BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.279 of 2020
Date of Instt. 09.09.2020
Date of Decision: 13.02.2023
1. Vikas Malhotra S/o Balraj Malhotra
2. Vaishali Malhotra W/o Vikas Malhotra
Both resident of WL-296, Basti Guzan, Near Panchwati Mandir, Jalandhar at present resident of H. No.24, Raja Garden, Basti Peer Dad Road, Near Durga Mandir, Jalandhar.
..........Complainants
Versus
1. Star Health and Allied Insurance Company Limited, Through its Authorized Signatory, Having its Office at: No.15, Sri Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai.
2. Star Health and Allied Insurance Company Limited, Through its Branch Manager, EH 199, 2nd Floor, Nirmal Complex, G. T. Road, Jalandhar.
3. Star Health and Allied Insurance Company Limited, Through its Authorized Signatory, Having its Regd. & Corporate Office at: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Vaneet Kaundal, Adv. Counsel for the Complainants.
Sh. A. K. Arora, Adv. Counsel for the OP.
Order
Dr. Harveen Bhardwaj (President)
1. This complaint has been filed by the complainants, wherein alleged that the Complainant no.2 purchased a Family Health Optima Insurance Plan from the OPs, bearing policy no.P/211215/01/2018/001058. At the time of execution of the policy the agent of the OPs assured the complainant's that all the Hospital expenses upto Rs.5,00,000/- are covered under the policy. On the assurance of agents of the OPs, the complainant no.2 purchased the policy of the OPs No.1 to 3. The husband of the complainant no.2 namely Vikas Malhotra is also beneficiary in the above noted health insurance plan. On 08-06- 2019 when the complainant no.1 was going towards his work in the morning on his Motor Cycle, all of sudden a cyclist came to the front of the complainant no.1, due to which the Motor cycle of the complainant was slipped and the complainant no.1 fell on the road and suffered injuries on his head and nose. Due to roadside accident the fracture was diagnosed in the inferior turbinate with deviated nasal septum of the Complainant no.1. The complainant no.1 was firstly taken to the Civil Hospital, Jalandhar and after giving first aid he was referred to the Mohak's Diagnostic Hospital, Jalandhar for further treatment, where he was admitted on 08-06-2019 and was discharged on 09-06-2019. But due to the continuous Nasal obstructions, swelling and Nasal bleeding, the complainant no.1 approached the Kataria Eye & Ent Hospital Pvt. Ltd, Jalandhar for the said problem. The treating Doctor namely Harish Nanda of Kataria Hospital advised the complainant to get the X-ray film of the nasal bones from Mann Diagnostic & Research Centre, Jalandhar. As per the advice of the doctor the complainant no.l visited at Mann Diagnostic Centre on 10-06-2019 and got conducted the X-Ray film of his Nose, but due to the clottage of the blood in the Nose of the complainant no.1, the X-Ray film did not clearly show the actual vision inside the Nasal of the complainant no.1. Due to the Deviation of the Nasal Septum and non clearance of the actual position of the Nasal Bones from the earlier X-Ray film, the Doctor namely Harish Nanda again advised the complainant no.1 to get X-Ray Film of the Nasal Bones from the Amarjeet CT Scan & Diagnostic Centre after getting the clean of the Nose as the treating doctor was not satisfied with the X-Ray film of the Mann Scan centre, Jalandhar and as per his opinion there is seems to be a definite fracture in the nasal bone of the complainant no.1, which was clearly shown from the position of the nose of the complainant no.1. On 14-06-2019 the complainant no.1 again got conducted the X-Ray film of the Nassal Bones from the Amarjeet CT Scan & Diagonstic Centre, Jalandhar after getting the clean of Nose from the doctor and got report dated 14-06- 2019 to the effect that ‘facture diastasis of naso- frontal region seen’ from Amarjeet CT Scan & Diagnostic Centre, Jalandhar, The complainant no.1 admitted in the Kataria Eye & Ent Hospital on 15-06-2019 and was discharged on 16-06-2019. The complainant no.1 undergone from the Nasal surgery at Kataria Eye & Ent Hospital due to the fracture in the Nassal Bone during his hospitalization and spent Rs.1,00,000/- on his treatment and Medicine. The complainant's lodged the claim with the OPs and the OPs issued a Claim Intimation no.CLI/2020/211215/0172242 to the complainants. The complainants have submitted all the necessary documents to opposite parties as per the instructions of the OPs. The complainant no.2 shocked to received a letter dated 05-07- 2019 from the OPs that the claim of the complainant no.1 was repudiated by the OPs on the false and fibulas grounds. The Repudiation of the claim of the complainant no.1 on the false and fibulas grounds are unlawful and illegal one and is unfair practice on the part of the OPs. Moreover, no opportunity of hearing was granted to the complainants explain the facts regarding the X-Ray film issued by the Mann Scan Centre. As per the policy terms and conditions of the policy, the OPs are supposed to pay the entire amount of the treatment and medicines of the complainant no.1 and the complainant no.1 is entitled for the same. The complainant's several times approached at the office OPS and requested the OPs to release the amount of claim of the complainant no.1, but all in vain. The complainants have also served the legal notice dated 17-01- 2020 upon the OPs through registered post, which was duly received by the opposite parties and Email regarding the same was sent to the complainants by the OPs, but no reply to the notice has sent by the OPs to the complainants nor release the amount of the claim and compensation to the complainants and as such necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the claim amount of Rs.1,00,000/- as medical expenses spent on the treatment of the complainant No.1 alongwith the interest @ 18% per annum and litigation expenses. Further, OPs be directed to pay Rs.50,000/- as compensation for causing mental tension and harassment to the complainant.
2. Notice of the complaint was given to the OPs, who filed reply and contested the complaint by taking preliminary objections that the complainant Mr. Vikas Malhotra was hospitalized at Kataria Eye and ENT, Jalandhar on 15.06.2019 for the treatment of fracture inferior turbinate with deviated nasal septum and submitted claim for Rs.42,723/-. Initially the claim was repudiated since the x-ray film dated 10.06.2019 shows there is deviation of bony septum with spur indicating pre existing deviation. However, on the request of the complainant the claim was again reviewed and amount of Rs.38,105/- was approved vide DD No.402936 dated 10.02.2020. But the complainant has not accepted the same. The reason for the deduction of the claim were as follows:-
As per the other excluded expenses no.72. an amount of Rs.1,000/- was deducted towards Investigation of HIV, HBAG, since it is not relevant to the present diagnosis.
The insured has not submitted prescription for the medicine bill dated 08/06/2019 for Rs.2.205/- + Rs.243/- and for bill dated 09/06/2019 Hence, altogether an amount of Rs.3,328/- was disallowed. If the prescription is submitted, the opponent is ready to pay the amount as per the T & C.
As per other excluded expenses No.34, an amount of Rs.290/- are disallowed otrinoz adult (Nasal drop), liquid paraffin (Liquid paraffin, also known as E paraffinum liquidum or Russian mineral oil, is a very highly refined mineral oil used in cosmetics and medicine), nesporin ointment are not payable.
The amount of Rs.38,105/- was approved towards the claim as per term and conditions of policy deducting an amount of Rs.4,618/-. It is further averred that the complainant is demanding reimbursement of expenses of treatment taken by him at Mohak Diagnostic Hospital, however he has never submitted any bills or treatment record for the same to the OPs. Further, he has never lodged any claim regarding the same with the OPs thus he is not entitled to receive any claim amount regarding the same. It is further averred that no cause of action has arisen in favor of the Complainant to file the present case. It is submitted that the Respondent/OP's has acted strictly on the basis of the terms and conditions contained in the policy. The present case is premature as the complainant had not submitted the required documents for the purpose of the claim despite of repeated requests by the answering respondents/OP's. The complaint has been filed by the complainant with the mala-fide intention, and further to grab the public money. Hence, the present complaint is liable to be dismissed. It is further averred that the relief sought in the present complaint is in violation of the terms and conditions contained in the policy. Therefore, the complaint is liable to be dismissed with exemplary costs. It is further averred that the complaint is bound by the terms and conditions as applicable and which were expressly made known to the complainant at the time of his taking the policy in question. The OP had at the time of issuing the policy explained to the complainant the exclusion clauses and the payment plan. It is further averred that the complainant has approached this Commission with unclean hands by not disclosing and misrepresenting material facts. The present complaint is false, frivolous, misconceived and vexatious in nature and has been filed with the sole intention of harassing the OPs. The complainant has knowingly and intentionally concealed the true and material facts from this Commission. The present complaint is a gross abuse of the process of law and is liable to be dismissed with costs. The present complaint is the misuse of the legal process. It is further submitted that the present complaint was filed only with the motive to harass the OPs. The complainant has no locus-standi and cause of action to file the present. On merits, the factum with regard to issuance of the insurance policy by the OP is admitted. It is also admitted that the complainant was taken treatment from Kataria Eye & ENT Hospital Jalandhar from 15.06.2019 to 16.06.2019 and then the complainant lodged a claim and the same was repudiated, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder not filed by the complainant.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
6. It is admitted and proved that the complainant No.2 purchased family health optima insurance plan from the OPs and the same was valid for 06.09.2018 to 05.09.2019. The copy of the insurance policy has been proved as Ex.C-1. The insurance policy has been admitted by the OPs. Perusal of Ex.C-1 shows that the sum insured was Rs.5,00,000/-. The complainant suffered road side accident on 08.06.2019 and he was taken to Civil Hospital, Jalandhar for treatment, but thereafter he was referred to Mohak’s Diagnostic Hospital, Jalandhar for further treatment where he was admitted on 08.06.2019 and was discharged on 09.06.2019. Ex.C-2 is the admission record of the complainant in the Civil Hospital and Ex.C-3 is the admission record and treatment record of the complainant in Mohak’s Diagnostic Hospital, Jalandhar. It has been specifically mentioned that he suffered accidental injuries and he was advised to consult ENT Specialist. He was admitted in the Kataria Eye and ENT Hospital on 15.06.2019 and was discharged on 16.06.2019. X-Ray and CT Scans were got conducted and as per the X-ray report, he had fracture diastasis of naso-frontal region. He had to undergo for Nasal surgery at Kataria Eye & ENT Hospital. He spent Rs.1,00,000/- on his treatment and medicine. He has proved on record the copy of discharge slip and the medicine bill and record of Kataria Hospital Ex.C-16 to Ex.C-19 and he has also proved the report of CT Scan, X-ray and the bills of Mohak’s Hospital Ex.C-4 to Ex.C-15. The claim was filed, but the same was repudiated by the OPs.
7. The contention of the OPs was that since he did not supply the documents despite the reminders for number of times, the claim was not paid and his claim was cleared for Rs.38,105/-, but the complainant refused to accept the same. The letter vide which the claim was repudiated is Ex.C-20. Ex.C-20 shows that the claim was repudiated on the ground that the X-ray film dated 10.06.2019 confirms no evidence of fracture and the complainant had undergone treatment for above disease during the second year of the policy. The complainant sent emails and even the OP has admitted that they received the documents sought from the complainant. The OP has referred the exclusion clause regarding the non-payment of the claim when the policy is in the second year of the commencement. The OPs have admitted the treatment taken by the complainant from the hospital and the discharge summary has been proved by the OPs as Ex.OP-5 and the treatment of Kataria Eye & E. N. T. Hospital Ex.OP-6 and they have also produced on record the letters repudiating the claim of the complainant Ex.OP-7 and Ex.OP-8. It has been alleged in the written statement by the OPs that the complainant has not produced on record the prescriptions of the medicines taken for Rs.3328/- and without prescription the claim cannot be settled. But this contention of the OPs is not tenable. The complainant has proved on record all the bills, discharge summary and admission dates and admission prescriptions of both the hospitals i.e Mohak’s Diagnostic Centre and Kataria Eye & ENT Hospital. Even the complainant has authorized the OP, vide letter produced on record by the OPs vide which the complainant has authorized OP to seek through the bearer of this authorization any medical information/record including ICP from the hospital or from the medical practitioner, who have attended on him in connection with the ailment and treatment given. Once the OP has been authorized to go through any record and seek and verify any medicine prescription from the concerned doctor and hospital, then question of repudiating the claim on the ground that prescription of the bills of Rs.3328/- have not been produced is without any basis and wrong and illegal.
8. More so, the policy was taken by the complainant on yearly basis and in such circumstances, the patient cannot wait for expiry of the period of two years to get the treatment, when it becomes urgent to get the treatment. Even otherwise, once the policy is on the yearly basis, the policy will come to an end on the expiry of a year and the period of two years would never reach and the condition laid down of waiting period of two years becomes of no value and meaningless. It has been held by the Hon’ble State Commission, in case titled as “New India Assurance Co. Ltd and others Vs. Ravinder Pal Singh”, 2008 CTJ 769 (CP) (SCDRC) that ‘the exclusionary clause, where there is a condition of three years cannot be made basis for repudiating the claim since the policy run on yearly basis after being renewed by the holder, the condition of three years had no logic underlying it-clearly it was a continuous Good Health Mediclaim Policy.’ In view of the above referred law and considering the facts of the case, the repudiation letter is held illegal and the same is hereby set-aside.
9. In view of the above detailed discussion, the complaint of the complainant is partly allowed and OPs are directed to reimburse the amount of Rs.38,105/- without interest as the complainant had refused to accept the same from the OPs and Rs.3328/- with interest @ 6% per annum from the date of lodging of mediclaim till its realization. Further, OPs are directed to pay Rs.15,000/- as compensation for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
10. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
13.02.2023 Member Member President
