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 on 04.03.2023, the complainant went to Sidhu Hospital and Diagnostic Centre, Moga for the complaint of headache, dizziness, vomiting, fever and loose stool from the last 15 days and on the same day doctor Devinder Singh Sidhu, conducted various tests from Apollo Diagnostic Labs and advised the complainant to admit in the hospital. Accordingly, the complainant admitted in the hospital and on the same day doctor conducted MRI of Brain of complainant from Mittal Scan Centre, Moga. On 06.03.2023, the complainant was discharged from the hospital and complainant paid Rs.7900/- to the said hospital. After discharge from the hospital complainant handed entire bills and documents to the office of Opposite Party No.2 for reimbursement of the claim, but on 28.03.2023, the Opposite Parties rejected the claim of the complainant. The complainant somehow arranged the amount and got deposited the same in the said hospital. Opposite Parties were asked many to pay the said amount to the complainant, 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.20,716/- with regard to the policy bearing no.P/211222/01/2023/003376.
b) To pay a sum of Rs.1,00,000/- as compensation on account of mental tension, and harassment.
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 material facts and documents from this Commission as well as from the Opposite Parties, therefore, the complainant is not entitled to any relief. The complainant has concealed the fact that he has violated the terms and conditions of policy in question and PED disclosed. Averred that the complainant availed the ‘Young Star Insurance Policy’ bearing No.P/211222/01/2023/003376 renewed for the period 06.07.2022 to 05.07.2023 and in this policy complainant, his wife Lakhvir Kaur and minor Azneet Kaur and Shawnvir Singh were insured for an amount of Rs.5 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 claim in dispute was reported in 2nd year of the policy and earlier to that claim has been taken and the claim was registered vide claim no.CIR/2023/211222/1693916. After this the insured has submitted the claim documents in present case regarding the medical reimbursement expenses towards treatment taken by him at Sidhu Hospital, Moga on 04.03.2023 to 06.03.2023 for the treatment of ‘Entric Fever’. Averred that on perusal of the claims documents, medical team of the Opposite Parties is of the opinion that the insured patient could have managed as an out patienet and hospitalization of the patient is not warranted and as per Exclusion Code 36 of the policy, the company is not liable to make any payment under the policy in respect of any hospitalization which are not medically necessary/does not warrant hospitalization and hence the claim was rejected vide repudiation letter dated 28.03.2023 and duly informed to the complainant. Averred further that it is very much evidence from the discharge summary and ICP that the vitals are stable throughout the hospitalization and further as per medical team of Opposite Parties, the diagnosis of enteric fever is not supported by investigation report. As per the widal test report of Apollo Diagnostic Labs dated 04.03.2023, the patient had mildly raised dilution and that can be treated on OPD basis. The range which is given in test report is showing enteric fever negative and report not signed by pathologist and signed by technologist. Hence, the claim was rightly repudiated by the Opposite Parties. 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.OP9 and affidavit of Sh.Sumit Kumar Sharma, Authorized Signatory, Star Health & Allied Insurance Co. Ltd. as Ex.OP10.
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 renewed health insurance policy namely ‘Young Star Insurance Policy’ bearing no.P/211222/01/2023/003376 for the period 06.07.2022 to 05.07.2023 for self, his wife and two dependent children for a sum insured of Rs.5,00,000/-. It is also proved on record that during the policy coverage, complainant suffered ‘Fever, Nausia, Vomitting, headache and dizziness got admitted in Sidhu Hospital & Diagnostic Centre Moga on 04.03.2023 and after the treatment, got discharged from the hospital on 06.03.2023. It is also proved on record that after discharge from the hospital, the claim lodged the claim with Opposite Parties for the reimbursement of the hospitalization expenses. But the claim of the complainant was repudiated by the Opposite Parties, vide letter dated 28.03.2023.
7. The Opposite Parties repudiated the claim of the complainant, vide letter dated 28.03.2023. 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 Enteric Fever.
On a perusal of submitted records, our medical team is of the opinion that the insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted.
As per Code Excl 36 of the above policy, the Company is not liable to make any payment under this policy in respect of any hospitalization which are not medically necessary/does not warrant 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. In our considered opinion, the plea/defence taken by the Opposite Parties while repudiating the claim of the complainant that hospitalization of the insured patient is not warranted, is not justified. We surprised to note that how the officials concerned of the Opposite Parties mistook to conclude that hospitalization of the insured was not warranted. It is matter of common prudence that decision qua hospitalization is the sole prerogative of the doctor concerned to decide which is need based and not at the sweet will of the patient concerned. The above stand of the Opposite Parties in repudiating the claim of the complainant also reflects the mal functioning of the Opposite Parties, which divulges that they are concerned to grab the premiums only while issuing the policies and are not bothered to pay the genuine claims of the policy holders. The Opposite Parties in the present case have not placed on record any opinion/report of medical expert on the basis of which they have repudiated the claim in question. We surprise to note that how the officials concerned of the Opposite parties without any expert opinion come to the conclusion that hospitalization of the insured was not warranted i.e. was not required. There is no report and opinion of the doctor concerned of the Opposite Parties opining that the hospitalization of the complainant was not required. In the absence of any substantial evidence on record countering the genuine claim of the complainant, this complaint deserves to be allowed. To repudiate the claim solely on the ground that hospitalization was not required is baseless and not sustainable. We do not find any reasonable justification in repudiating the genuine claim of the complainant by opposite parties.
9. In view of the above discussion, the instant complaint is allowed in part and Opposite Parties are directed to pay the claim for medical expenses incurred by the complainant for the hospitalization period in question during the coverage period (including pre and post hospitalization charges) on submission of relevant documents and medical bills by complainant as per terms and conditions of the policy. Further the complainant is hereby directed to submit the relevant documents alongwith medical bills to the Opposite Parties. Opposite Parties are further directed to settle and pay the claim next within 30 days from receipt of the copies of bills/documents from the complainant. Opposite Parties are also directed to pay compository cost of Rs.5000/-(Rupees Five Thousand only) as compensation and litigation expenses to the complainant. The pending application(s), if any also stands disposed of. In case, the Opposite Parties failed to comply with the order within stipulated period as given, they are further burdened with additional cost of Rs.5,000/-(Rupees Five 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
