Complaint No: 107 of 2023.

                                                                 Date of Institution: 30.05.2023.

                                                                         Date of order: 06.03.2024.

Sandeep Agnihotri aged about 44 years Son of Suresh Agnihotri, resident of House No. 640 Ward No. 19, Gali No. 2 Rulia Ram Colony, Tehsil and District Gurdaspur.

                                                                                                                                                                         …....Complainant.                                                                                                                                                                                                                                                                                                                                                                                                       

                                                                                     VERSUS

1.       STAR HEALTH AND ALLIED INSURANCE CO. LTD., Sri Balaji Complex, 15 Whites Road, Chennai – 600014, through its Authorized Signatory.

2.       STAR HEALTH AND ALLIED INSURANCE CO. LTD., Regd. & Corporate Office 1, New Tank Street Valluvar Kottam High Road, Nungambakkam, Chennai – 600034, through its Authorized Signatory.

3.       STAR HEALTH AND ALLIED INSURANCE CO. LTD., Branch office Pathankot 2nd Floor, Khajuria Complex, Opposite Hotel Venice, Dhangu Road Pathankot, through its Authorized Signatory / Branch Manager.    

                                                                                                                                                               ….Respondents.

4.       Indraprastha Apollo Hospitals Sarita Vihar, New Delhi – 110076, through its Authorized Signatory.

                                                                                                                               ….Performa Respondent.

                                              Complaint u/s 35 of Consumer Protection Act.

Present: For the Complainant: Sh.S.S. Litter, Advocate.

             For the Opposite Parties No.1 & 3: Sh.Sandeep Ohri, Advocate.

            Complaint against Opposite Parties No.2 & 4 had already been dismissed as withdrawn.

Quorum: Sh.Lalit Mohan Dogra, President, Sh.Bhagwan Singh Matharu, Member.

ORDER

Lalit Mohan Dogra, President.

          Sandeep Agnihotri, Complainant (here-in-after referred to as complainant) has filed this complaint under section 35 of the Consumer Protection Act (here-in-after referred to as 'Act') against Star Health & Allied Ins. Co. Ltd. Etc. (here-in-after referred to as 'opposite parties).

2.       Briefly stated, the case of the complainant is that the complainant has availed a Family Health Optima Insurance Plan SHAHLIP22030V062122, under policy No.P/211212/01/2022/003797, Customer Code: AA0022435499, Proposer Code: 25712645, SAC Code: 997133/Accident and Health Insurance Services, issuing Office Code: 211212, for his family, from the opposite parties No. 1 to 3 i.e. STAR HEALTH AND ALLIED INSURANCE CO. LTD., For period of insurance From: 25.12.2021 (16:45)  To  Midnight of 24.12.2022, Vide Invoice No. 31299Y22P0000420, Invoice date: 25.12.2021, and paid Rs.20,580/- and which was got renewed for next year i.e. For period of insurance From 29.12.2022 To Midnight of 28.12.2023, vide Invoice No. 31299Y23P0000364, Invoice dated: 19.12.2022, and again paid Rs.20,580/- to the opposite parties. It is pleaded that unfortunately, the complainant’s wife namely Ms. Vasudha Agnihotri, had to suffer from a very serious Diagnosis  i.e. TCC - Transitional Cell Carcinoma of bladder, and there was immediately became critical circumstances for medical treatment to save the life of his wife, and she was immediately got admitted at Indraprastha Apollo Hospital, and she had to remain admitted at Indraprastha Apollo Hospital i.e. Performa OP No. 4, w.e.f dated 30.01.2023 to 01.02.2023, for her medical treatment. It is further pleaded that the complainant spent a sum of Rs.2,63,333/- (Rupees Two Lakhs and sixty three thousands and three hundred thirty three only), on the treatment of his wife,  for saving her life, as per ESTIMATE Bill / receipt dated 30.01.2023. The complainant through Performa OP No. 4, i.e. Indraprastha Apollo Hospital sent claim intimation No. CIR/2023/211212/1427680 to STAR HEALTH AND ALLIED INSURANCE CO. LTD., i.e. OP’s No. 1 to 3 and they have illegally and without any reasonable cause rejected Authorization for Cashless Treatment. It is further pleaded that the complainant has availed the said family health insurance policy for the purpose of availing some financial assistance and benefits, but the OP’s No. 1 to 3, have caused unnecessary physical and mental harassment to the complainant, for which, the opposite parties, are held liable jointly and severally. It is further pleaded that the above mentioned mala fide act of the opposite parties, amounts to deficiency in service, on their part, because the complainant has availed the facility of Family Health Insurance, from the respondents for receiving medical claim, but unfortunately, the opposite parties have failed to provide the benefit of the same to the complainant without any reasonable cause. It is further pleaded that due to this illegal act and conduct of the opposite parties the complainant has suffered great loss and also suffered mental agony, Physical harassment and inconvenience. It is further pleaded that there is a clear cut deficiency in service on the part of the opposite parties.

          On this backdrop of facts, the complainant has alleged deficiency and unfair trade practice on the part of the opposite parties and prayed that necessary directions may kindly be issued to the opposite parties to reimburse / pay the medical claim of Rs.2,63,333/- (Rupees Two Lakhs and sixty three thousands and three hundred thirty three only), under the Family Health Optima Insurance Plan SHAHLIP22030V062122, under policy No. P/211212/01/2022/003797, Customer Code: AA0022435499, of the opposite parties No. 1 to 3  as per the medical record / payment bills / certificates etc. of the Performa OP No. 4 and the opposite parties may kindly be further  directed to pay Rs.50,000/- as mental and physical harassment caused to the complainant by the opposite parties alongwith Rs.20,000/- as litigation expenses and any other relief for which, this Hon’ble Commission deems sustainable in favour of the complainant, will also be passed, in the interest of justice.

3.       Upon notice, the opposite parties No.1 to 3 appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the complainant has no cause of action and locus standi to file the present complaint. The insurance is a contract based on Utmost Good Faith. It is the duty of the insured and after his death his legal Heirs / Nominee to disclose all the relevant and true facts. It is pleaded that the insurance is a contract between two parties and both the parties bind with the terms and conditions of the policy. The liability of the insurance co. is only as per terms and conditions of the policy and there is no deficiency in service on the part of the answering opposite parties / insurance co. It is further pleaded that the matter of fact is that the Family Health Optima Policy has been taken in 2021 by the complainant. The first policy was issued for a period from 21.12.2021 to 28.12.2022. The Family Health Plan has been taken by the complainant i.e. Sandeep Agnihotri for himself, his wife and children. The sum insured is of Rs.10,00,000/-. The policy was again renewed from 29.12.2022 to 28.12.2023. 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. It is further pleaded that it has been clearly stated in the Policy schedule that the insurance under the policy is subject to conditions, clauses, warranties and exclusions etc. as the policy is contractual in nature. The complainant has accepted the policy. The claim has been raised in the second year of the policy. The insured has requested for cashless and submitted the medical expenses towards the treatment of SOL Urinary Bladder at Indra Prastha Apollo Hospital on 30.01.2023. It is further pleaded that after going through the documents, it has been observed that hospitalization for the treatment of Sol Urinary Bladder has arisen within the two years from the date of commencement of the first policy. As per the waiting period exclusion clause No.2:- Specified disease / procedure waiting period - Code Excl 02: of the policy, the claim is not admissible for a period of 2 years from the date of first policy. Hence, the claim was rejected and conveyed to the insured vide letter dated 30.01.2023. It is further pleaded that as per exclusion 2:- Specified disease / procedure waiting period - Code Excl 02: Expenses related to the treatment of the following listed Conditions, surgeries / treatments shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident. All treatments (conservative, interventional, laparoscopic and open) related to Hepato-pancreato-biliary diseases including Gall bladder and Pancreatic calculi. All types of management for Kidney Calculi and Genitourinary Tract Calculi. 

          On merits, the opposite parties No.1 to 3 have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in service on the part of the opposite parties. In the end, the opposite parties prayed for dismissal of complaint with costs. 

4.       Complaint against opposite parties No.2 and 4 withdrawn vide order dated 23.01.2024.

5.       Learned counsel for the complainant has placed on file Self-Declaration of Sandeep Agnihotri, (Complainant) as Ex.CW-1/A alongwith Self-Attested documents as Ex.C-1 to Ex.C-11 alongwith complaint.

6.       Learned counsel for the opposite parties No.1 to 3 has placed on file affidavit of Sh. Sumit Kumar Sharma, (Senior Manager, Star Health & Allied Ins. Co. Ltd., New Delhi) as Ex.OPW-1to3/A alongwith other documents as Ex.OP-1to3/1 to Ex.OP-1to3/7 alongwith reply.

7.       Rejoinder filed by the complainant.

8.       Written arguments filed by the complainant but not filed by the opposite parties No.1 and 3.

9.       Counsel for the complainant has argued that complainant had availed health insurance policy from opposite parties No.1 to 3 and as per the policy complainant, his wife and children were insured for sum assured under the policy. It is further argued that wife of the complainant Ms.Vasudha Agnihotri suffered from TCC Transitional Cell Carcinoma of bladder and remained admitted at Indraprastha Apollo Hospital from 30.01.2023 to 01.02.2023 and had spent amount of Rs.2,63,333/- on the treatment of his wife. It is further argued that claim for cashless treatment was declined by the opposite parties No.1 to 3 which amounts to deficiency in service.

10.     On the other hand counsel for the opposite parties No.1 to 3 has argued that the claim has been raised in the second year of the policy and after going through the documents it was observed that hospitalization was for treatment of Sol Urinary Bladder which has arisen within two years from the date of commencement of the first policy. As per the waiting period exclusion clause No.2, specified disease/procedure waiting period Code Excl. 02, claim is not admissible for a period of two years from the date of policy. Accordingly, claim was rightly declined by the opposite parties No.1 to 3.

11.     We have heard the Ld. counsels for the complainant and opposite parties No.1 and 3 ad gone through the record.

12.     To prove his case complainant has placed on record his self declaration Ex.CW-1/A, copies of policies Ex.C1 and Ex.C2, copy of discharge summary Ex.C3, copies of cash receipts Ex.C4 and Ex.C5, copiesw of outpatient summary and prescription Ex.C6 and Ex.C7, copies of ultrasound report Ex.C8 and Ex.C9, copy of estimate Ex.C10 and cop of rejection of cashless treatment Ex.C11 whereas opposite parties No.1 to 3 has placed on record affidavit of Sumit Kumar Sharma Ex.OP-1 to 3/A, copies of policies Ex.OP-1 to 3/1 and Ex.OP-1 to 3/2, copy of terms and conditions Ex.OP-1 to 3/3, copy of request for cashless Ex.OP-1 to 3/4, copy of form filled by doctor Ex.OP-1 to 3/5, copy of ultrasound report Ex.OP-1 to 3/6 and copy of rejection of insurance treatment Ex.OP-1 to 3/7.

13.     It is admitted fact that complainant had availed family health optima insurance plan from opposite parties No.1 to 3 for period 25.12.2021 to 24.12.2022. It is further admitted fact that the policy was further renewed from 29.12.2022 to 28.12.2023. It is further admitted fact that wife of the complainant who was also beneficiary of the policy remained admitted at Indraprastha Apollo Hospital from 30.01.2023 to 01.02.2023 for TCC Transitional Cell Carcinoma of bladder. It is further admitted fact that complainant had spent amount on treatment from his own pocket. It is further admitted fact that cashless treatment was declined by the opposite parties No.1 to 3. The only issue for adjudication before this Commission is whether the opposite parties No.1 to 3 have validly rejected the cashless treatment of the wife of the complainant. Whether the complainant is bound by the terms and conditions of the policy.

14.     Perusal of policy documents Ex.C1 and Ex.C2 shows that the said policy documents is consisting of only four pages and no terms and conditions are attached with the said policies. Although, opposite parties No.1 to 3 have declined cashless treatment by relying upon exclusion clause No.2 mentioned in Ex.OP-1 to 3/3 but it has not come on record that the said clauses were part of the policy documents Ex.C1 and Ex.C2 and if the said documents were supplied then who had explained the said terms and conditions to the complainant that such and such diseases are not covered upto period of two years.

15.     We have relied upon judgment of our own State Commission in First Appeal No.1095 of 2022 decided on 01.12.2023 in case titled as Care Health Insurance Limited etc. Vs. Guriqbal Singh as per which it was held that failure on the part of the insurance companies to prove that the  terms and conditions were supplied and explained to the insurer and further act on the part of  insurance companies of repudiating the claim by relying upon the said exclusion clause is unjustifiecc. We are further of the view that health insurance is purchased for the purpose of medical emergencies and if the insured persons are made to wait for two years for getting cashless treatment then the very purpose of obtaining health insurance shall became useless. We are further of the view that insurance companies cannot be allowed to get enriched by receiving premiums for two years and when it comes to settlement and payment of the claim, then decline the payment of claim by relying upon exclusion clauses in respect of which insured person is not made aware. As such we are of the view that declining of cashless treatment to the wife of the complainant amounts to deficiency in service on the parties of opposite parties No.1 to 3.

16.     Accordingly, present complaint is partly allowed and opposite parties No.1 and 3 are directed to settle and pay the claim amount of Rs.2,63,333/- to the complainant alongwith interest @ 9% P.A. from the date of filing of the present complaint till realization within 30 days from the date of receipt of copy of this order.            

17.     Copy of the order be communicated to the parties free of charges. File be consigned.                                                                                                                                                               

            (Lalit Mohan Dogra)

                                                                                      President. 

Announced:                                                   (B.S.Matharu)

March. 06, 2024                                                    Member.

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