Order by:
Smt.Priti Malhotra, President
1. The complainants have filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant no.2 purchased medical health policy from Opposite Party and till then, the complainant no.2 used to renew the said policy, in which, whole family of complainant no.2 was insured. Unfortunately complainant no.1 i.e. daughter of complainant no.2 suffered severe disease and became seriously ill and the complainant no.2 consulted various doctors and ultimately complainant no.1 got admitted in Suresh Nursing Home on 24.11.2023 and got discharged on 28.11.2023. Thereafter, complainant no.2 lodged the claim with Opposite Party and sent all the documents to them, but the Opposite Party demanded unnecessary documents from the complainants, which were provided by them and surprisingly the Opposite Party again demanded the complete set of indoor case report, letter from treating doctors for further processing of the claim. Even though after a great efforts, the complainant supplied all the required documents to Opposite Party, but despite that the Opposite Party rejected the claim of the complainants, vide letter dated 20.02.2024. Hence, this complaint. Vide instant complaint, the complainants have sought the following reliefs:-
a) Opposite Party may be directed to pay a sum of Rs.30040/- on account of medical claim.
b) To pay an amount of Rs.50,000/- as compensation for mental tension and harassment alongwith Rs.50,000/- as litigation expenses and Rs.10,000/- being tying any other misc. charges.
c) 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 has been filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Party as per policy terms and conditions. Averred that the present complaint pertains to insurance claim under ‘Family Health Optima Insurance Plan-2021’ bearing No.P/211222/01/2023/012831 valid from 28.02.2023 to 27.02.2024 covering the complainant no.2, her spouse Karishma Maheshwari and dependent child Palak Maheshwari i.e. complainant no.1 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 Party 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 for reimbursement vide claim no.CIR/2024/211222/1203752 towards the medical expenses for the treatment of Enteric Fever at Suresh Nursing Home from 24.11.2023 to 28.11.2023. It has been observed that various discrepancies in the documents submitted to Opposite Party. All the details regarding the investigation and treatment of the insured patient are not transparently evidence. Averred further that there are multiple tampering noted in room number and IPD number not clear and it has been informed to the insured that for the reasons stated above Opposite Party was unable to settle the claim under the above policy and it was repudiated vide letter dated 18.12.2023. Averred further that the Opposite Party further received rejection reconsideration request and medical team of Opposite Party re-examined the claim records and observed various discrepancies in the documents submitted. Hence claim was rejected and conveyed to the insured vide letter dated 20.02.2024. Averred further that as per the medical team of the Opposite Party following discrepancies have been found:-
Discharge summary not showing any IPD number, registration number, room number.
All investigation reports are within normal range.
ICP’s not showing any room number.
Averred further that the claim has rightly been repudiated by the Opposite Party. Averred further that the instant complaint is neither maintainable in law nor on facts; no deficient services have been rendered by the answering Opposite Party 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; the complainant has not come with clean hands. 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 have placed on record affidavit of complainant no.2 as Ex.C1/A alongwith copies of documents Ex.C1 to Ex.C25.
4. On the other hand, Opposite Party has placed on record affidavit of Sh.Sumit Kumar, Authorized Signatory, Star Health & Allied Insurance Co. Ltd. Ex.OP/A alongwith copies of documents Ex.OP1 to Ex.OP9.
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 no.2 is the holder of Insurance policy namely “Family Health Optima Insurance Plan-2021” having no.P/211222/01/2023/012831 for the period 28.02.2023 to 27.02.2024 covering the complainant no.2, and his spouse Karishma Maheshwari and dependent children Palak Maheshwari (complainant no.1) and Aarush Maheshwari. It is also proved on record that during the policy coverage, the complainant no.1 suffered AFI i.e. Acute Febrile Illness and got admitted in Suresh Nursing Home and remained admitted there for the period 24.11.2023 to 28.11.2023. After getting discharge from the hospital the complainants lodged the claim with the Opposite Party for the reimbursement of expenses incurred on the treatment, but the claim of the complainants was repudiated vide letter dated 18.12.2023.It is also proved on record that the complainants again lodged the claim with the Opposite Party alongwith all the relevant documents, but again the claim of the complainants was repudiated/not admitted by the Opposite Party, vide letter dated 20.02.2024.
7. The claim of the complainants was repudiated/not admitted by the Opposite Party vide letter dated 18.12.2023 and vide letter dated 20.02.2024 (Ex.C4 & Ex.C3 respectively). The contents of said letters are reproduced as under:-
Letter dated 18.12.2023
“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of Enteric Fever.
We observe various discrepancies in the documents submitted to us. We final 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 position to admit your claim, as per Specific Condition No.18 of the above policy issued to you.
We therefore regret to inform you that for the reasons above we are unable to settle your claim.
Letter dated 20.02.2024
“After a comprehensive assessment by our medical team, we’ve observed that we’re unable to admit the claim because of the below-mentioned reason(s):
Policy Exclusion Clause No./Condition(s), if any: NA
Detailed Remarks:
We have received your request for reconsideration of your repudiated claim and we have scrutinized the submitted documents.
Our medical team which re-examined the claim records has observed 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 Specific Condition No.18 of the above policy issued to you.
Hence we regret to inform you that we are unable to pay the claim and reiterating our stand for repudiation.
8. The perusal of the record reveals that in the written reply, the Opposite Party mentioned the discrepancies allegedly found by them in the medical record of the complainant no.1, which is mentioned as under:-
i) multiple tampering noted in room number and IPD number not clear.
ii) discharge summary not showing any IPD number, registration number, room number.
iii) All investigation reports are within normal range.
iv) ICP’s not showing any room number.
9. We are of the considered view that all the discrepancies as mentioned in written reply are not genuine as the explanation to the claimed discrepancies are beyond the control of the complainants to comment upon, since all the documents so pointed out are being prepared at the hospital end as per the treatment given. Further, the said discrepancies are not mentioned in the repudiation letters dated 18.12.2023 and 20.02.2024 respectively issued by Opposite Party, so the same are not maintainable. Opposite Party on its part failed to get the claim investigated. Had the Opposite Party get verified from the hospital concerned about the discrepancies, they allegedly noticed, then they would have been justified in repudiating the claim, if anything contrary to the claim get proved. However, there is no document showing that it ever get verified from the hospital concerned about their queries/discrepancies as alleged. Opposite Party has failed to prove any malafide on the part of the complainants and evidently had taken treatment from the hospital in question.
10. Thus, in our considered opinion, the claim of the complainants for the reimbursement of the medical expenses incurred on her treatment is genuine and payable by the Opposite Party-Insurance Company.
11. Vide instant complaint, the complainants claimed the amount of Rs.30,040/-, which is duly proved on record, vide Ex.C6 to Ex.C8 and Ex.C10. Hence we allow the said amount.
12. In view of the above discussion, the instant complaint is allowed in part and Opposite Party is directed to pay a sum of Rs.30,040/- (Rupees Thirty Thousand Forty only) to the complainants. Opposite Party is also directed to pay compository cost of Rs.5000/-(Rupees Five Thousand only) as compensation and litigation expenses to the complainants. 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 further burdened with additional cost of Rs.5,000/-(Rupees Five Thousand only) to be paid to the complainants 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
