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 since, 17.01.2019, the complainant has been purchasing Family Health Optima Insurance Plan policy from other insurance company and the said policy was ported with the opposite party vide policy no. P/211222/01/2023/010816 for the period 17.01.2023 to 16.01.2024, covering complainant and his family. Alleged that during the policy period, on the unfortunate day of 25.08.2023 the complainant got severally ill and was diagnosis as Acute Febrile illness (Viral Fever) for which the complainant medically examined at Gupta Hospital, Bagha Purana and admitted in the said hospital for the period 25.08.2023 to 29.08.2023. The complainant spent approximately Rs.30,000/- for the said treatment. After discharge from the hospital, the complainant lodged the claim with Opposite Party for reimbursement of the medical bills and also completed all the required formalities and submitted all the required documents with the opposite party, but the Opposite Party vide reputation letter dated 19.09.2023, repudiated the claim of the complainant. Alleged further that the opposite party repudiated the rightful and lawful claim of the complainant on the false and frivolous ground that the insured patient was admitted and treated in an excluded provider (hospital). Alleged further that at the time of issuance of the policy, the opposite party never issued any terms and conditions of the policy documents. As such, the alleged terms and conditions, particularly the exclusion clause of the policy in question is not binding upon the insured. Alleged further that from the medical record, it is clear that complainant was admitted in the hospital in emergency conditions. The act of Opposite Party is illegal, unwarranted and uncalled for. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Party may be directed to reimburse the medical claim of the complainant amounting to Rs.30,000/- alongwith future interest @ 12% p.a. from the date of payment to the treating hospital till its actual realization.
b) To pay an amount of Rs.50,000/- on account of bills paid in Fortis Hospital and compensation for mental tension and harassment.
c) To pay an amount of Rs.51,000/- as cost of complaint.
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 Party appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present complaint is 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 further that the present complaint pertains to insurance claim under ‘Family Health Optima Insurance Plan-2021, bearing No.P/211222/01/2023/010816 valid from 17.01.2023 to 16.01.2024 covering the complainant self and her spouse Raman Kumar for a sum of Rs.5,00,000/- for the first time. However it is submitted that the aforesaid insurance policy was issued to the insured by the answering Opposite Party is subject to the terms and conditions of the insurance policy. Averred further that the insured has requested for reimbursement only and submitted the medical expenses towards the treatment AFI at Gupta Hospital, Bagha Purana on dated 11.01.2023. On scrutiny of claim documents, it has been observed that there are various discrepancies in the documents submitted to Opposite Party insurance company. The Opposite Party has found that all the details regarding the investigation and treatment of the insured patient are not transparently evident. The full facts of the case may not have been presented by the insured. Therefore, the Opposite Party was not in a position to admit the claim, as per terms and Specific Conditions No.18 of the policy issued to insured. Hence claim was rejected and conveyed to insured vide letter dated 19.09.2023. The instant complaint is neither maintainable in law nor on facts; no deficient services have been rendered by answering Opposite Party as alleged by the complainant; the complainant has not come with clean hands. He has not disclosed the entire true facts. 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.C8.
4. On the other hand, Opposite Party has placed on record affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP/A alongwith copies of documents Ex.OP1 to OP10.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. It is well proved on record that the complainant availed Insurance policy namely ‘Family Health Optima Insurance Plan-2021’ for the period 17.01.2023 to 16.01.2024 covering herself and her spouse. It is also proved on record that during the policy coverage, the complainant suffered ‘High grade fever with chills, vertigo, General Weakness, Headache, body ache, cough’ and got admitted in Gupta Hospital, Baghapura (Moga) on 25.08.2023 and after treatment got discharged on 29.08.2023 (Ex.C6). It is also proved on record that after discharge from the hospital, the complainant lodged the claim with Opposite Party for the reimbursement of the medical expenses, which was also repudiated by the Opposite Party vide letter dated 19.09.2023.
7. The perusal of the record reveals that the Opposite Party repudiated the claim of the complainant vide letter dated 19.09.2023 on the following grounds:-
“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of AFI.
We observe various discrepancies in the documents submitted to us. We find all the details regarding the investigation and treatment of the insured patient are not transparently evident. The full facts of the case may not have been presented to us. Therefore, we regret we are not in a position to admit your claim, as per the terms and conditions no.18 of the policy issued to you.
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.”
The ground taken by Opposite Party for repudiation of the claim is not sustainable, as first of all besides discharge summary test report, there is no any other medical record has been placed on record by the Opposite Party, in which, they found discrepancies. Further from the perusal of discharge summary and test report, we do not find any type of discrepancy. However, if the Opposite Party has found any type of discrepancy in medical record of the complainant and complainant failed to clarify about the same, the Opposite Party should have get it verified from the hospital concerned. Had they got verified the same from the hospital concerned about the discrepancies, they noticed, then they would have been justified in repudiating the claim. However, there is no document showing that they ever got verified from the hospital concerned about their alleged queries/discrepancies.
8. In these circumstances, the repudiation of the genuine claim of the complainant by the Opposite Party is unjustified.
9. Vide instant complaint, the complainant claimed the amount of Rs.30,000/- spent by him on the treatment, but he failed to prove the said amount, rather vide bills placed on record by the complainant as Ex.C4 and Ex.C5, the amount of Rs.25,749/- only is proved. Hence, we allow the same.
10. In view of the discussion above, we allow the complaint of the complainant in part and direct the Opposite Party to pay an amount of Rs.25,749/-(Rupees Twenty Five Thousand Seven Hundred Forty Nine only) to complainant. Opposite Party is 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 Party within 30 days from the date of receipt of copy of this order, failing which, the Opposite Party is burdened with additional cost of Rs.10,000/-(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
