and was discharged on 02.04.2022. The complainant spent Rs.34,267/- for the treatment of his son. After discharge from the hospital, complainant lodged the claim with the OP for reimbursement but OP did not pay the claim and repudiated the same, vide repudiation letter dated 25.04.2022 and 07.05.2022 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 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 multiple tampering noted in the Vital Chart submitted 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 family members of the complainant namely Davinder Kaur-Spouse and Krish Allang-Dependent child. It is also admitted the son of complainant admitted in the Virk 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.C6/Ex.R9 dated 07.05.2022 on the ground, which is reproduced as under:-

“There is multiple tampering noted in the indoor case record and moreover the hospitalization of the insured patient is not warranted.”

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 blame for that. Moreover, on perusal of the medical record, there is no such type of huge 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 judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OP while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

15.           The complainant spent Rs.34,267/- on the treatment of his son and in this regard he has placed on record claim form Ex.C2/Ex.R5 alongwith medical bills. The sum insured is Rs.3,00,000/-. The said bill has not been 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.34,267/- (Rs. thirty four thousand two hundred sixty seven only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of claim i.e. 07.05.2022 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:26.03.2024

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Suman Singh)

                          Member                           Member