Delhi

New Delhi

CC/128/2022

SH. OMDEV - Complainant(s)

Versus

STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED - Opp.Party(s)

26 May 2023

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-VI

(NEW DELHI), ‘M’ BLOCK, 1STFLOOR, VIKAS BHAWAN,

I.P.ESTATE, NEW DELHI-110002.

Case No.128/2022

IN THE MATTER OF:

 

Sh. Omdev

B-71, Bharat Vihar, Part-2

Kakrola, New Delhi-110078                                                  ....Complainant

 

 

VERSUS

 

Star Health and Allied Insurance Company Limited

1st Floor, Himalaya House,

23, Kasturba Gandhi Marg,

New Delhi-110001                                                               ....Opposite Party

 

Quorum:

 

Ms. Poonam Chaudhry, President

Sh. Bariq Ahmad, Member

Sh. Shekhar Chandra, Member

 

                                                                                                                           Date of Institution:-30.05.2022                                                                                                                                                                          Date of Order   : -  26.05.2023.

 

ORDER

 

POONAM CHAUDHRY, PRESIDENT

 

 

1. The present complaint has been filed under Section 12 and 35 of the Consumer Protection Act, 1986 (in short CP Act) against Opposite Party (in short OP) alleging deficiency of services.
2. Briefly stated the facts of the case are that the complainant had taken a online health insurance policy bearing no. P/160000/01/2022/010161 on 20.12.2021 from the opposite party. It is further stated that the said policy was valid from 20.12.2021 to 19.12.2022 for the sum insured of Rs.5,00,000/- (Rupees Five Lakh).
3. The complainant’s wife Sapna got admitted in the Mahavir Multispecialty Hospital, New Delhi for treatment on 22.03.2022 and remained hospitalized till 03.04.2022. The said hospital generated the final bill of Rs.2,10,783/- (Rupees Two Lakh Ten Thousand Seven Hundred Eighty Three) which was paid by the complainant to the Mahavir Multispecialty Hospital.
4. Complainant thereafter claimed the aforesaid bill from the opposite party, but the same was rejected by the opposite party vide letter 20.04.2022 with the reason “Excluded Provider” (Hospital). Complainant sent a letter dated 25.04.2022 to the OP but no response was received from the insurance company.
5. Thus the complainant having been left with no option approached this Court, hence the present complaint. It is alleged that the cause of action to file present case arose when the claim of the complainant was rejected by opposite party on 20.04.2022. It is alleged the complainant resides at ‘Kakrola’ New Delhi. Hence, this Court has jurisdiction to entertain the complaint.
6. It is prayed that OP be directed to pay a sum of Rs.2,10,783/- (Rupees Two Lakh Ten Thousand Seven Hundred Eighty Three) to the complainant with pendent elite and future interest @ 18 % p.a. from the date of repudiation of claim 20.04.2022 till its realization. OP be also directed to verify and produce the medical treatment record and bills of treatment of complainant’s wife Sapna from 22.03.2022 to 03.04.2022. Cost of litigation be also awarded.
7. Notice of the complaint was issued to OP, upon which OP entered appearance and filed written statement contesting the case on various grounds inter alia that the complaint is not maintainable, as no cause of action ever arose in favour of the complainant and the same is hit by Section VII Rule 11 of CPC. It was further alleged that the present complaint has been filed on false and frivolous facts and has suppressed the material facts.
8. It was further alleged that as per settled principle of the rights and liabilities strictly governed by the policy of insurance- No exception or relaxation can be made on ground of equity. The complainant has filed the present complaint with malafide intention and ulterior motives to grab illegal amount from the opposite party.
9. It was also alleged that opposite party had rendered all possible services to the complainant, and there was/is no deficiency in services on the party of the insurance company, as such the complaint deserves to be dismissed.
10. It was further alleged that respondent denies each and every allegation, averments and statement made in the complaint which is contrary to and/or inconsistent with what has been stated in the reply and nothing stated in the complaint be deemed to have been admitted unless the same is expressly admitted.
11. It was alleged that the complainant had obtained the Policy i.e. Young Star Insurance Policy (Floater) for Mr. Omdev-(Self), Ms. Sapna (Spouse) and two dependent children Amit and Nitesh and the sum Insured was Rs.5,00,000/- (Rupees Five Lakh) on 20.12.2021 for a period of 19.12.2022 vide Policy No. P/160000/01/2022/010161 from the answering respondent.
12. 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 along with the Policy Schedule. Moreover it was clearly stated in the policy schedule “The insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. attached”.
13. It was also alleged on 22.03.2022 the insured patient Sapna 31 years/female was hospitalized at Mahaveer Multispecialty Hospital, Uttam Nagar, Delhi for a period 22.03.2022 to 03.04.2022 for the treatment of UTI, Sepsis and Entric Fever. The complainant has submitted the documents for reimbursement of the claim i.e. Rs.2,10,783/- (Rupees Two Lakh Ten Thousand Seven Hundred Eighty Three). It was alleged that bare perusal of the documents revealed  that:

• The insured patient was taken the treatment in the above mentioned hospital, which is an excluded provider hospital.

Excluded Provider:- That as per Exclusion No. 11 and as per IRDA circular on standardization of health insurance Chapter III: Standard Wordings for some of the exclusions in Health Insurance policies: K. Code Excl. 11: Excluded Providers, “Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website/notified to the policy holders are not admissible. However, in case of life threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.”

The treating hospital has been designated as excluded provider on 11.01.2022 which is before the date of admission. Hence the claim was repudiated and communicated to the insured vide letter’s dated 20.04.2022 and 05.05.2022.

• It was further submitted that the complainant was admitted on 22.03.2022 but intimation of claim was given on 15.04.2022 after 24 days of said admission whereas the condition 1(d) of the above policy states that “Upon the happening of the event, notice with full particulars shall be sent to the company within 24 hours from the date of occurrence of the event irrespective of whether the event is likely to give rise to a claim under the policy or not”.

OP/respondent rejected the claim of the complainant vide letter dated 20.04.2022, as the complainant violated the terms and conditions of the above policy.

 

14. Complainant filed rejoinder reiterating therein the averments made in the complaint and denying all the allegation made in the written statement. Both parties thereafter filed their evidence by way of affidavits.
15. Complainant relied upon the policy, the treatment record and bills issued by Mahavir Multispecialty hospital. It is to be noted that in the rejoinder complainant stated that OP has not filed any document to show that the said Hospital was excluded. It was also stated that OP has to failed to show whether the exclusion of said Hospital was mentioned in the terms and conditions of the policy.
16. We have heard the AR of complainant and Ld. Counsel for  OP and perused the evidence and material on record as well as their written arguments.
17. It is admitted case that complainant had obtained the policy in question from OP which was valid with effect from 20.12.2021 to 19.12.2022. and complainant’s wife was hospitalized during the tenure of coverage of the insurance policy.  It is the case of OP the claim of complainant was repudiated for violation of the terms and conditions of the policy.
18. It is to be noted that complainant filed all medical bills, purchase vouchers, laboratory reports issued and attested by the Mahaveer Multispecialty Hospital. The repudiation letter states that the claim was repudiated as insured was admitted and treated in an excluded provider Hospital, which was violation of the terms and conditions of the policy.
19. It is to be noted that OP failed to show that the terms and conditions of policy which included the exclusions clause were served on the complainant. Thus we are of the view  the claim could not be repudiated under the exclusion clause as alleged.
20. It is also to be noted that OP has not filed any document to show that the terms and conditions of the policy which included the exclusion clause were communicated or served on the insured/complainant. Moreover, OP had accepted the premium from complainant for the policy in question.
21. As regard the liability of Insurance Company in case the terms and conditions of the policy which included the clause regarding rejection of claim due to misrepresentation of facts  were not communicated or served on the insured, it has been held by the Hon’ble Supreme Court in M/s Modern Insulators  Ltd. Vs. The Oriental Insurance Company 2000 (2) SCC 734 as under :

“It is the fundamental principle of insurance law that utmost good faith must be observed by the contracting parties and good faith forbids either party from non-disclosure of the lads which the parties known. The insured has a duty to disclose and similarly it is the duty of the insurance company and its agents to disclose ill material facts in their knowledge since obligation of good faith applies to both equally.

In view of the settled position of law we are of the opinion that the view expressed by the National Commission is not correct. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant respondent cannot claim the benefit of the said exclusion clause.Therefore, the finding of the National Commission is untenable in law.”

 

22. We accordingly hold that OP guilty of deficiency of services and direct OP i.e. Star Health and Allied Insurance Company Limited to pay Rs.2,10,783/- (Rupees Two Lakh Ten Thousand Seven Hundred Eighty Three) to the complainant with interest @ 9% per annum from date of repudiation of claim within four weeks of date of receipt of order failing which OP will be liable to pay interest @ 12% per annum till realization. We also direct OP to pay compensation of Rs.50,000/- (Rupees Fifty Thousand only) for mental agony and Rs.10,000/- (Rupees Ten Thousand only) toward litigation expenses to the complainant.

A copy of order be sent to all the parties free of cost. The order be also uploaded on the website of the Commission (www.confonet.nic.in).

File be consigned to the record room along with a copy of the order.

 

Poonam Chaudhry

(President)

 Bariq Ahmad                                                                                                                         Shekhar Chandra

    (Member)                                                                                                                                 (Member)