Haryana

Karnal

CC/346/2018

Shyam Singh Advocate - Complainant(s)

Versus

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

Abhishek Tanwar

11 Jul 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                            Complaint No.346 of 2018

                                                         Date of instt. 07.02.2018

                                                         Date of decision:11.07.2019

 

Shyam Singh Advocate son of Shri Gobind Singh aged about 46 years resident of house no.1455-A, Sector-6, Housing Board Colony, Karnal (Aadhaar no.636060733684)

                                                                         …….Complainant

                                                        Versus

 

Star Health and Allied Insurance Company Limited, having its branch office at SCO no.137, 2^nd floor, Sector-13, Karnal.

 

                                                                         …..Opposite Party.

 

           Complaint u/s 12 of the Consumer Protection Act.          

 

Before   Sh. Jaswant Singh……President.  

      Sh.Vineet Kaushik ………..Member

                Dr. Rekha Chaudhary……Member

 

 Present  Complainant in person.

                  Shri Naveen Khaterpal Advocate 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 has purchased a medi-claim insurance policy from the OP in the year 2014 bearing policy no.P/211114/01/2018/002807 which is valid from 8.8.2017 to 7.8.2018 and thereafter same has been renewed for further one year. The said insurance policy is having insurable interest of Rs.14.50 lakhs. Son of the complainant was suffering from poor intake and persisting vomiting. On 8.5.2018 the applicant took his son to Nishant clinic, who after check up gave medicines to the son of applicant and he was referred to the PGI Chandigarh. Thereafter, for getting second opinion on 17.05.2018 the applicant took his son to Parmar Hospital Karnal and he gave medicines to the son of complainant but his illness could be cured. After that complainant took his son to the PGI Chandigarh on 24.05.2018 and he was called on 26.5.2018. In PGI the condition of the son of complainant more critical and on 26.05.2018 he was shifted to the Fortis Hospital, Mohali. On 28.05.2018 the complainant took his son to Cygnus Hospital Karnal and Doctor Amit Sharma referred the son of complainant Chutani Medical Centre, Chandigarh. Accordingly, on 1.6.2018 the applicant shifted his son to C.M.C. Chandigarh and Dr. B.R. Thapa called him to M.M. Institute of Medical Science, Ambala where his several tests were conducted. After conducting all the tests he was given medicines and was sent back to home. During treatment at home, the condition of son of applicant became critical on 14.07.2018 and then he was taken to Dr. Gurmeet Singh in Shri Hari hospital, Karnal where he remained admitted upto 19.07.2018. Hospital authorities charged an amount of Rs.36923/-+Rs.29917.30. On 14.07.2018 an intimation was given to the OP about the admission of his son. Shri Hari Hospital is not on the panel of the OP, hence the applicant was instructed by the OP to make payment from his pocket and OP will disburse the said amount to the complainant. After discharge complainant submitted all the original bills to the OP and submitted his claim application. Thereafter, the OP on 5.9.2018 sent a text message to the applicant for clearing some quarries regarding illness of the son of the complainant, the complainant with medical reports gave reply of the same on 15.09.2018 and after getting reply the applicant was assured that his claimed amount would be disbursed very soon but the same was not disbursed. Complainant visited the office of OP so many times and requested for reimbursement of the claim but OPs did not pay any claim and lastly repudiated the claim of the complainant without assigning any good cause. In this way there was deficiency in service on the part of the OPs. 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; mis-joinder and non-joinder of necessary parties; complainant is estopped by his own act and conduct and concealment of true and material facts. On merits, it is pleaded that insured availed Family Health Optima, covering complainant self, Geeta Spouse, Neha Singh and Shiv Raj Singh both dependent minor children  for sum insured of Rs.10,00,000/-, vide policy no.P/211114/01/2018/002807 for the period from 8.8.2017 to 7.8.2018. It is further pleaded that 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. Moreover, it is clearly stated in the policy schedule “The Insurance under this policy is subject to conditions, clauses, warranties, exclusion etc. attached.” The policy is contractual in nature and the claims arising therein are subject to terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. The insured submitted claim documents for reimbursement for medical expenses for Rs.29,953/- for the treatment of Age. On scrutiny of the same, it is observed that:

a)     As per discharge summary dated 14.07.2018 to 19.07.2018, the insured was diagnosed with age with poor intake and Persistent vomiting.

b)     As per the consultation slip dated 26.05.2018, the insured is a known case of autism and on some ayurvedic medicine.

Thus, OP has called for the following documents vide letter dated 5.9.2018 and 20.9.2018.

a) Medical record of autism.

b) Letter from treating doctor stating when was autism first diagnosed cause for gastritis in the patient.

c) Patient is on ayurvedic treatment for autism. Kindly provide the details for the same and submit first consultation papers, prescriptions and investigation reports.

        In reply, the insured submitted clarification letter, but the same is not sufficient to process the claim. In the absence of the documents related to autism it is not possible to process the claim. The condition no.3 reads as follows:

        “The insured person/s shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim is based and shall also give the company such additional information and assistance as the company may require in dealing with the claim.”

       The insured has not submitted the mandatory claim documents to process the claim. Thus, the claim was rejected and the same was informed vide letter dated 03.10.2018. Hence 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.CW1/A and documents Ex.C1 to Ex.C76 and closed the evidence on 08.03.2019.

4.             On the other hand, OP tendered into evidence affidavit of Rajiv Jain Ex.RW1/A and documents Ex.R1 to Ex.R17 and closed the evidence on 3.7.2019.

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

6.             The case of the complainant is that he has purchased a medi-claim insurance policy from the OP in the year 2014 bearing policy no.P/211114/01/2018/002807 which is valid from 8.8.2017 to 7.8.2018 and thereafter same has been renewed for further one year. The said insurance policy is having insurable interest of Rs.14.50 lakhs. The son of complainant was suffering from poor intake and persisting vomiting. On 8.5.2018 the applicant took his son to Nishant clinic, who after check up gave medicines to his son and referred to the PGI Chandigarh. Thereafter, for getting second opinion on 17.05.2018 the applicant took his son to Parmar Hospital Karnal and he gave medicines to the son of complainant but his illness could be cured. After that complainant took his son to the PGI Chandigarh on 24.05.2018 and he was called on 26.5.2018. In PGI the condition of the son of complainant more critical and on 26.05.2018 he was shifted to the Fortis Hospital, Mohali. On 28.05.2018 the complainant took his son to Cygnus Hospital Karnal and Doctor Amit Sharma referred the son of complainant Chutani Medical Centre, Chandigarh. Accordingly, on 1.6.2018 the applicant shifted his son to C.M.C. Chandigarh and Dr. B.R. Thapa called him to M.M. Institute of Medical Science, Ambala where his several tests were conducted. After conducting all the tests he was given medicines and was sent back to home. During treatment at home, the condition of son of applicant became critical on 14.07.2018 and then he was taken to Dr. Gurmeet Singh in Shri Hari hospital, Karnal where he remained admitted upto 19.07.2018. Hospital authorities charged an amount of Rs.36923/-+Rs.29917.30. On 14.07.2018 an intimation was given to the OP about the admission of his son. Shri Hari Hospital is not on the panel of the OP, hence the applicant was instructed by the OP to make payment from his pocket and OP will disburse the said amount to the complainant. After discharge complainant submitted all the original bills to the OP and submitted his claim application. Thereafter, complainant visited the office of OP so many times and requested for reimbursement of the claim but OPs did not pay any claim and lastly repudiated the claim of the complainant on the false grounds.

7.             On the other hand, the case of the OP is that insured availed Family Health Optima vide policy no.P/211114/01/2018/002807 for the period from 8.8.2017 to 7.8.2018 for sum insured Rs.10,00,000/-. 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. The policy is contractual in nature and the claims arising therein are subject to terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. The insured submitted claim documents for reimbursement for medical expenses for Rs.29,953/- for the treatment of Age. On scrutiny of the same, it is observed that:

a)     As per discharge summary dated 14.07.2018 to 19.07.2018, the insured was diagnosed with age with poor intake and Persistent vomiting.

b)     As per the consultation slip dated 26.05.2018, the insured is a known case of autism and on some ayurvedic medicine.

8.             Admittedly, the complainant had purchased the mediclaim policy covering complainant self, Geeta Spouse, Neha Singh and Shiv Raj Singh both dependent minor children. Minor son of complainant namely Shiv Raj Singh had taken the treatment from various hospital namely Nishant Clinic Karnal, Parmar Hospital Karnal, PGI Chandigarh, Fortis Hospital Mohali, Cygnus Hospital Karnal, CMC Chandigarh, M.M. Institute of Medical Science, Amabala and Shri Hari Hospital, Karnal and spent Rs.36923/-+Rs.29917/-. This fact has been proved from the medical record, medical bills and emails Ex.C2 to Ex.C75. Treatment was taken by minor son of the complainant during subsistence of the insurance policy.

9.             Claim of the complainant was repudiated by the OP, vide repudiation letter Ex.C17 on the following grounds that the insured was diagnosed with AGE with poor intake and Persistent vomiting, (ii) insured was known case of autism and on some ayurvedic medicine. (iii) required documents not submitted. On perusal of record, it is nowhere mentioned in the insurance policy that insured is prohibited from taking the treatment of abovementioned disease. The policy in question was taken by the complainant in the year of 2014 and son of the complainant was suffering from above mentioned disease in the year of 2018. It is not a case of OP that son of the complainant was suffering pre-existing disease. As per record, the complainant has already submitted the required document to the OP. Thus, we are of the firm views that act of the OP amount to deficiency in service and unfair trade practice.

10.            Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.36923+29917=66840/-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.15,000/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:11.07.2019

                                                                        President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

 

                     (Vineet Kaushik)       (Dr. Rekha Chaudhary)

                        Member                     Member