Order by:
Aparana Kundi, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant has been purchasing the insurance policy from Opposite Party No.2 since, 2019, which is still continue. On 02.06.2023 son of the complainant suffered vomiting associated with pain in abdomen and distension abdomen from the last one day and unable to pass stool, so he went to Sahil Heart & Diabetes Center, Moga and on the same day son of the complainant was admitted by Dr.Sahil Gupta at Sharma Surgical City Hospital and during this period the doctor conducted various tests and x-ray of the complainant’s son and thereafter discharge from the hospital on 06.06.2023. After discharge from the hospital, the complainant submitted all the documents alongwith medical bills to Opposite Party No.2. Alleged that the complainant paid Rs.34,300/- to Sahil Heart & Diabetes Centre, Moga on 06.06.2023 and paid Rs.1900/- to Rishi X-ray and Scan Centre, Moga. On 25.06.2023, Dr. Satish Gupta of Sahil Heart & Diabetes Centre again got conducted the CT Scan of the complainant’s son from Rishi x-ray & Scan Centre and the said center received Rs.700/- from the complainant and the complainant also handed over the said bill to Opposite Parties. However, the Opposite Parties vide letter dated 01.08.2023 repudiated the claim of the complainant. Thereafter the Opposite Parties were asked many time to refund the said amount, but they flatly refused to do so. 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.36,900/- with regard to the policy no.P/211222/01/2023/011167.
b) To pay a sum of Rs.1,00,000/- as compensation on account of mental tension, and harassment.
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 the present pre mature complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Parties as per insurance terms and conditions. Averred further that the present complaint pertains to insurance claim under ‘Family Health Optima Insurance Plan-2021’ bearing no.P/211222/01/2023/011167 valid from 27.01.2023 to 26.01.2024 covering the complainant, his spouse Renu Singla and dependent Child Ashish Singla 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 Parties, subject to the terms and conditions of the insurance policy. The insured 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 the reimbursement of the medical expenses vide claim no.CIR/2024/211222/0479281 towards the treatment ‘Subacute intestinal obstructions (SAIO) at Sahil Heart and Diabetes Centre, Moga for the period 02.06.2023 to 06.06.2023. The Opposite Parties have observed various discrepancies in the documents submitted. Opposite Parties found all the details regarding the investigation, but treatment of the insured patient are not transparently evident. The full facts of the case may not have been presented to Opposite Parties. Therefore, Opposite Parties were not in a position to admit claim as per the terms and Specific Condition no.18 of the policy issue to insured. Some of the discrepancies are mentioned as follows:-
i. Cause of SAIO not given.
ii. Alcohol history details not given.
iii. Discharge summary and bill is not showing any room number, registration number, IPD number.
Hence claim was rejected and conveyed to insured vide letter dated 01.08.2023. Averred further that the instant complaint is neither maintainable in law nor on facts and the same is liable to be dismissed in limine; no deficient services have been rendered by the answering Opposite Parties as alleged by the complainant; the complainant has come with clean hands. He has not disclosed the entire true facts and suppressed the material facts from this Commission as well as from the answering Opposite Parties. 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.C14.
4. On the other hand, Opposite Parties have placed on record affidavit of Sh.Sumit Kumar Sharma, Authorized Signatory, Star Health & Allied Insurance Co. Ltd. as Ex.OP1, 2/A and 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 admitted that the complainant has been availing the health insurance policy from the Opposite Parties since, 2019 and again renewed it for the 4th time, vide policy ‘Family Health Optima Insurance Plan’ bearing no.P/211222/01/2023/011167 for the period 27.01.2023 to 26.01.2024 covering self, his spouse and his dependent child. It is also proved on record that during the policy coverage, complainant’s son suffered ‘SAIO i.e. Subacute Intestinal Obstruction’ and got admitted in ‘Sahil Health and Diabetes Centre, Moga on 02.06.2023 and after the treatment got discharged from the hospital on 06.06.2023. It is also proved on record that the claim lodged for the reimbursement of the said hospitalization period was repudiated by the Opposite Parties, vide letter dated 01.08.2023.
7. The Opposite Parties repudiated the claim of the complainant vide letter dated 01.08.2023. 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 SAIO.
We observe 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.
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. However in the above said repudiation letter Opposite Parties have not mentioned which discrepancies they found, however in the written reply they have mentioned three discrepancies i.e. Cause of SAIO not given, Alcohol history details not given, Discharge summary and bill is not showing any room number, registration number. Regarding the plea taken by the Opposite Parties that cause of SAIO not given, it is submitted that in the discharge summary placed on record by both the parties (Ex.C8 and Ex.OP1,2/6), it is clearly mentioned that a 24 years old male came to hospital with complaints of vomiting associated with a abdomen pain and distension abdomen and he is facing this problem since 1 day and there is no history of the said ailment is mentioned in discharge summary. Further the Opposite Parties have taken the plea that Alcohol history details are not given, but the Opposite Parties have failed to point out anything in the placed document from which it comes out that complainant’s son is consuming alcohol. Moreover in the discharge summary (Ex.C8), no where it is mentioned that complainant’s son is drinking alcohol or he is suffering from this problem due to alcohol. The other discrepancy raised by the Opposite Parties is that in the discharge summary and bill is not showing any room number and registration number, but we are of the concerted view that the production of the discharge summary clearly shows the admission of the patient in the hospital, so there is no requirement to mention the room number and registration number on the discharge summary. Hence, the repudiation of the claim of the complainant on account of aforesaid discrepancies is not found to be satisfactory.
9. Vide instant complaint, the complainant claimed the amount of Rs.36,900/- as medical expenses and paced on record the final bill as Ex.C11. The thorough perusal of the same reveals that charges of Nursing Care, Doctor Fees, Room AC and other are appears to be genuine, but the charges on account of medicines are ingenuine, because for different days, the bills can increased or decreased, but the same amount of medicines for all the 5 days is dubious.
10. From the sequel of the above discussion, the present complaint is allowed in part and Opposite Parties are directed to pay to the complainant Rs.20,000/-(Rupees Twenty Thousand only) (as nursing care Rs.1500/-, doctor fees Rs.2500/-, AC room charges Rs.15,000/- and other charges Rs.1000/-) and regarding the payment of medicines, the complainant has to produce the bills pertaining to medicines for different days in order to get reimbursement of the same and after the submission of bills by the complainant, the Opposite Parties will pay for medicine charges as per the bills produced. Opposite Parties are also directed to pay compository cost of Rs.3,000/-(Rupees Three Thousand only) as compensation and 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 burdened with additional amount 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
