Order by:
Smt.Priti Malhotra, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that in the year, 2019, the complainant availed the insurance policy from Opposite Parties continued it till 2023. Unfortunately, in the month of April, 2021 the complainant suffered “Abdominal problem” and visited Moga Medi-City, Super Specialty Hospital, Moga on 09.04.2021, where he was diagnosed with “Stone problem”. Thereafter, the complainant went to Dayanand Medical College and Hospital, Ludhiana on 13.04.2021 for the operation of stone, where he also suffered from Covid-19. The complainant got discharge from the hospital on 14.04.2021. Alleged that the complainant spent Rs.16,505/- on the treatment. Thereafter on 15.05.2021 the complainant suffered from “COPD with Pneumonitis Chest” and admitted in Shakuntla Hospital, Zira Road, Kot Ise Khan, District Moga, where doctor conducted the treatment of complainant and thereafter discharged from the hospital on 17.05.2021. The complainant spent Rs.32,716/- on the treatment. Thereafter, the complainant lodged the claim with Opposite Parties, but vide letter dated 03.02.2023 they rejected the claim of the complainant. After that the complainant again arranged the entire query documents from the concerned hospital and hand over the same to the office of Opposite Parties, but on dated 20.03.2023, the Opposite Parties again rejected the claim of the complainant. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay Rs.49,221/-.
b) To pay an amount of Rs.1,00,000/- as compensation for mental tension and harassment.
c) To pay an amount of 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 the present pre mature complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Party as per policy terms and conditions. Averred further that the present complaint pertains to insurance claim under ‘Family Health Optima Insurance Plan’ bearing No.P/211222/01/2021/007702 valid from 08.02.2021 to 07.02.2022 covering the complainant self and his spouse Rajbir Kaur and dependent Children namely Isha Arora, Jasleen Kaur and Khushpreet Kaur for a sum of Rs.5,00,000/-. However it is submitted that the aforesaid insurance policy was issued to the insured by the answering Opposite Party subject to the terms and conditions of the insurance policy. 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 had requested for cashless and submitted the medical expenses towards the treatment Ureteric Calculi Right at Dayanand Medical College and Hospital on dated 13.04.2021 and the Opposite Parties had given pre-authorization initial approval to hospital of an amount of Rs.30,000/-, but further received the letter from the insured for cancellation of pre-authorization. Hence, pre authorization approval was rejected and conveyed to insured vide letter dated 09.01.2022. But the Opposite Parties have not received the claim reimbursement afterwards from the insured side i.e. the insured did not preferred or lodged any claim subsequently till date and has never submitted any claim form and relevant documents for processing of the claim so far. Thereafter, the insured has submitted the medical expenses towards the treatment of “COPD with Pneumonitis Chest” incurred at Shakuntala Hospital, Kot Ise Khan on 15.05.2021 to 17.05.2021. Then Opposite Parties vide letters dated 20.12.2022, 04.01.2023 and 19.01.2023 asked the complainant to furnish the following documents and information:-
Letter from treating doctor stating when was COPD first diagnosed? Its initial first OPD consultation and its exact duration and past treatment records.
Previous history of hospitalization for the same patient
All past investigation records like Xray Chest, CT Chest, PFT for supporting diagnosis.
Complete set of indoor case sheet papers.
Cash paid receipt/s in original alongwith hospital seal and sign for amount of Rs.32,716/- towards the final bill it is mandatory.
But despite so many written requests, the insured did not submit the documents called for which amounts to non submission of required documents. In the absence of the above documents/details, Opposite Parties are not able to further process the claim. As per Condition No.2 of the above policy, the insured person has to submit all the required documents and details called for by the Opposite Parties. Hence, claim was rejected and conveyed to Insured vide our letter dated 20.03.2023. Averred further that the instant complaint is neither maintainable in law nor on facts; no deficient services have been rendered by the answering Opposite Parties as alleged by the complainant; the complaint being pre-mature and false is not maintainable; the complainant has not come with clean hands. 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 his case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C19.
4. On the other hand, Opposite Parties have tendered into evidence affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1, 2/A alongwith copies of documents Ex.OP1, 2/1 to Ex.OP1, 2/16.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. It is well proved on record that the complainant is the holder of Insurance policy namely ‘Family Health Optima Insurance Plan’ having no.P/211222/01/2021/007702 for the period 08.02.2021 to 07.02.2022 covering complainant self his spouse and dependent children. It is also proved on record that during the policy coverage, the complainant suffered with ‘Stone problem’ and got admitted in Dayanand Medical College and Hospital, Ludhiana on 13.04.2021 and got discharged on 14.04.2021. It is also proved on record that at the time of admission in the hospital, the complainant requested Opposite Parties for cashless authorization, which was accepted and an amount of Rs.30,000/- was approved by the Opposite Parties (Ex.OP1,2/6), however later vide letter dated 09.12.2022 (Ex.OP1,2/7), the cashless approval was rejected as withdrawn by Opposite Parties on the basis of previous request of the complainant, which too is not denied by the complainant. Thereafter, the complainant again got admitted in Shakuntata Hospital, Kot Ise Khan, Moga for the period 15.05.2021 to 17.05.2021 for the treatment of ‘COPD with Pneumonitis Chest’ and after discharge from the hospital, the complainant lodged the claim with Opposite Parties. Thereafter, the Opposite Parties issued various letters to the complainant demanding documents as follows:-
Letter from treating doctor stating when was COPD first diagnosed? Its initial first OPD consultation and its exact duration and past treatment records.
Previous history of hospitalization for the same patient
All past investigation records like Xray Chest, CT Chest, PFT for supporting diagnosis.
Complete set of indoor case sheet papers.
Cash paid receipt/s in original alongwith hospital seal and sign for amount of Rs.32,716/- towards the final bill it is mandatory.
When the complainant failed to supply the said documents, then, vide letter dated 20.03.2023 they repudiated the claim of the complainant for want of aforesaid documents.
7. There is no denial of the fact that during the first hospitalization period from 13.04.2021 to 14.04.2021, the pre authorization request for cashless treatment was approved for an amount of Rs.30,000/- and the said request was withdrawn by the complainant as during that period he got infected with Covid-19, so he get discharge from the hospital. There is no further record revealing that the complainant ever lodged the claim for reimbursement of expense incurred during his stay at hospital for the above noted period, Ex.OP1,2/7 is evident of the fact mentioned above.
8. We thus now fall back upon the second claim. Evidently vide Ex.C8, the complainant got admitted in Shakuntata Hospital, Kot Ise Khan, Moga for the period 15.05.2021 to 17.05.2021 for the treatment of ‘COPD with Pneumonitis Chest’. Also proved on record that after discharge from the hospital, the complainant lodged the claim with Opposite Parties for the reimbursement of expenses incurred during his stay at hospital for the second hospitalization. Thereafter the Opposite Parties issued letters dated 20.12.2022, 04.01.2023, 19.01.2023 and 03.02.2023 requiring the documents i.e. letter from treating doctor stating when was COPD first diagnosed? Its initial first OPD consultation and its exact duration and past treatment records; previous history of hospitalization for the same ailment; all past investigation records like Xray Chest, CT Chest, PFT for supporting diagnosis; complete set of indoor case sheet papers; cash paid receipt/s in original alongwith hospital seal and sign for amount of Rs.32,716/- towards the final bill it is mandatory. Thereafter vide letter dated 20.03.2023, the Opposite Parties repudiated the claim of the complainant for want of aforesaid documents. It is evident on record that during the second hospitalization period, the complainant incurred an amount of Rs.32,716/-. Claim Form Ex.OP1,2/8 further corroborate the said fact, where the claim only for an amount of Rs.32,716/- has been raised for the expenses incurred for the second hospitalization period. The thorough perusal of the record reveals that the ground for repudiation of the second claim is not only unreasonable but also not sustainable in the eyes of law for the simple reason that Opposite Parties failed to consider the well explained certificate so issued by the treating doctor, who vide Certificate dated 08.02.2023 (Ex.C13) certified as under:-
i. Certified that Pt. Bhupinder Singh has come in my hospital with COPD and Pneumonitis Chest. He admitted in the hospital IPD no.26/2021.
ii. There is no previous history in records of the patients because he was first time come in my hospital for above diagnosis. There is no entry of the patient in my OPD. He is direct admitted in IPD.
It transpires that the officials of Opposite Parties are reluctant to perform their part of duty and thus opted to reject the claim arbitrarily without applying their mind. Thus, from the above, it is well clear that there was no requirement left to be asked for the treatment record when once it has duly been certified by the treating doctor that there is no past history of the ailment in question. Hence, the complainant is duly entitled for his rightful claim.
9. Vide instant complaint, the complainant has claimed an amount of Rs.49,221/-/- i.e. expenses incurred for two hospitalization periods. However, it is evident on record that the expenses incurred during the first hospitalization period for an amount of Rs.16,505/- were declined by the Opposite Parties stating that the complainant had not lodged the claim for those expenses. Further there is no denial of fact by the complainant. Thus we refrain to pass any order qua the said amount. However, complainant is at liberty to lodge the claim with Opposite Parties. Now come to the amount of Rs.32,716/- claimed by the complainant for the second hospitalization, which is duly proved on record vide E x.C9. Hence we allow the said amount.
11. In view of the discussion above, we party allow the complaint of the complainant and direct the Opposite Parties to pay an amount of Rs.32,716/-(Rupees Thirty Two Thousand Seven Hundred Sixteen only) to complainant. Opposite Parties are further directed to pay compository cost of Rs.7000/-(Rupees Seven Thousand only) to be paid to the complainant on account of compensation and litigation expenses incurred. 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 burdened with additional cost of Rs.15,000/-(Rupees Fifteen 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
