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 20.03.2023, the complainant suffered pain in abdomen, vomiting, loose motion and dizziness and went to Sidhu Hospital and Diagnostic Centre, Moga, where various blood tests of the complainant got conducted and on the same day, he was admitted in the said hospital and Opposite Parties were duly informed about the admission of the complainant. After discharge from the hospital, the complainant submitted the entire hospital and medical bills with Opposite Parties and Opposite Parties assured that the bill amount will be transferred in the account of the complainant. However, vide letter dated 18.06.2023, the Opposite Parties rejected the claim of the complainant. It has been alleged that an amount of Rs.18,614/- was spent on the treatment of the complainant and Opposite Parties were asked many times to pay the amount of the treatment, 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.18,614/- with regard to the policy bearing no.P/211222/01/2023/001417.
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 ‘Family Health Optima Insurance Policy’ bearing No.P/211222/01/2023/001417 for the period 19.05.2022 to 18.05.2023 and in this policy complainant self and his wife Sunita Rani 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. Averred further that the claim in dispute is reported in the 2nd year of the policy and earlier to that no claim has been taken. The claim was registered vide no.CIR/2024/211222/0226239. Averred further that the insured has submitted the claim documents regarding the medical reimbursement expenses towards the treatment of ‘AGE’ taken by him at Sidhu Hospital on 20.03.2023 to 22.03.2023. After receiving the claim form, it is observed from the claim documents that the above said treatment was taken by the complainant in the hospital on 20.03.2023 to 22.03.2023 and intimation to this effect was given on 20.05.2023 and as per Standard Conditions Clause D, the intimation has to be given within 24 hours of hospitalization, hence the claim was rejected vide repudiation letter dated 18.06.2023 and duly informed to the complainant. Averred further that the complainant has no locus standi or cause of action to file the present complaint against the Opposite Parties; the complaint is not maintainable in the present form; the complainant has violated the terms and conditions of the policy. 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.C17.
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. It is admitted and proved on record that the complainant availed health insurance policy namely ‘Family Health Optima Insurance Plan’ bearing no.P/211222/01/2023/001417 for the period 19.05.2022 to 18.05.2023 for self and his wife. It is also proved on record that during the policy coverage, complainant suffered ‘abdomen pain, nausea, vomiting, loose motion, dizziness and headache’ and got admitted in Sidhu Hospital, Moga on 20.03.2023, where he was diagnosed as ‘Acute Gastroenteritis’ and after treatment got discharged from the hospital on 22.03.2023. It is also not disputed that the claim lodged for the reimbursement of the said hospitalization period was repudiated by the Opposite Parties, vide letter dated 18.06.2023 (Ex.OP8). 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 AGE.
It is observed from the submitted medical records that the insured patient was admitted in the hospital on 20.03.2023, whereas the intimation regarding the admission was given to us only on 20.05.2023.
Please note that as per policy issued to you, Condition- Standard Conditions-Clause D- Notification of claim, the intimation has to be given within 24 hours of 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. We have considered the rival contentions of the ld. counsels for both the parties and have gone through the record. It is argued by the counsel for the Opposite Parties that the complainant was admitted in the hospital on 20.03.2023 whereas the intimation regarding the admission was given on 20.05.2023 and as per policy conditions, the intimation has to be given within 24 hours of hospitalization. In our considered opinion, when the policy is admitted, admission of the complainant in the hospital admitted, lodging of the claim admitted, then repudiation the claim of the complainant on the ground of delay in intimation by Opposite Parties is unjustified. Moreover, there is delay of two months by the complainant to file the claim, but it does not mean he has not taken any treatment. As far as the treatment of this period was concerned, the Opposite Parties can enquire it from the hospital on their own. Reliance in this regard be placed on IRDA circular issued to the Insurance Companies stating that the genuine claims shall not be rejected on hyper technical grounds i.e. delay etc. which for the sake of convenience is reproduced as under:-
“INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY
Ref. IRDA/HLTH/MISC/CIR/216/09/2011 Dated:20.09.2011 CIRCULAR
To All life insurers and non-life insurers.
Re: Delay in claim intimation/documents submission with respect to
i. All life insurance contracts and
ii. All Non-life individual and group insurance contracts.
The Authority has been receiving several complaints that claims are being rejected on the ground of delayed submission of intimation and documents.
The current contractual obligation imposing the condition that the claims shall be intimated to the insurer with prescribed documents within a specified number of days is necessary for insurers for effecting various post claim activities like investigation, loss assessment, provisioning, claim settlement etc. However, this condition should not prevent settlement of genuine claims, particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances.
The insurer’s decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policyholders losing confidence in the insurance industry, giving rise to excessive litigation.
After going through the above circular, we are of the considered opinion, the repudiation of the claim of the complainant on the ground of delay in intimation is unreasonable.
9. Vide instant complaint, the complainant claimed the amount of Rs.18,614/-, which is duly proved on record vide Ex.C5, Ex.C6, Ex.C8, Ex.C9 to Ex.C12, Ex.C14 and Ex.C15. Hence we allow the said amount..
10. In view of the above discussion, we allow the instant complaint in part and direct the Opposite Parties to make the payment of Rs.18,614/- (Rupees Eighteen Thousand Six Hundred Fourteen only) alongwith interest @ 6% per annum from the date of filing the complaint till its actual realization to the complainant. However, keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. 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 this order, failing which, Opposite Parties are liable to pay interest on the awarded amount @ 9% per annum from the date of filing of the complaint till its actual realization. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.
Announced in Open Commission
