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, 2022, the complainant purchased a policy from the Opposite Parties, which he continued till 2023. On 01.03.2023 son of the complainant suffered Dehydration and was thus admitted in Suresh Nursing Home for the period 01.03.2023 to 03.03.2023 and during this period doctor conducted various tests of his child and the said hospital received Rs.13,800/- from the complainant i.e. Rs.12,900/- as hospital bill and Rs.900/- as lab tests. Thereafter the complainant lodged the claim with the Opposite Parties for its reimbursement under the policy in question. On 26.04.2023, the Opposite Parties sent a letter to the complainant for requirement of additional documents and as per requirement got a writing from Dr.Chandan Singhal, who narrated on the letter head that previous admission/hospitalization records are not available. Moreover doctor also stated that patient has not admitted for same illness in past and same letter head was handed over to the employee of the Opposite Parties, but despite that the Opposite Parties rejected the claim of the complainant vide letter dated 09.08.2023. 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.13,800/-.

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 pre mature complaint has been 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/211222/01/2022/012227 valid from 31.03.2022 to 30.03.2023 covering the Complainant self and his spouse Palwinder Kaur and dependent children namely Jaspreet Kaur and Gurasees Singh 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 documents for the reimbursement for the treatment of ‘AGE with dehydration’ at Suresh Nursing Home    dated 01.03.2023. On scrutiny of claim documents some documents were necessary to process the claim, hence Opposite Parties advised the insured vide various letters to furnish the documents i.e. discharge summary of previous admissions/hospitalizations; birth discharge summary; NICU admission discharge summary; any delay in development milestones? Past pediatric consultations for the same; complete set of indoor case papers with the temperature, SPO2, vitals monitoring chart; all past treatment records. Further insured has submitted the query reply, on scrutiny of claim documents, it has been observed that the insured has not submitted the indoor case records called for by Opposite Parties which amounts to non submission of required documents. In the absence of the above documents/details, Opposite Parties were not able to further process the alleged claim. As per condition no.18 of the policy, the insured person has to submit all the required documents and details called for by the Opposite Parties. Hence, the claim was repudiated vide letter dated 09.08.2023. 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.C13.

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 OP1,2/12.

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 Policy’ bearing No.P/211222/01/2022/012227 from Opposite Parties valid from 31.03.2022 to 30.03.2023 covering self and his spouse Palwinder Kaur and dependent children namely Jaspreet Kaur and Gurasees Singh for a sum of Rs.5,00,000/-. It is also proved on record that during the policy coverage in question, son of the complainant namely Gurasees Singh suffered ‘Gabrahat and  moderate to severe dehydration’ and got admitted in Suresh Nursing Home for the period 01.03.2023 to 03.03.023. There is no denial that after his discharge from the hospital, the complainant lodged the claim for the reimbursement of Rs.13,800/- i.e. expenses incurred for the treatment with Opposite Parties. Thereafter Opposite Parties issued various letters requiring certain documents from the complainant and after that vide letter dated 09.08.2023 repudiated the claim of the complainant.

7.       Vide repudiation letter dated 09.08.2023, the Opposite Parties repudiated the claim of the complainant on the following grounds:-

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

It is observed that the insured has not submitted the indoor case records called for by us which amounts to non submission of required documents. In the absence of the above documents/details, we are not able to further process your claim.

As per Condition No.18 of the above policy, the insured person has to submit all the required documents and details called for by us.

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.       The thorough perusal of the record reveals that the ground for repudiation of the 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, vide Ex.C9 dated 24.05.2023, wherein the treating doctor has clearly mentioned that “Child Gurasees Singh s/o Gurwinder Singh was admitted on 01.03.2023 for AGE Ghabrahat with severe dehydration. His previous admission/hospitalization records are not available for the same. Patient was not seen admitted for same illness in past. Patient is a pediatric group  so birth summary is insignificant. NICU admission has nothing to do with present admission”.

Thus, from the above, it is well clear that there was no requirement left to be asked for the documents 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. Also the record of the Opposite Parties is silent in regards to any investigation or verification been done on their part to question the genuinenity of the claim in question. It transpires that the officials of the Opposite Parties are least bother to perform their part of duty qua verification of the claims filed and very conveniently while sitting in their offices, they found it easy to issue letters asking for the records and hardly trouble themselves to verify from the hospital concerned or to verify the genuinenity of the claim.

9.       Vide instant complaint, the complainant has claimed the amount of Rs.13,800/-i.e. Rs.12,900/- as hospital bill and Rs.900/- as lab tests, which is duly proved on record vide Ex.C8 and Ex.C10. 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.13,800/-(Rupees Thirteen Thousand Eight Hundred 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