Order by:
Aparana Kundi, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that on 26.08.2022 son of the complainant namely Mivan Mittal suffered from fever, cough and cold and on the same day he was admitted at Dhaliwal Hospital, Moga, where doctor got conducted various blood tests and ultrasound of the son of the complainant. After discharge from the hospital, the complainant submitted all the documents to the official of the Opposite Parties alongwith letter head of doctor, but on 08.11.2022, the Opposite Parties rejected the claim of the complainant on the ground of non submission of documents. On 22.06.2023, the complainant again sent an email to the Opposite Parties to consider the claim. Thereafter on 02.09.2023, the Opposite Parties sent a reply to complainant stating that ‘query raised on 24.09.2023, unable to re-open’. Alleged that the complainant paid an amount of Rs.17,942/- to the said hospital from his own pocket. The Opposite Parties were asked many times to pay the amount of the claim, but to no effect. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay an amount of Rs.17,942/- with regard to the policy bearing no.P/211222/01/2023/004030.
b) To pay a sum of Rs.1,00,000/- as compensation on account of mental tension, harassment and for deficient services.
c) To pay Rs.50,000/- as litigation expenses.
d) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination, which is not possible in the summary procedure under C.P. Act; the complainant has concealed the fact and documents from this Commission as well as from the Opposite Parties, therefore, the complainant is not entitled to any relief. Insured has violated the terms and conditions of the policy in question and not provide the required documents to process the claim in question even after reminders. Averred that the complainant availed the ‘Young Star Insurance Policy’ bearing No.P/211222/01/2023/004030 for the period 23.07.2022 to 22.07.2023 and in this policy complainant, his wife Ankita Mittal and minor Mivan Mittal were insured for an amount of Rs.4 lakh (but as per policy placed on record by complainant sum insured is Rs.10 lakh). The terms and conditions of the policy were explained to the complainant at the time of proposing the policy and same were served to the complainant alongwith policy schedule. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Averred further that the insured availed the said policy through online proposal form and in the online proposal form the insured verified the fact by confirming OTP sent on his mobile number and hence the insured himself authenticated the details by entering the OTP on 22nd July, 2020, 8:01:35 pm received by SMS. Averred further that the Opposite Parties have already given claim to the insured for Mivaan Mittal for AGE for an amount of Rs.9,480/- having claim no.CIR/2023/211222/1541999. Now, the claim was registered vide claim no.CIR/2023/211222/0738944 and the complainant has submitted the claim documents in the present case regarding the medical reimbursement expenses towards treatment taken by his son Mivaan Mittal at Dhaliwal Hospital on 26.08.2022 to 29.08.2022 towards the treatment of Acute Whezzy Bronchitis. On scrutiny of claim documents, the Opposite Parties demanded documents which are necessary to process the claim vide letters dated 24.09.2022, 09.10.2022, 24.10.2022 such as:-
i) Kindly submit treating doctor letter stating when was Acute Wheezy Bronchitis first diagnosed? Its initial OPD consultation and its exact duration.
ii) Kindly submit previous history of hospitalization for the same ailment.
iii) Kindly provide all past investigation records for supporting diagnosis.
iv) Complete set of indoor case sheet papers with temperature chart.
Even after reminders, the complainant did not supply the documents to the Opposite Parties. The above documents were mandatory for the processing the claim and Opposite Parties were unable to process the claim without the above queried documents and hence the Opposite Parties were forced to repudiate the claim. Averred further that as per condition no.18 of the above policy, the insured person has to submit all the required documents and details called for by Opposite Parties. Hence, the claim was rejected vide repudiation letter dated 08.11.2022 and duly informed to the complainant. Averred further that the complainant has no locus standi or cause of action to file the present complaint against the Opposite Parties; the complaint is not maintainable in the present form; the complainant has violated the terms and conditions of the policy. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. In order to prove the case, complainant has placed on record his affidavit as Ex.C1 alongwith copies of documents Ex.C2 to Ex.C21.
4. On the other hand, Opposite Parties have placed on record copies of documents Ex.OP1 to Ex.OP10 and affidavit of Sh.Sumit Kumar Sharma, Authorized Signatory, Star Health & Allied Insurance Co. Ltd. as Ex.OP11.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. It is admitted and proved on record that the complainant availed health insurance policy namely ‘Young Star Insurance Policy’ bearing no.P/211222/01/2023/004030 for the period 23.07.2022 to 22.07.2023 for self, his wife Ankita Mittal and minor Mivan Mittal for a sum insured of Rs.10,00,000/-. It is also proved on record vide policy (Ex.C3) placed on record by the complainant that the policy in question is in its third year, as in the said policy the date of inception of first policy is mentioned as 23.07.2020. Further there is no point of dispute that during the policy coverage, son of the complainant suffered ‘Fever, Cough and Cold’ and got admitted in Dhaliwal Hospital, Moga on 26.08.2022 and after the treatment got discharged from the hospital on 29.08.2022. It is also proved on record that the claim lodged with Opposite Parties and on receipt of the claim intimation, the Opposite Parties issued different letters on different dates requiring certain documents, which the complainant failed to supply and thereafter vide letter dated 08.11.2022 (Ex.OP10), the Opposite Parties rejected the claim of the complainant for want of documents.
7. The perusal of the rejection letter dated 08.11.2022 reveals that Opposite Parties demanded the documents i.e. (i) treating doctor letter stating when was Acute Wheezy Bronchitis first diagnosed, ii) previous history of hospitalization, iii) all past investigation records. We are of the concerted view that the demand of aforesaid documents by the Opposite Parties is ingenuine, as Opposite Parties have not placed on record any document from which, they came to know that son of the complainant suffered from the ailment in question prior to his admission in the hospital. Moreover, son of the complainant is mere a child of age of 4 and half years only and he admitted in the hospital with complaints of ‘Fever, Cough and Cold’, which is very common problem among children of this age especially during change in season and can be occurred at any time and at any stage of age. Furthermore in the discharge summary, no where it is mentioned that son of the complainant has past history of the ailment in question. Careful perusal of the record reveals that after admission of the son of the complainant in the hospital, various tests of the complainant’s son have been got conducted and thereafter he was diagnosed as ‘Acute Wheezy Bronchitis’ and moreover, if the son of the complainant already suffered from the ailment in question or complainant knows about the disease of his son as alleged by Opposite Parties then what was the necessity for the complainant to spend a huge amount on the tests and examination of his son again.
8. Further the Opposite Parties demanded complete set of indoor case sheet paper with temperature chart, which has already been placed on record by the complainant and the same has been sent to the Opposite Parties alongwith notice of this complaint and if the Opposite Parties are willing to settle the claim of the complainant, they can it done at the time of receiving the notice of the complaint alongwith documents, but they did not bother to do so and forced the complainant to file the present complaint. Hence, we are of the considered view that Opposite Parties wrongly and illegally repudiated the claim of the complainant.
9. Vide instant complaint, the complainant has claimed the amount of Rs.17,942/-, which is duly proved on record, vide Ex.C7 to Ex.C9, Ex.C12 to Ex.C16 and Ex.C18. Hence, we allow the said amount.
10. In view of the above discussion, the instant complaint is allowed in part and Opposite Parties are directed to pay a sum of Rs.17,942/-(Rupees Seventeen Thousand Nine Hundred Forty Two only) to the complainant. Opposite Parties are also directed to pay compository costs of Rs.3,000/-(Rupees Three Thousand only) as compensation and litigation expenses to the complainant. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 30 days from the date of receipt of copy of this order, failing which, the Opposite Parties are further burdened with additional cost of Rs.3,000/-(Rupees Three Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission
