Order by:

Smt.Aparana Kundi, Member

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that husband of the complainant namely Rohit Jindal has taken the Joint Health Insurance policy from Opposite Parties since 08.05.2019 for himself and complainant, which has been renewed time to time. The said policy again renewed vide policy no.P/211222/01/2024/000997 for the period 08.05.2023 to 07.05.2024 for a sum insured of Rs.5 lakhs alongwith bonus and recharge benefits. Unfortunately, complainant suffered with Acute Gastroenteritis and was admitted in Aastha Hospital and Test Tube Baby Centre for the period 06.04.2023 to 07.04.2023 and complainant spent Rs.9872/- on her treatment and Opposite Parties were duly informed by the said hospital. After discharge from the hospital, the complainant submitted claim for reimbursement alongwith original medical record and bills to the Opposite Parties. However, the claim of the complainant was declined/repudiated by the Opposite Parties. Alleged that the Opposite Parties repudiated the claim of the complainant on flimsy grounds. Complainant also sent a legal notice dated 22.11.2023 to the Opposite Parties, but to no effect. Due to such act and conduct of the Opposite Parties, the complainant has suffered mental tension and harassment. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to reimburse/pay the amount of medical claim of Rs.9872/- with interest  @ 12% p.a. to the complainant from the date of filing of present complaint till its realization

b)      To pay an amount of Rs.50,000/- as compensation on account of mental tension and harassment and for deficiency in service.

c)       To pay an amount of Rs.5500/- as cost of complaint.

2.       Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Parties as per insurance policy terms and conditions . Averred that the present complaint pertains to insurance claim under “Family Health Optima Insurance Plan Policy-2021 bearing no.P/211222/01/2023/000970 valid from 08.05.2022 to 07.05.2023 covering the complainant self and her spouse Rohit Jindal and Ishika and Ridham Jindal dependent children  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 Parties 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 has submitted the claim for reimbursement of medical expenses towards the treatment of AGE (Acute Gastroenteritis) at Aastha Hospital and Test Tube Baby Centre, Moga on dated 06.04.2023. It is observed from the submitted medical records that the insured patient was admitted in the hospital on 06.04.2023 whereas the intimation regarding the admission was given to company only on 25.04.2023. Thus for the reasons stated above the Opposite Parties was unable to settle the claim under the above policy and the same was repudiated on dated 25.05.2023. The claim of the complainant has rightly been repudiated in the light of terms and conditions of the policy and as per Clause-D of Standard Condition.           Averred 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. 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, the complainant has placed on record her affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C15.

4.       On the other hand, Opposite Parties have placed on record affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. as Ex.OP1,2/A alongwith copies of documents Ex.OP1,2/1 to Ex.OP1,2/10.

5.         We have heard the ld. counsel for both the parties and also gone through the record.

6.       The complainant availed the policy bearing no.P/211222/01/2023/000970 for the period 08.05.2022 to 07.05.2023 from the Opposite Parties covering the complainant self for a sum of Rs.5,00,000/- is not disputed. It is also not disputed that during the policy coverage the complainant suffered ‘Acute Gastroenteritis’ and got admitted in Aastha Hospital and Test Tube Baby Centre, Moga on 06.04.2023 and thereafter got discharged from the hospital on 07.04.2023. It is again admitted that the complainant lodged the claim for the reimbursement of the expenses incurred by her on her treatment, but the Opposite Parties repudiated the claim of the complainant vide letter dated 25.05.2023 (Ex.OP1,2/10) on ground of late intimation.

7.       The Opposite Parties repudiated the claim of the complainant, vide letter dated 25.05.2023. The contents of which are reproduced as under:-

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

It is observed from the submitted medical records that the insured patient was admitted in the hospital on 06.04.2023 whereas the intimation regarding the admission was given to us only on 25.04.2023.

Please note that as per policy issued to you, Condition – Standard Conditions- Clause D- Notification of claim, the intimation has to be given within 24 hours of hospitalization.

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.”

8.       We are of the considered opinion that if the policy is admitted, treatment in question is admitted, then repudiation of the genuine claim of the complainant on the ground of late intimation to the Opposite Parties is not genuine. However, no doubt that there is delay in intimation of about 19 days about the admission of complainant and there is breach of terms and condition of the policy in question. In these circumstances, we observed that the claim of the complainant should be settled on non standard basis” even if some of the conditions of the insurance policy are not adhered by the insured. In this regard, we are supported with judgment  in  case titled National Insurance Company Limited versus Kamal Singhal IV (2010)CPJ297 (NC) wherein the Hon'ble National Consumer Disputes Redressal Commission, New Delhi relying upon various decisions of the National Consumer Disputes Redressal Commission in the matter of (1) National Insurance Company Ltd. v. J. P. Leasing & Finance Pvt. Ltd. (RP No. 643/2005), (2) Punjab Chemical Agency v. National Insurance Company Ltd. (RP No. 2097/2009), (3) New India Assurance Co. Ltd. v. Bahrati Rajiv Bankar, (RP) No. 3294/2009) and (4) National Insurance Company Ltd. v. Jeetmal, (RP No.3366/2009) and also judgment of the Hon'ble Apex Court in the matter of National Insurance Company Versus Nitin Khandewal IV (2008) CPJ 1(SC), held the  breach of condition of the policy was not germane. The Hon'ble Supreme Court has further held that; “even assuming that there was a breach of policy, the appellant Insurance Company ought to have settled the claim on “non-standard basis.” Hon'ble Apex Court in back drop of these features, in these cases, allowed 75% of the claim of the claimant on the “non-standard basis”.

9.       Vide instant complaint, the complainant claimed the amount of Rs.9872/-, which is duly proved on record vide Ex.C7, Ex.C8 and Ec.C11. Hence we allow 75% of the said amount of Rs.9872/-.

10.     In view of the judgement referred above and from the discussion above, we allow the instant complaint in part and direct the Opposite Parties to make the payment of Rs.7404/- (Rupees Seven Thousand Four Hundred Four only) i.e. 75% of the amount of Rs.9872/- to the complainant. Opposite Parties are further directed to pay Rs.1500/- (Rupees One Thousand Five Hundred only) as compensation and Rs.1000/-(Rupees One Thousand only) as 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 this order, failing which, they are further burdened with 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 cost. File be consigned to record room after compliance.

Announced in Open Commission