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 he availed a joint policy in his name alongwith his wife namely Reetu and Children namely Akshra Singla and Arush bearing policy no.P/211222/01/2023/002054 from Opposite Parties valid from 31.05.2022 to 30.05.2023 and as per the said policy basic floater sum assured is Rs.5,00,000/-. During the policy period, unfortunately daughter of complainant namely Akshra Singla suffered from weakness in her both limbs and was unable to bear her own weight and unable to walk, thus she was admitted at American Spine & Medical Institute, Ludhiana. She remained admitted in the hospital from 30.06.2022 to 04.07.2022. Prior to this, the daughter of complainant had also undergone her medical treatment for the above said ailment from Dayanand Medical College and Hospital, Ludhiana from 03.06.2022 and from Dhanuka Neurocare, Ludhiana. The complainant submitted all the relevant documents with them for claim on the basis of abovesaid policy and immediately intimated the admission of his daughter in the hospital and filed the requisite form as per the requirement of policy, but despite all that Opposite Parties have not paid the amount of medical bills. The Opposite Parties arbitrarily and illegally rejected the claim of the complainant. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite parties may be directed to release the amount of Rs.79,775/- to the complainant alongwith interest alongwith interest @ 24% per annum thereon.

b)      To pay an amount of Rs.1,00,000/- as compensation.

c)       To pay an amount of Rs.20,000/- as costs of the 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 has been filed without any cause of action, as the claim of the complainant was denied by answering Opposite Parties as per policy terms and conditions and as per Exclusion Code No.04(A), the Opposite Parties is not liable to make any payment under the policy for the expenses related to any claim primarily for diagnostics and evaluation purposes. Averred that the present complaint pertains to ‘third insurance claim’ under Family Health Optima Insurance Plan Policy bearing no.P/211222/01/2023/002054 valid from 31.05.2022 to 30.05.2023 covering the complainant self and his spouse Reetu and Dependent Children namely Akshara Singla and Arush 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 terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of contract. Moreover, the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the 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. Therefore, in case, if any liability would arise against the answering Opposite Parties, then it would be subject to terms and conditions of the insurance policy. Averred further that on receipt of the claim documents of the hospitalization of the insured’s daughter’s Akshra Singla, for the period 21.11.2021 to 29.11.2021, the claim was processed and an amount of Rs.45,107/- was approved and paid to insured through NEFT-N206214919178 dated 22.06.2022. No objection and complaint has ever been made by the complainant till today qua this payment and he has accepted the claim payment as full and final settlement of the first claim.

          Subsequently insured again approached Opposite Parties for cashless hospitalization. On receipt of the claim documents of the hospitalization of the  insured’s daughter’s for the period 10.06.2022 to 14.06.2022 for the treatment of Acute Abdomen, the claim was processed and an amount of Rs.14,509/- after deductions was approved and paid to insured through NEFT-N206181991381 dated 20.06.2022. The complainant also not objected to the deduction so made.

          Thereafter, the insured again submitted the reimbursement of the medical expenses (not cashless this time) towards the treatment of Right Lower Limb Weakness of her daughter at Americal Spine & Medical Institute, Ludhiana dated 30.06.2022. Claimed further that from the submitted records, the present claim of the insured person seems primarily for investigation and evaluation purposes only. As per Exclusion- Investigation & Evaluation – Code Excl No.04 (A) of the policy, the company is not liable to make any payment for expenses related to any claim primarily for diagnostic and evaluation purposes. Hence, claim was rejected and conveyed to insured vide letter dated 18.11.2022. No deficient services have been rendered by answering Opposite Parties as alleged by the complainant. Averred further that the claim in question was duly entertained, inquired into and after due application of mind the alleged claim has been repudiated on the basis of terms and conditions of insurance policy; the complainant has failed a vague, contradictory, baseless and frivolous complaint which is liable to be dismissed with compensatory costs. 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.CW1/A alongwith copies of documents Ex.C1 to Ex.C83.

4.       On the other hand, Opposite Parties have placed on record affidavit of Sh.Sumit Kumar, Chief Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1 to 3/A, copy of power of attorney Ex.OP1 to 3/B alongwith copies of documents Ex.OP1 to 3/1 to Ex.OP1 to 3/19.

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

6.       It is admitted that the complainant availed a joint mediclaim policy from Opposite Parties valid from 31.05.2022 to 30.05.2023, covering himself, his wife namely Reetu and Children Akshra Singla and Arush, vide policy no.P/211222/01/2023/002054. During the said policy period, daughter of complainant namely Akshra Singla suffered from weakness in her both limbs as unable to bear her own weight and unable to walk, thus she was admitted at Americal Spine & Medical Institute, Ludhiana on the advice of the doctor and she remained admitted in the said hospital from 30.06.2022 to 04.07.2022. However, the grievance of the complainant is that despite completing all the formalities and despite being provided all the relevant documents, the Opposite Parties have not paid the disputed claim amount.

7.       On the other hand plea taken by Opposite Parties is that the present claim is third claim of the complainant, before this they have already settled and paid two claims of the complainant. The present claim of the insured has not been settled and paid, as the hospitalization of the daughter of the complainant (duly covered under the policy) was primarily for investigation and evaluation purposes. Hence as per Exclusion- Investigation & Evaluation– Code Excl No.04 (A) of the policy terms and conditions, the claim is not payable.

8.       The perusal of the record reveals that the complainant has claimed the amount of Rs.79,775/- on account of treatment taken by his daughter for the period 30.06.2022 to 04.07.2022 and thereafter raised the claim for reimbursement of the amount. Record reveals that on receipt of the claim, the Opposite Parties thoroughly processed it and assessed the amount of Rs.39,698/- vide Ex.OP1 to 3/19. It is on record that till date the Opposite Parties have not paid even the assessed amount to the complainant and thus forced him to file the present complaint. It has been observed that despite the assessment being done, they chose to repudiate the claim of complainant stating that claimed amount has been incurred only for the investigation and evaluation purposes and as per terms and conditions of the policy, the expenses for investigation and evaluation purposes is not payable. But in our concerted opinion, the stand of the Opposite Parties is not maintainable for the simple reason that daughter of the complainant got admitted in Americal Spine & Medical Institute, Ludhiana with complaint of ‘Right Lower Limb Weakness’ and she was advised for admission vide Ex.C2 and during her stay in hospital she was thoroughly been investigated and was prescribed medicines and thereafter was got discharged on 04.07.2022. So by any stretch of imagination we cannot presume that admission is for tests and investigation purposes only, rather she got admitted with chief complaints of Right Lower Limb Weakness and it is to be considered that patient in question is of teen age i.e. 13 years and one cannot presume that one would got admitted in the hospital only for getting the tests and investigation. So, repudiation on this ground is not genuine.

9.       Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant claimed the amount of Rs.79,775/-. However, perusal of claim form Ex.OP1 to 3/13 reveals that complainant filed the claim form, claiming the amount of Rs.44,300/- only and not for Rs.79,775/-. So, he is not entitled for Rs.79,775/-. Perusal of the record further reveals that on receipt of the claim of Rs.44,300/-, Opposite Parties processed it and assessed the Final Admissible amount to the tune of Rs.39,698/- after imposing deductions. Record reveals that the complainant has not objected to the deductions so made by the Opposite Parties in his earlier two claims submitted with Opposite Parties and duly paid thereafter. Hence, we are of the view that ends of justice would be fully met, if the amount of Rs.39,698/- as assessed by Opposite Parties is ordered to be allowed.

10.     In view of the discussion above, we party allow the present complaint and direct Opposite Parties to pay Rs.39,698/- (Rupees Thirty Nine Thousand Six Hundred Ninety Eight only) to the complainant. Further Opposite Parties are directed to pay compository costs of Rs.5,000/-(Rupees Five Thousand only) for deficiency in service and litigation expenses to the complainant. However, complainant is at liberty to approach the Opposite Parties for claiming the remaining amount of bills which he has not claimed while filing the present complaint. 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 further burdened with additional cost of Rs.10,000/-(Rupees Ten 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