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 month of March, 2023, the complainant purchased a policy from the Opposite Parties under the name of ‘Youngstar Insurance Policy’ including complainant Gurkirat Singh, Kirandeep Kaur wife and Harmeet Singh dependent Child. On 08.05.2023 Harmeet Singh son of the complainant suffered Dehydration and was admitted in Suresh Nursing Home for the period 08.05.2023 to 10.05.2023 and during this period doctor conducted various tests of his child and the said hospital received Rs.14,000/- from the complainant. Thereafter the complainant lodged the claim with the Opposite Parties., but however, the Opposite Parties rejected the claim of the complainant. 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 pay Rs.14,000/-.
b) To pay an amount of Rs.1,00,000/- as compensation on account of harassment, mental tension and for deficient services.
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 complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Party as per insurance policy terms and conditions. Averred that the present complaint pertains to insurance claim under ‘Young Star Insurance Policy’ bearing No.P/211222/01/2023/014711 valid from 31.03.2023 to 30.03.2024 covering the Complainant self and his spouse Kirandeep Kaur and Haremeet Singh dependent child 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 submitted the claim for reimbursement of the medical expenses towards the treatment Age at Suresh Nursing Home, Moga admitted on dated 08.05.2023. It is observed from the submitted medical records that the insured patient was admitted in the hospital on 08.05.2023 whereas the intimation regarding the admission was given to them only on dated 26.06.2023 and documents were submitted on 26.07.2023. As per the policy Condition- Standard Conditions- Clause C- Notification of claim, the intimation has to be given within 15 days from the date of discharge from the hospital, thus for the reasons stated above, the Opposite Party insurance company repudiated the claim on dated 01.08.2023. No deficient service has 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 his case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C9.
4. On the other hand, Opposite Parties has 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 OP1,2/11.
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 ‘Young Star Insurance Plan Policy’ bearing No.P/211222/01/2023/014711 valid from 31.03.2023 to 30.03.2024 covering the complainant self and his spouse Kirandeep Kaur and Harmeet Singh dependent child for a sum of Rs.5,00,000/-. It is also proved on record during the policy coverage, son of the complainant namely Harmeet Singh suffered ‘Gabrahat and severe dehydration’ and got admitted in Suresh Nursing Home for the period 08.05.2023 to 10.05.2023. After his discharge from the hospital, the complainant lodged the claim with Opposite Parties, which the Opposite Parties vide letter dated 01.08.2023 repudiated.
7. The Opposite Parties vide its repudiation letter dated 01.08.2023 repudiated the claim of the complainant. 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 claim documents have been submitted to us after 15 days of discharge from the hospital.
Please note that as per policy issued to you, Condition- Standard Conditions- Clause C for reimbursement of claims time limit is claim must be filed within 15 days from the date of discharge from the hospital.
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.”
The repudiation of the claim by the Opposite Parties on the abvoesaid ground is not genuine and this decision of ours is based upon the IRDA circular issued to the Insurance Companies stating that the genuine claims shall not be rejected on hyper technical grounds i.e. delay etc. which for the sake of convenience is reproduced as under:-
“INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY
Ref. IRDA/HLTH/MISC/CIR/216/09/2011 Dated:20.09.2011 CIRCULAR
To All life insurers and non-life insurers.
Re: Delay in claim intimation/documents submission with respect to
i. All life insurance contracts and
ii. All Non-life individual and group insurance contracts.
The Authority has been receiving several complaints that claims are being rejected on the ground of delayed submission of intimation and documents.
The current contractual obligation imposing the condition that the claims shall be intimated to the insurer with prescribed documents within a specified number of days is necessary for insurers for effecting various post claim activities like investigation, loss assessment, provisioning, claim settlement etc. However, this condition should not prevent settlement of genuine claims, particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances.
The insurer’s decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policyholders losing confidence in the insurance industry, giving rise to excessive litigation.
8. Further the Opposite Parties repudiated the claim of the complainant, without getting verified its genuinenity from the hospital concerned. Had they verified from the hospital concerned regarding fakeness or ingenuinenity of the claim, then they would have been justified in repudiating the claim, if it found fake. However, there is no document showing that they ever get verified from the hospital regarding the admission of the son of the complainant. Thus the repudiation of the claim, only on the ground of late submission of documents with a delay of 15 days is not genuine. In these circumstances, the repudiation of the genuine claim of the complainant by the Opposite Parties is unjustified.
9. Vide instant complaint, the complainant has claimed the amount of Rs.14,000/-, which is duly proved on record vide Ex.C6. Hence we allow the same.
10. 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.14,000/-(Rupees Fourteen Thousand 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. 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
