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 on 29.11.2023, the complainant has availed ‘Accident & Health Insurance Policy’ bearing no.11240536360600 from Opposite Party No.1  for the period 29.11.2023 to 28.11.2024 covering complainant and his wife Pooja Arora and daughter Hitika Arora and wife of the complainant is also nominee in the said policy. On 19.02.2024, the wife of the complainant namely Pooja Arora suffered Heavy menstrual bleed about 2 weeks back, Blood spots (petechiae) over whole body, generalized weakness, outside HB/TLC/PLT-6.60/7.20/10K, ultrasound transvaginal 18/2: Bulky uterus right ovarian hemorrhagic cyst and got admitted in Deep Hospital, Model Town, Ludhiana where she was admitted w.e.f 19.02.2024 to 23.02.2024. The complainant paid Rs.56,700/- for final bill, Rs.29,450/- to blood bank of Deep Nursing Home, Rs.1940/- + Rs.640/- to Lal Path Lab, Rs.1200/- to Life Diagnostic and Rs.11,361/- of medicines bills. Alleged that inspite of filing the claim, the Opposite Parties refused to make the payment to the said hospital. The complainant numbers of times visited the office of Opposite Parties and requested to pay his genuine claim, but all in vain. Thereafter, the Opposite Parties vide letter dated 22.02.2024 refused to admit the rightful claim of the complainant. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-   

a)       Opposite Parties may be directed to pay the amount of Rs.1,01,691/- alongwith interest @ 18 % per annum till the date of payment.

b)      To pay a sum of Rs.5,00,000/- as compensation on account of mental tension, harassment and for deficient services.

c)       To pay Rs.21,000/- as litigation expenses.

d)      And to grant any other relief which this Commission may deem fit and proper in the interest of justice.

2.       Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the 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 material facts and documents from this Commission as well as from the Opposite Parties, therefore, the complainant is not entitled to any relief. The complainant has violated the terms and conditions of policy in question and no PED was declared qua himself and only declared qua his wife Pooja Arora only to the complications related to the surgeries or procedures performed previously. Averred further that complainant availed the ‘Star Health Assure Insurance Plan Policy’ bearing No.11240536360600 renewed for the period 29.11.2023 to 28.11.2024 and in this policy complainant, his wife Pooja Arora, his daughter Hitika Arora were insured for an amount of Rs.5 lakh. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form and no pre-existing disease was declared by the insured for himself except his wife. The claim in dispute is reported in the First year of the policy and the cashless claim & reimbursement claims were registered vide claim no.CIR/2024/211222/1619677. Insured has submitted cashless claim and on the basis of the claim documents the cashless was denied with the reason documents requires further evaluation for the admissibility of claim vide letter dated 22.02.2024 and he was asked to submit the documents in reimbursement of the claim and accordingly complainant applied for medical reimbursement expenses towards the treatment of his wife taken by her in Deep Nursing Home and Children Hospital, Ludhiana on 19.02.2024 to 23.02.2024 towards the treatment of ‘Bicytopenia’. After seeing the medical record, medical team of the Opposite Parties observed that there are various discrepancies in the documents submitted with Opposite Parties. The Opposite Party-Insurance Company find all the details regarding the investigation and treatment of the insured patient are not transparently evident. Submitted that after lodging the claim for reimbursement, company also verified the claim from independent agency who submitted his report dated 10.04.2024 i.e. ‘vigilance claim verification report.’ The Opposite Parties, therefore unable to settle the claim under the above policy. Hence, the claim was repudiated vide letter dated 16.04.2024 as per the policy terms and conditions.         Averred further that as per icp, patient has bodyaches and generalized weakness since 2 months. Patient had undergone Iscs 2 years ago. She is k/c/o hypothyroidism since 10-12 years. Now medications stopped since last 2 years. Esr high, iron low, hb low platelets, hr high, pr high. Rdp transfusions going on.  Moreover, as per findings of the claim verification officer of the Opposite Party Company:-

1.       TOA TOD not mentioned in DS.

2.       Exact duration of Immune Thrombocytopenia not mentioned in DS to the reasons best known to the treating doctor.

3.       The hospital has raised a Pre Authorization for cashless treatment for an amount of Rs.47,500/- approximately but after denial, the hospital has raised a Final bill of Rs.60,187.35 and hospital has given discount of Rs.3,487.35 reducing the Final bill to Rs.56,700/- which is not a Tax Invoice and no GST is charged from the patient.

4.       Final bill receipts up loaded in Galaxy are non Tax Receipts and do not have mandatory GST number mentioned on them and no GST is charged from the patient and mode of payment by the patient is in cash, credit card and UPI mode.

5.       As per the FVR report the patient had Thyroid problem from 10/12 years, but is now recovered but the patient failed to mention the same at the time of inception of the policy which amounts to non disclosure of material facts and is against the company rules.

6.       As per one ICP, cutting was done in progress sheet of Deep Hospital dated 20.02.2024 morning. Cutting done after writing the real facts. It was written: complaints of Bodyache 2 months back, Got done CBC, Platelet 90k, received IV Drips recovered then. But after writing all these facts, cutting done over it. As policy taken on 29.11.2023 and admitted in hospital on 19.02.2024. These facts shows that this ailment is PED which was not disclosed during inception of policy.

7.       Treatment Charts at page No.28-29/39 are written by single person.

          In view of the above submissions, it is very much clear that the insured deliberately hide the material facts from the Opposite Parties in order to extract claim from the Opposite Party Company. So, the insured is required to submit all the necessary documents as per condition no.18 of the terms and conditions of the policy required for proper processing of the claim. 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.CW1/A alongwith copies of documents Ex.C1 to Ex.C11.

4.       On the other hand, Opposite Parties have placed on record copies of documents Ex.OP1 to Ex.OP13 and affidavit of Sh.Sumit Kumar Sharma, Authorized Signatory, Star Health & Allied Insurance Co. Ltd. as Ex.OP14.

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 ‘Star Health Assure Insurance Plan Policy’ bearing no.11240536360600 for the period 29.11.2023 to 28.11.2024 covering self and his wife Pooja Arora and Dauther Hitika Arora for a sum insured of Rs.10,00,000/-. It is also proved on record that during the policy coverage, the wife of the complainant suffered Immune Thrombocytopenia, DCT positive, ANA profile positive for SS-A/Ro60, SS-A/Ro52, SS-B/La, PM-Scl., Iron deficiency, Secondary to blood loss, Steroid induced hyperglycemia and got admitted in Deep Hospital, Ludhiana on 19.02.2024 and after treatment got discharged from the hospital on 23.02.2024. It is not disputed that the complainant applied Opposite Parties for cashless treatment. On receipt of the cashless treatment, the Opposite Parties raised query/documents from the complainant, vide letter dated 20.02.2024 and thereafter they denied the cashless request of the complainant, vide letter dated 22.02.2024. Thereafter the complainant lodged the claim with Opposite Parties for the reimbursement of the expenses incurred on the treatment of his wife, but the claim of the complainant was denied/not admitted by the Opposite Parties.

7.       We have given the due consideration to the admitted and proved facts on record and also considered the rival contentions of the ld. Counsels for both the parties and have gone through the record meticulously. The perusal of the record reveals that the denial letter placed on record by the complainant is different from the denial letter placed on record by the Opposite Parties. The complainant has placed on record copy of the denial letter dated 21.02.2024, vide which, the Opposite Parties denied/not admitted the claim of the complainant on the following grounds:-

“It is noted from the records that the insured patient has been hospitalized and treated for a Disease/illness/condition which is not admissible for the first two years of the policy. Therefore, the claim is not admissible as per Exclusion No- Ex.cl02.

          On the other hand, the Opposite Parties have placed on record copy of denial letter dated 16.04.2024, vide which, the Opposite Parties denied/not admitted the claim of the complainant on the following grounds:-

“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. 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.”

8.       Perusal of both the refusal letters reveals the arbitrary inclination of the Opposite Parties towards the claim rejection and too without any cogent reason. The plea taken by the Opposite Parties for the denial/non admission of the claim of the complainant, vide letter 21.02.2024 by the Opposite Parties is not genuine, as the ailment in question for which the complainant is been treated does not fall under the exclusion clause of the policy in question as alleged by the Opposite Parties. Discharge summary of Deep Hospital, Ludhiana (Ex.C10) evident of the fact that wife of the complainant landed up in the hospital with the problem of ‘Immune Thrombocytopenia’ and the Opposite Parties in written reply submitted that wife of the complainant has taken treatment for Bicytopenia, which as per the policey in question does not fall in the exclusion clause as alleged by the Opposite Parties. The dictionary meaning of the term ‘Bicytopenia’ is as under:-

“Bicytopenia is the reduction of any of the two cell lines of blood, i.e., erythrocytes, leukocytes or platelets.” 

From the definition above and considering the ailment suffered, it is apparent that the wife of the complainant suffered all the problems due to the above said disease i.e. ‘Bicytopenia’, which the Opposite Parties failed to prove being covered under the exclusion clause as alleged.

Further the plea taken by the Opposite Parties, vide letter dated 16.04.2024 that they found various discrepancies in the documents submitted by the complainant is also not genuine, as first of all Opposite Parties have not mentioned in the said letter that what types of discrepancies was found by them in the medical record of the complainant. However, the Opposite Parties have mentioned about the discrepancies in the written reply, which are as follows:-

1.       TOA TOD not mentioned in DS.

2.       Exact duration of Immune Thrombocytopenia not mentioned in DS to the reasons best known to the treating doctor.

3.       The hospital has raised a Pre Authorization for cashless treatment for an amount of Rs.47,500/- approximately but after denial, the hospital has raised a Final bill of Rs.60,187.35 and hospital has given discount of Rs.3,487.35 reducing the Final bill to Rs.56,700/- which is not a Tax Invoice and no GST is charged from the patient.

4.       Final bill receipts up loaded in Galaxy are non Tax Receipts and do not have mandatory GST number mentioned on them and no GST is charged from the patient and mode of payment by the patient is in cash, credit card and UPI mode.

5.       As per the FVR report the patient had Thyroid problem from 101-12 years, but is now recovered but the patient failed to mention the same at the time of inception of the policy which amounts to non disclosure of material facts and is against the company rules.

6.       As per one ICP, cutting was done in progress sheet of Deep Hospital dated 20.02.2024 morning. Cutting done after writing the real facts. It was written: complaints of Bodyache 2 months back, Got done CBC, Platelet 90k, received IV Drips recovered then. But after writing all these facts, cutting done over it. As policy taken on 29.11.2023 and admitted in hospital on 19.02.2024. These facts shows that this ailment is PED which was not disclosed during inception of policy.

7.       Treatment Charts at page No.28-29/39 are written by single person.

Even at the cursory glance of the above, it is clearly made out that the alleged discrepancies are beyond the control of the complainant 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 denial letter issued by Opposite Parties, so the same are not maintainable. We have gone through the Vigilance Claims Verification Report placed on record by Opposite Parties (Ex.OP13) and it also failed to justify the non admission of the claim of the complainant on account of pre-existing disease as alleged in that report. Opposite Parties have failed to prove any malafide on the part of the complainant and evidently had taken treatment from the hospital in question.

8.       Thus, in our considered opinion, the denial/non admission of the claim of the complainant vide letters dated 21.02.2024 and 16.04.2024 by the Opposite Parties is wrong, illegal and thus payable by the Opposite Party-Insurance Company. The Opposite Parties rendered deficient services towards the complainant while denying the genuine claim of the wife of the complainant.

9.       Vide instant complaint, the complainant claimed the amount of Rs.1,01,691/- i.e. expenses incurred for the treatment taken by his wife, which are duly proved on record, vide Ex.C3 to Ex.C9.

10.     From the above discussion, we allow the instant complaint in part and direct the Opposite Parties to pay an amount of Rs.1,01,691/- (Rupees One Lakh One Thousand Six Hundred Ninety One only) to the complainant. Opposite Parties are also directed to pay compository costs of Rs.10,000/-(Rupees Ten 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 further burdened with additional cost of Rs.10,000/-(Rupees Ten 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