Order by:

Smt.Aparana Kundi, Member

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that since 20.09.2018, husband of the complainant has been taking the health insurance policy from the Opposite Parties covering himself and complainant, which was duly renewed from time to time by the complainant and her husband. The said policy was further renewed for the period 21.09.2022 to 20.09.2023 and thereafter for the period 21.09.2023 to 20.09.2024 for sum insured of Rs.15 lakh alongwith bonus and recharge benefit. Unfortunately on 04.02.2023, the complainant suffered with viral fever on 04.02.2023 and got admitted in Suresh Nursing Home, Akalsar Road, Moga for the period 04.02.2023 to 07.02.2023. Alleged that the complainant spent Rs.17,569/- on her treatment. The complainant approached the Opposite Parties and submitted his claim of medical reimbursement alongwith original medical record of said hospital and bills, but however vide letter dated 18.11.2023, the Opposite Parties declined/repudiated the claim of the complainant. Thereafter complainant sent a legal notice dated 22.11.2023 to the Opposite Parties, but to no effect. Due to aforesaid 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.17,569/- with interest @ 12% per annum to the complainant from the date of filing of present complaint till its realization

b)      To pay an amount of Rs.50,000/- as damages on account of mental agony etc. caused by Opposite Parties.

 c)      To pay an amount of Rs.5500/- as cost of complaint.

2.       Opposite Parties 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 ‘Star Women Care Insurance Policy’ bearing No.P/211222/01/2023/006571 valid from 21.09.2022 to 20.09.2023 covering the complainant self, her spouse Sahil Garg and dependent child Naira Garg 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 the reimbursement of medical expenses towards the treatment of Viral Pneumonia for hospitalization from 04.02.2023 to 07.02.2023 at Suresh Nursing Home, Moga. On scrutiny of claim documents, the medical team of the answering Opposite Party 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. Thus based on these findings, the claim was repudiated vide letter dated 10.06.2023 as according to the Exclusion Clause no.36 of the policy. The claim was repudiated under the ambit of specific condition/exclusion code no.36 as mentioned under the policy terms and conditions. The exclusion clause no.36 is reproduced here under:-

“The Company is not liable to make any payment under the policy in respect of any hospitalization which are not medically necessary/does not warrant hospitalization.”

As such, in terms of the said provision of the insurance policy, the insurance company have repudiated the claim of applicant in a proper manner, after due application of mind. Averred further that no deficient services have been rendered by answering Opposite Parties as alleged by the complainant. 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 her affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C18.

4.       On the other hand, Opposite Parties has placed on record 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 OP1,2/9.

5.         We have heard the ld. counsel for both the parties and also gone through the record.

6.       The availing of insurance policy bearing no.P/211222/01/2023/006571 valid from 21.09.2022 to 20.09.2023 by the complainant covering herself, his spouse and one dependent child is not disputed. During the policy coverage, the admission of complainant in the Suresh Nursing Home, Moga for the period from 04.02.2023 to 07.02.2023 for ‘Viral Pneumonia’ is also not disputed. Thereafter lodging of the claim for the reimbursement of the expenses incurred by the complainant with Opposite Parties is also not disputed.  The only dispute arises between the parties, when the claim lodged by the complainant was rejected by the Opposite Parties, vide letter dated 10.06.2023.

7.       The perusal of the record reveals that the Opposite Parties repudiated the claim of the complainant, vide letter dated 10.06.2023 (Ex.OP1,2 /9) on the following grounds:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of Viral Pneumonia.

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 Exclusion–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 are 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 concerted view, the ground taken by the Opposite Parties for the repudiation of the claim as mentioned above said repudiation letter is not genuine, as doctor is the expert of his field and he can decide whether the admission of the patient is required or not. Further it is a 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. Moreover, as per the Discharge Card (Ex.C8), the complainant admitted in the hospital with complaints of Cough, Fever and Difficulty in Breath, where she got herself checked from the doctor and thereafter she at the decision of the doctor, who is expert in his field, got her admitted in the hospital. Moreover, the insurance company has not placed on record any evidence or the report from any other doctor, which states that the patient can be treated as an outpatient and hospitalization of the insured patient is not warranted. In these circumstances, we are of the concerted view that the repudiation of the genuine claim of the complainant by the Opposite Parties is unjustified.

9.       Vide instant complaint, the complainant claimed the amount of Rs.17,569/-, which is duly proved on record vide Ex.C13. Hence we allow the said amount.  

10.     From the discussion above, we allow the complaint of the complainant in part and direct the Opposite Parties to pay a sum of Rs.17,569/- (Rupees Seventeen Thousand Five Hundred Sixty Nine only) alongwith interest @ 6% per annum from the date of filing of the complaint i.e. 01.02.2024 till its actual realization. Further Opposite Parties are directed to pay Rs.2,000/- (Rupees Two Thousand only) as compensation and Rs.2,000/-(Rupees Two Thousand only) as litigation expenses to the complainant. 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 copy of this order, failing which, the Opposite Parties are further burdened with additional cost 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