Order by:

Aparana Kundi, Member

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that on 25.04.2023, the complainant suffered abdomen pain, weakness and vomiting and he went to Sham Nurshing Home & Heart Centre, Railway Road, Moga and on the same day Dr.Seemant Garg and Dr. Sham Sunder Garg admitted the complainant  and got conducted the Hamatology report, liver function test, blood report and Lipid Profile Test of the complainant. Complainant remained admitted in the hospital for the period from 25.04.2023 to 29.04.2023 and the said hospital received Rs.30,250/- from the complainant. The complainant also paid Rs.3879/- to Monika Drug Store inside Sham Nursing Home. After discharge from the hospital the complainant submitted all the documents with Opposite Parties for reimbursement of the claim, but the Opposite Parties repudiated the claim of the complainant vide letter dated 07.06.2023. In these circumstance, the complainant has to pay Rs.34,129/- from this own pocket. The complainant approached the Opposite Parties several time with a request to pay the claim amount, 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.34,129/- with regard to the policy bearing no.P/211222/01/2023/001687.  

b)      To pay a sum of Rs.1,00,000/- as compensation on account of mental tension, harassment and for deficient services.

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 the fact and documents from this Commission as well as from the Opposite Parties, therefore, the complainant is not entitled to any relief.  Insured has violated the terms and conditions of the policy in question and no PED was disclosed. Averred that the complainant availed the ‘Young Star Insurance Policy’ bearing No.P/211222/01/2023/001687 for the period 25.05.2022 to 24.05.20023 and in this policy complainant, his wife Kimi Soor and minor Samiara and Lovish 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 and no pre existing disease was declared by the insured. Claim in dispute is reported in the First year of the policy of this company. The claim was registered vide claim no.CIR/2024/211222/0178963. After this, the insured submitted the claim documents in the present case regarding the medical reimbursement expenses towards the treatment taken by him at Sham Nurshing Home, Moga from 25.04.2023 to 29.04.2023 for Pain ABD, Vomiting. On perusal of submitted records for medical reimbursement at Sham Nursing Home, it is observed by medical team of the company that the insured patient could have been managed as an outpatient and hospitalization of this patient is not warranted. Averred further that it is evident from the discharge summary and ICP that the vitals are stable throughout the hospitalization. The patient with Pain ABD, Vomiting can be cured at home only, but instead patient was hospitalized only for claim purpose. As per Exclusion Code 36 of the 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 and hence the claim was rejected vide letter dated 07.06.2023. 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.C16.

4.       On the other hand, Opposite Parties have placed on record copies of documents Ex.OP1 to Ex.OP8 and affidavit of Sh.Sumit Kumar Sharma, Authorized Signatory, Star Health & Allied Insurance Co. Ltd. as Ex.OP9.

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/211222/01/2023/001687 valid from 25.05.2022 to 24.05.2023 by the complainant and during the policy period, the complainant suffered Abdomen Pain and weakness and got admitted in Sham Nursing Home & Heart Centre on 25.04.2023 and after treatment got discharged from the hospital on 29.04.2023 is not disputed. It is also not disputed that the complainant lodged the claim with Opposite Parties for the reimbursement of the expenses incurred by him on his treatment. The only dispute arises between the parties, when the claim lodged by the complainant was repudiated by the Opposite Parties, vide letter dated 07.06.2023.

7.       The Opposite Parties repudiated the claim of the complainant, vide letter dated 07.06.2023 (Ex.OP8). The contents of the said letter is reproduced as under:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of Pain ABD, Vomiting.

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 Exclusion – 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 concerted view, the ground taken by the Opposite Parties for the repudiation of the claim as mentioned above said repudiation letter is not genuine, as doctor is the expert of his field and he can decide whether the admission of the patient is required or not. Further it is a 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. Moreover, as per the discharge summary (Ex.C6), the complainant got admitted in the hospital with the complaint of Abdomen Pain and Weakness, where he got himself checked from the doctor and after  conducting various tests, complainant was diagnosed as “Pain Abdomen and Vomiting” and thereafter he at the decision of the doctor, who is expert in his field got admitted him in the hospital. Moreover, the insurance company has not placed on record any evidence or the report from any other doctor, which states that the patient can be treated as an outpatient and hospitalization of the insured patient is not warranted. In these circumstances, we are of the concerted view that the repudiation of the claim of the complainant by the Opposite Parties is unjustified.

9.       Vide instant complaint, the complainant claimed the amount of Rs.34,129/-, which is duly proved on record vide Ex.C7 to Ex.C14. Hence we allow the said amount.  

10.     From the discussion above, we allow the complaint of the complainant in part and direct the Opposite Parties to pay a sum of Rs.34,129/- (Rupees Thirty Four Thousand One Hundred Twenty Nine only) to the complainant. Further Opposite Parties are directed to pay compository cost of Rs.2000/- (Rupees Two Thousand only) as compensation and litigation expenses to the complainant. 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 Rs.3000/- (Rupees Three 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