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 complainant purchased a policy from the Opposite Parties in the year, 2021 which was continue till, 2023. Alleged that the complainant suffered knee problems and in the month of april, 2023, she went to Goyal Hospital, Moga for check up and on the same day doctor conducted the x-ray of both keens of complainant and advised her to replace both the knees and thereafter on 28.04.2023, the complainant admitted in the hospital for operation. At the time of admission, the complainant handed over the copy of the policy to the hospital and the hospital applied for cashless treatment to the Opposite Parties and on 26.04.2023, the Opposite Parties initially approved Rs.30,000/- for cashless treatment against the total estimated amount of Rs.2,65,000/-. In the said authorization letter, Opposite Parties remarked that “This is only the provisional amount, final amount will be worked out once the hospital submit the final bill with discharge summary and other related documents.” Thereafter, the complainant discharged from the hospital on 05.05.2023 and paid the hospital bill of Rs.2,20,000/- from her own pocket. Alleged further that on 04.05.2023, the Opposite Parties rejected and withdrawn the cashless approval as given earlier without assigning any reason. After discharge from the hospital, the husband of the complainant handed over the entire document to the employee of the Opposite Parties and thereafter the complainant visited many times in the office of Opposite Parties regarding the reimbursement of the claim, but to no effect. Thereafter, on 13.10.2023, the complainant again submitted a letter to the Opposite Parties regarding the query of reimbursement, but however on 13.10.2023, the Opposite Parties sent a reply through email that they unable to consider request of reopening this case, as it has crossed 90 days. Due to such act and conduct of 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.2,20,000/-
b) To pay an amount of Rs.1,00,000/- as compensation harassment and for deficiency in service.
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 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. Averred that the complainant availed ‘Family Health Optima Insurance Plan Policy no.P/211222/012023/012390 for the period 18.02.2023 to 17.02.2024 and in this policy, complainant, her husband Sukhpal Singh are insured for an amount of Rs.5 lakhs. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form and pre-existing disease was declared by the insured to the extent of Hypertension and its complications only, except this nothing have been disclosed by complainant. Averred further that the claim in dispute is reported in the third year of the policy and the claim was registered vide claim no.CIR/2024/211222/0113386 and the said policy is in this company was started from 18.02.2021. After this insured has submitted the claim documents in the present case regarding medical expenses towards the treatment taken by her at Goyal Hospital from 28.04.2023 to 04.05.2023 towards the treatment of both OA knee replacement. Averred that the complainant through hospital applied for cashless and submitted the medical expenses towards the treatment of OA knees at Goyal Hospital, Moga on 28.04.2023 and Opposite Parties initially authorized an initial approval of 30,000/- against Rs.2,65,000/- and further after scrutiny of documents they have raised the query on dated 03.05.2023 that patient symptomatic since 3 to 4 years inspite of repeated queries of non submission of the said records claim has been rejected on 04.05.2023. Thereafter again customer has submitted rejection consideration request on reviewing the documents, but the answering Opposite Party stand on their earlier rejection and informed the complainant accordingly. Averred further that the present admission is from 28.04.2023 to 03.05.2023 with Diagnosis: Oseoarthritis Bilateral Knee. Patient under TKR B/L. Claim was initially authorized and later rejected/withdrawn on the basis of Field Visit Report saying that the ‘Insured had been suffering from this ailment for the last 3-4 years and was taking medicines on OPD basis for the same’. Averred further that the requisite documents are mandatorily required to ascertain the admissibility of the claim. However, the complainant instead of submitting the document preferred to file the present complaint and thereby the answering Opposite Parties got no opportunity to decide the claim of the complainant with complete medical record. The complainant is not the consumer of Opposite Parties; the complainant has not locus standi or cause of action to file the present complaint. 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 her case, the complainant has placed on record her affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C17.
4. On the other hand, Opposite Parties has placed on record copies of documents Ex.OP1 to OP9 and affidavit of Sh.Sumit Kumar, Senior Manager, 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. The availing of insurance policy bearing no.P/211222/01/2023/012390 valid from 18.02.2023 to 17.02.2024 by the complainant and during the policy coverage, the admission of complainant in the Goyal Hospital, Moga for the period from 28.04.2023 to 04.05.2023 is not disputed. There is also no dispute that during the hospitalization, the complainant applied for cashless pre authorization and initially the Opposite Parties approved the amount of Rs.30,000/- for cashless treatment and thereafter, they rejected the cashless approval of the complainant vide letter dated 04.05.2023.
7. The perusal of the record reveals that the Opposite Parties rejected the cashless approval given earlier, vide letter dated 04.05.2023 (Ex.OP9) on the following grounds:-
“We have approved an amount of Rs.30000 on 26-APR-2023 for the treatment of above diagnosed disease of the insured patient based on the pre-auth request and other documents submitted by the hospital.
As per available records patient is known to have OA Knee since 3-4 years inspite of repeated query non submission of the records claim has been rejected.
We are therefore unable to approve the claim and the authorization already given for cashless treatment of the above diagnosed disease stands withdrawn.
8. In our concerted view, the ground taken by the Opposite Parties for the rejection of cashless approval as mentioned above is not genuine as it is proved on record vide Ex.C5 that the complainant has been obtaining the insurance policy from the Opposite Parties since the year 2021 without any break, meaning thereby that the policy in question is in its 3rd year of continuation, so it cannot be said that complainant is suffering from pre-existing disease. Moreover, if the complainant was suffering from any disease prior to issuance of the policy, in question, the same must not have escaped from the notice of the empanelled doctors of the Insurance Company, if he was medically examined at the time of the issuance of policy, but the Opposite Parties have not placed on record any document showing they examined the complainant/insured at the time of issuance of policy. So, at this stage, the ground so taken by the Opposite Parties while rejecting the cashless approval of the complainant with regard to pre existing disease is not genuine.
9. Further the Opposite Parties have not placed on record any document, from which, it has been observed by them that complainant is suffering from the said disease from the last 3-4 years. Perusal of the record reveals that there is no iota of evidence showing the complainant suffered from the disease in question prior to issuance of policy. Hence, the rejection by the Opposite Parties is unjustified.
10. As it came out from the reply that the Opposite Parties has also taken the plea that the complainant never approached them for the reimbursement of medical claim and she never came up with the requisite documents and has not filed the claim with them. Rather instead of representing her claim to the Opposite Parties, the complainant preferred to file the present complaint.
11. As it is already discussed in the above paragraphs that the claim of the complainant found to be genuine and hence complainant is directed to file the claim before the Opposite Parties with all the bills and documents and the Opposite Parties are directed to assess and pay the claim of the complainant as per the bills placed on record as soon as they received the claim form.
12. From the above discussion, the instant complaint is hereby disposed of with a direction to the complainant to lodge the claim with Opposite Parties alongwith all the medical bills and requisite documents and thereafter the Opposite Parties are directed to assess and pay the claim of the complainant as per the bills and documents submitted by complainant next within 45 days from the lodging of claim by the complainant. If, the Opposite Parties failed to assess and pay the claim within stipulated period of 45 days, then they shall be liable to pay Rs.15,000/- (Rupees Fifteen Thousand only) to the complainant for non compliance of the order. The pending application(s), if any also stands disposed of. 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
