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 the complainant has been availing the insurance policy from HDFC Ergo from the last three years and in the month of May, 2022 on the allurement of official of the Opposite Parties, the complainant availed the insurance policy of Opposite Parties. Alleged that in the month of November, 2022, the complainant was suffering from blood with stool and got admitted in DMC & Hospital, Ludhiana on 13.11.2022 and applied for cashless treatment according to the policy with Opposite Parties, but cashless treatment was rejected by the Opposite Parties and in these circumstances, the complainant has to pay the amount of Rs.39,935/- incurred on the treatment from his own pocket. After discharge from the hospital, the complainant again submitted the entire documents with the Opposite Parties for reimbursement of the claim, but the Opposite Parties lingered on the matter on one pretext or the other. On 14.12.2022, the complainant again suffered from the said disease and visited Orison Hospital, Ludhiana and from 14.12.2022 to 16.12.2022 complainant every day visited the Orison Hospital as per advise of doctor and on 19.12.2022, the complainant was admitted in Orison Hospital, Ludhiana and on the same day, the complainant again applied cashless treatment with the Opposite Parties, but they again rejected the claim on 20.12.2022 and again the complainant has to pay the amount of Rs.36,500/- and Rs.39,614/- for tests and medicines from his pocket. After discharge from the hospital, the complainant submitted all the documents with Opposite Parties, but on 25.04.2023, the Opposite Parties again rejected the claim of the complainant on the ground that complainant has not submitted a letter from the treating doctor stating the exact duration of crohn’s disease and rheumatic heart disease and its past treatment records. Alleged further that on 05.06.2023, the complainant handed over the letter written by the treating doctor regarding the exact duration of crohn’s disease and rheumatic heart disease and its past treatment record to the Opposite Parties, but to no effect. Alleged further that in the month of March, 2023, the complainant again visited the Orison Hospital, Ludhiana and paid Rs.6029/- to the hospital. Due to act and conduct of the Opposite Parties, the complainant has suffered mental tension and harassment. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay Rs.1,30,055/-.

b)      To pay an amount of Rs.1,00,000/- as compensation for mental tension and harassment.

c)       To pay an amount of 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 the present pre mature complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Party as per the policy terms and conditions. As per Condition No.18, the Opposite Party Insurance Company is not liable to make payment under the policy in respect of expenses incurred at the hospital for as the insured/claimant has failed to submit all the required documents and details called for by the answering Opposite Party. Averred further that the present complaint pertains to insurance claim under ‘Young Star Insurance Policy bearing no.P/211222/01/2023/000651 valid from 22.05.2022 to 21.05.2023 covering himself and his spouse Komal Priya and dependent Children namely Samarbir Singh and Samaira 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 said terms and conditions were handed over to the insured at the time of the contract. 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 has submitted his first claim and submitted the documents for the reimbursement for the treatment of LGI Bleed at Dayanand Medical College and Hospital, Ludhiana on 13.11.2022, which was denied for the reason that “Exact line of management was not clear. The insured was requested to revert back with complete workup and discharge summary. Subsequently insured has submitted the same in reimbursement. Averred that as certain documents were necessary to process the claim, hence vide letters dated 05.01.2023, 20.01.2023 and 04.02.2023, the complainant was advised to furnish the same, thereafter the insured has submitted the same, but on scrutiny of claim documents, it was observed that despite request of the Opposite Parties, the insured has not submitted a letter from the treating doctor stating the exact duration of crohn’s disease and rheumatic heart disease and its past records. So, in the absence of those documents, the Opposite Parties were not able to process his claim. Averred further that again the insured has requested for cashless and submitted claim documents for the treatment of K/C/O Crohn’s Disease at Orison Super Specilaity Hospital Infertility & Trauma Centre, Ludhiana on dated 19.12.2022 to 22.12.2022, but the cashless was denied as it was observed from the hospital records that the insured patient has the above disease which is a long lasting ailment and the Opposite Parties were not able to ascertain the duration of the disease based on the document/details submitted by the insured. Thereafter, the complainant submitted the reimbursement of the medical expenses, but the Opposite Parties were in need of documents to process the claim and the Opposite Parties advised the complainant vide letters date 13.01.2023, 28.01.2023 and 14.02.2023 to furnish that documents, but the complainant has not submitted that documents despite many reminders. Hence claim of the complainant was repudiated vide letter dated 01.03.2023. Averred further that the instant complaint is neither maintainable in law nor on facts; no deficient services have been rendered by the answering Opposite Parties as alleged by the complainant. The claim in question was duly entertained, inquired into and after due application of mind the alleged claim has been repudiated on the basis of terms and conditions of the policy; the complaint is pre-mature; the complainant has not come with clean hands and 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 his case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C56.

4.       On the other hand, Opposite Parties have tendered into evidence affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1, 2/A, Power of Attorney as Ex.OP1, 2/B alongwith copies of documents Ex.OP1, 2/1 to Ex.OP1, 2/26.

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 “Young Star Insurance Policy” having no.P/211222/01/2023/000651 for the period 22.05.2022 to 21.05.2023. It is also proved on record that during the policy coverage the complainant suffered with problem of “Stool with Blood” and got admitted in DMC and Hospital, Ludhiana for the treatment for the period 13.11.2022 to 16.11.2022 (copy of discharge summary is Ex.C24). Also proved that at the time of admission, he duly applied for cashless authorization, but the request for cashless treatment was rejected by the Opposite Parties vide letter dated 14.11.2022 (Ex.C-25) and 16.11.2022 (Ex.OP1 to 2/6). To the utter surprise, there are two different cashless rejection letters of different dates stating different reason for the cashless rejection, the reason of which is known to the Opposite Parties only. Thereafter when after discharge from the hospital the complainant lodged the claim for the reimbursement of the expenses, the same was also rejected by the Opposite Parties, vide letter dated 25.04.2023 (Ex.C52). It is apt to add here that Opposite Parties in their evidence have placed on record, the rejection letter dated 19.02.2023 (OP1 to 2/14) qua the 1^st claim, whereas the complainant was conveyed with said rejection of claim on 25.04.2023. It is also proved on record that for the period from 14.12.2022 to 16.12.2022, the complainant again visited Orison Super Speciality Hospital with complaints of ‘fever from 6 days’ and during this period various tests of complainant got conducted and some medicines were also prescribed by the doctor concerned, which is proved on record vide Ex.C26 to Ex.C35 and when there was no relief to the complainant, he again got admitted in Orison Hospital, Ludhiana on 19.12.2022 with complaints of ‘Fever with chills (high grade), Loose Stools and Generalized weakness since 7 days’ and get discharged from the hospital on 22.12.2022 (copy of discharge summary of Orison Super Speciality Hospital is Ex.C36). At the time of admission, the complainant again applied for cashless authorization to Opposite Parties, but the Opposite Parties rejected the cashless request of the complainant, vide letter dated 20.12.2023 (Ex.C50). Again to our astonishment, there are two cashless rejections letters  of different dates containing different contents one is of dated 20.12.2023 (Ex.C50) and another is of dated 21.12.2022 (Ex.OP1 to 2/17). The reason of the same is best known to the Opposite Parties. Evident further that after discharge from the hospital, the complainant again lodged the claim with Opposite Parties. Thereafter, the Opposite Parties issued various letters dated 13.01.2023, 28.01.2023 and 14.02.2023 requiring certain documents, as the complainant allegedly failed to supply the same, so vide letter dated 01.03.2023 (Ex.OP1 to 2/26), the Opposite Parties also rejected the 2^nd claim raised by the complainant. Complainant vide present complaint has challenged both the repudiations of the claims lodged by him.

7.       Now in reference to the proved facts, we have to adjudge qua the genuinenity of the claims and their rejections.

8.       It is been reiterated that the complainant got admitted in DMC and Hospital, Ludhiana for the period 13.11.2022 to 16.11.2022 and at the time of admission, he duly applied for cashless authorization, but the request for cashless treatment was rejected by the Opposite Parties vide letter dated 14.11.2022 (Ex.C-25) and 16.11.2022 (Ex.OP1 to 2/6 placed on record by the Opposite Parties), both stating different grounds of rejection, for the reasons best know to the Opposite Parties. Record is evident of the fact that when the complainant lodged claim for the reimbursement of the expenses incurred, the Opposite Parties issued various letters to the complainant dated 05.01.2023, 20.01.2023 and 04.02.2023 requiring following documents i.e. Letter from treating doctor clarifying exact duration of Crohn’s disease, RHD, Mitral, Aortic Regurgitation, IBD; First Consultation for ECHO dated 8/11; Insured patient is known case of RHD, Crohn’s disease, kindly submit initial consultation papers; All past investigation and treatment records and as per ECHO patient is diagnosed with RHD. Kindly mention its duration and its first consultation, investigation and treatment records; All past admission and follow up treatment records, which as per the Opposite Parties the complainant failed to supply the same, thus they repudiated the abovesaid claim vide letter dated 25.04.2023 (Ex.C-52). The contents of repudiation letter dated 25.04.2021 are reproduced as under:-

We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of lower astrointestinal bleeding.

It is observed that despite our request, the insured has not submitted a letter from the treatment doctor stating the exact duration of crohn’s disease and rheumatic heart disease and its past treatment records.

In the absence of those documents/details, we are not able to further process your claim.

As per Condition No.18 of the policy, the insured person has to submit all the required documents and details called for by us.

Further, the insured patient has the above longstanding disease prior to our policy. The present admission and treatment of the insured patient is for non disclosed disease.

You have earlier taken medical insurance policies from M/s HDFC Ergo General Insurance Company Limited and subsequently taken policy from our company from 22.05.2022 to 21.05.2023 under portability.

At the time of porting the policy, you have not disclosed the above mentioned medical history/health details of the insured-person in the proposal form and other documents submitted to us which amounts to misrepresentation/non disclosure of material facts.

As per Condition no.1 of the policy issued to you, if there is any misrepresentation/non disclosure of material facts whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim.

We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.

The above said repudiation letter against the claim raised for the reimbursement of the expenses incurred for the treatment of “blood with stool” is altogether unjustified and in genuine. The Opposite Parties vide above referred letters asked the complainant to submit the documents for the ailment i.e. ‘Crohn’s disease’ for which he neither was diagnosed nor taken any treatment for the same. The said fact is evident in the discharge summary of that period i.e. 13.11.2022 to 16.11.2022 (Ex.C24). It is been reiterated that we do not agree with the grounds/pleas taken by the Opposite Parties while repudiating the 1^st claim of the complainant, as in the discharge summary duly issued by DMC and Hospital, Ludhiana (Ex.C24), nowhere it is mentioned that complainant ever suffered from  crohn’s disease and rheumatic heart disease as mentioned in the referred letters. It is mentioned in the discharge summary that complainant admitted in the hospital with problem of blood with stool and moreover, in the discharge summary, nowhere it is mentioned that the complainant has any past history of crohn’s disease and rheumatic heart disease as alleged. Thus, the repudiation of the 1^st claim is held not genuine and is unjustified. Also there is no record on file revealing that complainant ever suffered from above diseases before admission of the complainant in DMC and Hospital, Ludhiana on 13.11.2022. Thus, it reveals the lackadaisical attitude of the officials of the Opposite Parties as rather enquiring the genuinenity of the claim from the hospital concerned, they put the burden on the shoulders of the complainant and thereafter arbitrarily rejected the genuine claim.        

9.       Perusal of the record further reveals that secondly again the complainant got admitted in Orison Hospital, Ludhiana for the period  19.12.2022 with complaints of Fever with chills (high grade), Loose Stools and Generalized weakness since 7 days and got discharged from the hospital on 22.12.2022 (Ex.C36). At the time of admission, the complainant again applied for cashless authorization to Opposite Parties, but the Opposite Parties again rejected the cashless request of the complainant, vide letter dated 20.12.2023 (Ex.C50). After discharge from the hospital, the complainant lodged the claim with Opposite Parties. Thereafter, the Opposite Parties issued various letters dated 13.01.2023, 28.01.2023 and 14.02.2023 requiring the following documents:-

Record reveals that the same was also rejected by the Opposite Parties, vide letter dated 01.03.2023 (Ex.OP1to2/26) for want of documents demanded by them vide letters dated 13.01.2023, 28.01.2023 and 14.02.2023 as mentioned above.

10.     From the above, it is proved that the second claim of the complainant too was rejected for want of documents, which were demanded by Opposite Parties from the complainant at the time of 1^st reimbursement claim filed by the complainant. As we have already discussed that repudiation of first claim of the complainant for want of documents revealing “Crohn’s disease, RHD, Mitral Aortic Regurgitation, First Consultation for ECHO and all past investigation and treatment records” is not justified as the complainant neither was diagnosed nor was treated for any Crohn’s disease or for RHD as alleged, so the demand for previous medical record pertaining to Crohn’s Disease or RHD allegedly suffered by the complainant is again held baseless and it further confirms the lackadaisical attitude of the officials of the Opposite Parties. The Opposite Parties even did not take cajoles to consider the duly issued certificate of the qualified Doctor (Ex.C51) who treated the complainant wherein, it is clearly mentioned that “complainant has no past record or history of RHD etc. and also certified that complainant was not diagnosed for Crohn’s disease. So, the allegations of the Opposite Parties that complainant had the past history of Crohn’s disease is absolutely wrong and baseless. In these circumstances, the repudiation/rejection of the 2^nd claim of the complainant by the Opposite Parties too is held as unjustified and illegal.

11.     Also the perusal of the repudiation letter dated 25.04.2023 reveals that in the said letter Opposite Parties have admitted that complainant/insured has been taking medical insurance policies since, 2019 from M/s HDFC Ergo General Insurance Company Limited and subsequently taken policy from their company from 22.05.2022 to 21.05.2023 under portability. In the policy document (Ex.C3), the inception date is mentioned as 22.05.2019. Meaning thereby that the policy in question is in its 4^th year of continuation and no document has been made part of the record showing that complainant ever had taken any claim for any expenses incurred on the treatment of above said ailments during the previous policy year or before portability.

12.     Under given circumstances, not only the deficiency in service on the part of the Opposite Parties is proved but it also establishes unfair trade practice adopted by the Opposite Parties. Thus, the complainant is entitled for his right full claims raised under the policy coverage for the period from 22.05.2022 to 21.05.2023.

13.     Vide instant complaint, the complainant has claimed for the expenses incurred i.e. he claimed for an amount of Rs.1,30,055/- for both the claims for the period 13.11.2022 to 16.11.2022 and 19.12.2022 to 22.12.2022, which have duly been proved on record vide Ex.C-8 to Ex.C-23, Ex.C29 to Ex.C32and Ex.C37 to Ex.C48.

14.     In view of the discussion above,  we party allow the complaint of the complainant and direct the Opposite Parties to pay an amount of Rs.1,30,055/-(Rupees One Lakh Thirty Thousand Fifty Five only) to the complainant. Opposite Parties are burdened with compensation of Rs.20,000/-(Rupees Twenty Thousand only) to be paid to the complainant for rendering deficient services towards complainant and for resorting to unfair trade practice and also Rs.10,000/-(Rupees Ten Thousand only) for thrusting avoidable litigation. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 45 days from the date of receipt of copy of this order, failing which, the Opposite Parties are burdened with additional amount of Rs.15,000/-(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