Haryana

Karnal

CC/138/2023

Surbhi Juneja - Complainant(s)

Versus

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

Mohit Sachdeva

08 Aug 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                      Complaint No. 138 of 2023

                                                      Date of instt.28.02.2023

                                                      Date of Decision:08.08.2024

 

Surbhi Juneja daughter of Shri Parveen Juneja, resident of house no.196, near Lancer Public School, Shakri Puram, 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   Shri Jaswant Singh……President.

              Ms. Sarvjeet Kaur……Member

          

Argued by:  Shri Mohit Sachdeva, 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 Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant purchased a Health Insurance Policy from the OP, vide policy no.P/211114/01/2022/008825 in the year 2014. The complainant had been paying renewals for the said policy since eight years. Now the period of the said policy was from 30.10.2022 to 29.10.2023. The complainant was insured vide the said policy. On 31.12.2022, complainant was diagnosed Acute Abdomen Renal Colic, due to which she was admitted in PRP Multi-Specialty Hospital, Kidney Centre, Trauma Centre and Blood Center, situated opposite Civil Hospital, Karnal. Complainant was got admitted on 31.12.2022 in the above hospital and was discharged on 07.01.2023. The intimation regarding the admission of the complainant was duly provided to the OP telephonically, vide claim intimation no.CIR/2023/211114/ 1296907. The complainant had spent an amount of Rs.94,253/- for her treatment in the said hospital including IPD Bill of the Hospital, Lab and Investigation Bills, Medicine bills and CT scan etc. All the original bills submitted with the OP alongwith claim form. Thereafter, complainant requested the OP several times for reimbursement of the abovesaid amount but OP did not pay any heed to the request of complainant and lingered the matter on one pretext of the other and lastly repudiated the claim of the complainant 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 insured availed the Medi Classic Insurance policy (individual) through Branch office covering Surbhi Juneja-self for the sum insured of Rs.3,00,000/-, vide policy no. no.P/211114/01/2023/ 009787, valid from 30.10.2022 to 29.10.2023 (medi Classic), P/211114/-01/2022/008825, valid from 30.10.2021 to 29.10.2022 (Medi-Classic), no.P/211114/01/2021/007635, valid from 30.10.2019 to 29.10.2020 (Medi-Classic), P/211114/01/ 2019/006221, valid from 30.10.2018 to 29.10.2019 (FHO)-5 lakh, P/211114/01/2018/004793, valid from 30.10.2017 to 29.10.2018 (FHO)-5 lakh, P/211114/01/2017/003768, valid from 30.10.2016 to 29.10.2017 (FHO)-5 lakh, P/211114/01/2016/002481, valid from 30.10.2015 to 29.10.2016 (FHO)-5 lakh, P/211114/01/2015/001565, valid from 30.10.2014 to 29.10.2015 (FHO)-5 lakh. It is further pleaded that the claim was reported on the abovesaid policy was registered as claim no.CIR/2023/211114/1296907. The insured has submitted the reimbursement of the medical expenses towards the treatment Acute Abdomen Renal Colic at PRP Multispecialty Hospital Karnal on 31.12.2022. It was observed from the submitted records that the insured patient has taken treatment in the PRP Multispecialty Hospital Karnal, which is an excluded provided hospital. The hospital was made an excluded provider by this insurance company on 08.09.2022 that hospital is reflecting in the website under excluded provided hospital. Moreover, there are severe network hospital in the locality of the insured where he could have been managed. On perusal of the Discharge Summary, the insured was admitted the complaints of nausea and vomiting and diagnosed with Acute Abdomen Renal Colic. Thus, the insured patient was not admitted on emergency basis. Hence, as per exclusion no.(II). Excluded Providers-Code Excl.11 of the abovesaid policy, the 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 policyholders are not admissible. Hence, claim was rejected and conveyed to insured vide order dated 09.02.2023. 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 OPD slip of PRP Multispecialty Hospital Karnal Ex.C2, copy of discharge summary Ex.C3, copy of final bill Ex.C4, copy of receipts Ex.C5, copy of medical bills Ex.C6, copy of authorization letter Ex.C7, copy of claim form Ex.C8, copy of repudiation letter dated 09.02.2023 Ex.C9 and closed the evidence on 27.07.2023 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.OPW1/A, copy of proposal form Ex.OP1, copy of insurance policy Ex.OP2, copy of terms and conditions of the policy Ex.OP3, copy of claim form Ex.OP4, copy of discharge summary Ex.OP5, copy of OPD slip of PRP Multispecialty Hospital Karnal Ex.Ex.OP6, copy of intimation details Ex.OP7, copy of final bill Ex.OP8, copy of repudiation letter dated 09.02.2023 Ex.OP9, copy of assessment sheet Ex.OP10, copy of emails Ex.OP11, copy of intimation details Ex.OP12 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 in the year 2014 complainant purchased a health insurance policy from the OP and renewed the same continuously without any break. On 31.12.2022, complainant was diagnosed for Acute Abdomen Renal Colic, due to which she was admitted in PRP Multispecialty Hospital, Karnal and was discharged on 07.01.2023. The complainant spent Rs.94,523/- on her treatment. 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 because the complainant has taken the treatment from the hospital, which have already excluded in this insurance company. He further argued that insured was not admitted on emergency basis and as per exclusion no.(II),  the amount incurred by her is not admissible and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, in the year 2014, complainant purchased a health insurance policy from OP. It is also admitted that complainant get renewed the said policy without any break. It is also admitted that during the subsistence of the insurance policy the complainant has taken the treatment from PRP Multispecialty Hospital Karnal and spent an amount of Rs.94,253/-.

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.C9/Ex.OP9 dated 09.02.2023 on the ground, which is reproduced as under:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of Acute Abdomen Renal Colic.

It is observed from the submitted records that the insured patient was admitted and treated in an excluded provider (hospital).

As per Exclusion no.(11), Excluded-Providers-Code Excl.11 of the above policy, the 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 policyholders are not admissible.

We therefore, regret to inform you that for the reasons stated above we are unable to settle your claim under the above policy and we hereby repudiate your claim.”    

 

12.           The claim of the insured has been repudiated by the OP on the aforesaid ground. The OP has alleged that the hospital from which the insured had taken the treatment was made an excluded provider by this insurance company on 08.02.2022. Complainant has purchased the policy in question since the year 2014 and at that time, it is not the case of the OP that said hospital was not on the panel of the insurance company. If the said hospital had de-paneled on 08.09.2022, it was the duty of the OP to inform to all their customers, so that they can got the knowledge of the same. It is not the case of the OP that in this regard, they had informed to their customers including complainant.  Hence, the plea taken by the OP is only on the basis of presumption and assumption, which is not admissible 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, 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 the complainant amounts to deficiency in services and unfair trade practice, which is otherwise proved genuine one.

15.           The complainant has claimed Rs.94,253/- and in this regards he has placed on file final bill Ex.C4. The said amount 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.94,253/- (Rs. ninety four thousand two hundred fifty three only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 09.02.2023 till its realization. We further direct the OP to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs. 11,000/- towards 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:08.08.2024

         President,

      District Consumer Disputes                           

      Redressal Commission, Karnal.

 

                           (Sarvjeet Kaur)   

                              Member