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 husband of the complainant namely Rajesh Kumar Grover has been taking the joint health insurance policy from the Opposite Parties since, 22.12.2021, which has been renewed from time to time and earlier the same was renewed vide policy no.P/211222/01/2023/009667 for the period 22.12.2022 to 21.12.2023 covering the complainant and her husband. Unfortunately, the complainant suffered with AFI (Acute Febrile Illness) on 22.10.2023 and got admitted at Sidhu Hospital & Diagnostic Centre, Moga for the period 22.10.2023 to 25.10.2023, where she spent Rs.25271/- on her treatment. Thereafter the complainant submitted her claim of medical reimbursement alongwith original medical record alongwith medical bills to the Opposite Parties and they issued claim intimation no.CIR/2024/211222/1038196 to complainant. However, vide letter dated 03.11.2023, the Opposite Parties repudiated the claim of the complainant. Submitted that complainant sent all the necessary documents which were demanded by the Opposite Parties from time to time. Complainant also sent legal notice dated 04.12.2023 to Opposite Parties, 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 Rs.25,271/- with interest @ 12% per annum to complainant from the date of filing of present complaint till its realization.

b)      To pay an amount of Rs.50,000/- as compensation for mental tension and harassment.

c)       To pay an amount of Rs.5500/- 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 No.1 & 2 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 the answering Opposite Parties as per policy terms and conditions. Averred that the present complaint pertains to insurance claim under ‘Family Health Optima Insurance Policy’ bearing No.P/211222/01/2023/009667 valid from 22.12.2022 to 21.12.2023 covering complainant self and her spouse Rajesh Kumar Grover for a sum of Rs.15,00,000/-. However it is submitted that the aforesaid insurance policy was issued to the insured by the answering Opposite Parties subject to the terms and conditions of the insurance policy. 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 insured submitted the claim documents for reimbursement of medical expenses towards the treatment of AFI i.e. Acute Febrile Illness for hospitalization from 22.10.2023 to 25.10.2023 at Sidhu Hospital, Moga. On scrutiny of claim documents the medical team of the answering company observed that the insured patient’s vital signs were stable throughout the period of hospitalization and the insured patient could have been managed as an outpatient and hospitalization was not warranted. Averred further that patient was hospitalized only for claim purpose. Thus based on these findings, the claim was repudiated vide letter dated 03.11.2023 as per Exclusion Clause No.36 of the policy. Hence claim was finally rejected and conveyed to the insured. Averred further that no deficient services have been rendered by the answering Opposite Parties as alleged by the complainant; The claim in question was duly entertain, inquired into and after due application of mind the alleged claim has been repudiated. 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, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C20.

4.       On the other hand, Opposite Parties No.1 & 2 have placed on record affidavit of Sh.Sumit Kumar, Authorized Signatory, Star Health & Allied Insurance Co. Ltd. Ex.OP1, 2/A alongwith copies of documents Ex.OP1, 2/1 to Ex.OP1, 2/11.

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 is the holder of Insurance policy namely “Family Health Optima Insurance Policy-2021” having no.P/211222/01/2023/009667 for the period 22.12.2022 to 21.12.2023 covering herself and her spouse Rajesh Kumar Grover. It is also proved on record that during the policy coverage, the complainant suffered AFI i.e. Acute Febrile Illness and got admitted in Sidhu Hospital, Moga, where she remained admitted for the period 22.10.2023 to 25.10.2023. After getting discharges from the hospital the complainant lodged the claim with the Opposite Parties for the reimbursement of expenses incurred on the treatment, which was rejected by the Opposite Parties vide letter dated 03.11.2023 (Ex.OP1,2/11).

7.       The Opposite Parties repudiated the claim of the complainant, vide letter dated 03.11.2023. 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 AFI.

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/ground 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.       Vide instant complaint, the complainant claimed the amount of Rs.25,271/-, which is duly proved on record, vide Ex.C4, Ex.C5, Ex.C7, Ex.C8, Ex.C9, Ex.C10, Ex.C11, Ex.C12, Ex.C13 and Ex.C14.

10.     In view of the above discussion, the instant complaint is allowed in part and Opposite Parties are directed to pay a sum of Rs.25,271/- (Rupees Twenty Five Thousand Two Hundred Seventy One only) to 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