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 the complainant has been purchasing the family health policy from the Opposite Parties, since 2017, which he got renewed regularly. After adding the bonus, timely renewal and payment of premium in the year, 2022, the said policy for Rs.10 lac became a coverage limit of Rs.17 lac and on the persuasion of Opposite Parties, the top up premium was paid and the policy of family of complainant became enhanced upto Rs. One Crore vide which the complainant no.1 and his wife complainant not.2 and son namely Shubam Goyal were covered. Unfortunately, wife of the complainant suffered with a severe disease and became seriously ill in the first week of January and the complainant alongwith his wife has consulted with various doctors and has gone through various tests and examinations and ultimately complainants were advised to approach PGI i.e. Post Graduate Medical Institute at Chandigarh. Ultimately the wife of the complainant got admitted in PGI after OPD consultation on 22.02.2023 and after treatment got discharged on 12.03.2023. After discharge from the hospital, complainant no.1 lodged the claim with Opposite Party and sent all the documents for the claim ofRs.2,47,193/- alongwith medical bills. Thereafter the Opposite Party started demanding unnecessary documents even though the complainant has provided all the documents. Surprisingly again the Opposite Party demanded the complete set of indoor case report, letter from treating doctors stating the exact cause and duration of diffuses and other documents for processing the claim, which the PGI, Chandigarh refused to give to complainant. Then, the complainant applied all these documents under RTI and supplied the said documents to Opposite Party, but despite supplying of documents, Opposite Party intentionally and knowingly vide its letter dated 23.09.2023 had allowed and paid only the claim of Rs.43,580/- out of Rs.2,47,193/- and Rs.2,03,613/- is remained due and the said amount i.e. Rs.43,580/- was paid on 05.10.2023. Unfortunately, after two and half months again health of complainant no.2 deteriorated and again she was admitted in PGI, Chandigarh on 21.05.2023 and got discharged on 26.05.2023 and intimation of the same was given to Mr.Vikas, D.O of Opposite Party No.1. Again a claim of Rs.63065/- was lodged with Opposite Parties alongwith documents and medical bills and said claim of Rs.63065/- is still lying with Opposite Parties. Afterward for the post treatment another claim of Rs.34,253/- was lodged with Opposite Party which was paid by them on 01.12.2023 without any deduction, but the Opposite Party remained silent for second claim of Rs.63065/-. Again fourth claim of Rs.34,353/- was lodged with Opposite Party alongwith all necessary documents, which is still pending with Opposite Party. Thus, a balance claim of Rs.2,03,613/-, Rs.63065 and Rs.34,353/- is pending with Opposite Party. Alleged that due to such wrongful act on the part of Opposite Party, the complainant has suffered mental agony as well as financial loss. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Party may be directed to pay an amount of Rs.3,01,031/- i.e. Rs.2,03,613/- as balance of first claim and Rs.63065/- on account of second claim and Rs.34,353/- for fourth claim alongwith interest thereon @ 24% per annum.
b) To pay a sum of Rs.5,00,000/- as compensation on account of mental tension, and harassment.
c) To pay Rs.150,000/- as litigation expenses and Rs.10,000/- being typing and other misc. charges alongwith Rs.3000/- as RTI expenses and for cancellation of their license due to poor service and unnecessary harassment.
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 intricate questions of law and facts are involved in the present complaint which required 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 concealed the fact that he has violated the terms and conditions of policy in question and no PED was declared and the policy in question was ported out in their company in 2017 and real facts are that complainant namely Sandeep Goyal was availed the Family Health Optima Insurance Plan Policy No.P/211222/01/2023/013205 renewed for the period 28.03.2023 to 27.03.2024 and in this policy Sandeep Goyal complainant no.1, Kirti Goyal, complainant no.2 and Shubham Goyal were insured for an amount of Rs 10 Lac. The terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. The complainant has 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. Averred that the present complaint is associated with four claims namely CIR/2023/211222/1621056, CIR/2024/211222/0394042, CIR/2024/211222/1159802 and CIR/2024/211222/1242309.
Details of First Claim no CIR/2023/211222/1621056 is as under:-
The insured KIRTI GOYAL was hospitalized PGIMER on 23.02.2023 to 12.03.2023 for the treatment of SYSTEMIC SCLEROSIS ILD HTN and DIFFUSE CUTANEOUS claim was received for Rs. 108980/-. Based on the submitted reimbursement documents, the claim was processed and an amount of Rs.43580/- was approved and paid to Insured through NEFT 278232672169057 dated 05.10.2023 and the reason for the deductions during hospitalization period is as under:-
As per submitted claim document patient has received active treatment during the first 10 days of admission only. Thereafter there was no active line of treatment. Hence claim payable for during 10 days and Rs 23,200/-are deducted. Further no detail breakup for lab is provided hence 80% payable, ......no report for USG, doppler, LFT and CRP hence Rs 2235/-are not payable. As per the Other Excluded Expenses of the Policy, the charges pertaining to admission and diet of Rs.4700/- not payable and deducted.
The reason for the deductions during pre-hospitalization period is as under:-
There is no report for bill date 01-Mar 03, Mar 04, Mar 05, Mar 06, Mar 07-Mar, 09-Mar, 11-Mar, 20-Feb, 22-Feb, 28-Feb, 01 Mar, no prescription for bill dated on 20.02.23 hence disallowed Rs 14650/- and deducted.
The reason for the deductions during post-hospitalization period is as under:-
As per the other excluded expenses of the policy, no prescription for submitted post bills 28-Apr, 20-Mar, 28- Feb, 27-Feb, 26-Feb, 14-Mar, 16-Mar 04-Apr, 13-Apr, 26-Apr, 06-May, no report for 28-Apr, 20-Mar, 27-Feb, 26-Feb, hence an amount of Rs 19965/- is deducted. As per the other excluded expenses of the policy, the charge Rs 650/- is towards heating pad not payable. Hence Maximum payable Rs 43580/-is already paid to insured and Rs 65400/- is not payable.
Total amount Rs.108980/-
Deduction Rs.65400/-
Total Payable Amount Rs.43580/-
Details of 2nd Claim no CIR/2024/211222/0394042 is as under:-
The insured has submitted the reimbursement of the medical expenses towards the treatment DIFFUSE CUTANEOUS SYSTEMIC SCLEROSIS ILD HTN at PGI- (Post Graduate Institute of Medical Sciences) on dated 21.05.2023 to 26.05.2023 and claim was received for Rs.63065/-. It is observed from the submitted medical records that the insured patient was admitted in the hospital on 21.05.2023 whereas the intimation regarding the admission was given to us only on 26.06.2023 and documents were submitted on 21.09.2023 and as per policy, Condition Conditions- Clause D- Notification of claim, the intimation has to be given within 24 hours of hospitalization. Further, the claim documents have been submitted after 15 days of discharge from the hospital on 26.05.2023 and as per policy issued to complainant, Condition- Standard Conditions- Clause C for reimbursement of claims, claim must be filed within 15 days from the date of discharge from the hospital. Hence claim was repudiated and conveyed to Insured vide our letter dated 22.09.2023.
Details of 3rd Claim no CIR/2024/211222/1159802 is as under:-
The insured has submitted the reimbursement of the medical expenses towards the treatment of SCLEROSIS at PGI- (Post Graduate Institute of Medical Sciences) on dated 20.09.2023 for Rs.34253/-. Based on the submitted reimbursement documents, the claim was processed and an amount of Rs.34253/- was approved and paid to the insured through NEFT N335232761721696 dated 01.12.2023.
Details of 4th Claim no CIR/2024/211222/1242309 as under:-
The insured has informed vide online mode on 02.12.2023 that the insured Kirti Goyal has been admitted to PGI- (Post Graduate Institute of Medical Sciences) on dated 29.11.2023 and further no documents were submitted. However three reminder letters dated 17.12.2023, 01.01.2024 and 16.01.2024 were sent to the insured for submission of documents but all in vain. Hence the claim was closed for non submission of documents.
In view of the above submissions, it is clear that the claim has been paid/repudiate as per terms and conditions of the policy. Averred further that the complainant has no locus standi or cause of action to file the present complaint against the Opposite Party; 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.A1 to Ex.A38, Ex.B1 to Ex.B28, Ex. C1 to Ex.C24, Ex. C25, Ex.C27, II-1 to II-21, Ex. D-1 to Ex. D8.
4. On the other hand, Opposite Party has placed on record copies of documents Ex.OP1 to Ex.OP15 and affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP16
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 ‘Family Health Optima Insurance Plan’ bearing no.P/211222/01/2023/013205 for the period 28.03.2023 to 27.03.2024 covering complainant no.1, complainant no.2 and their son Shubham Goyal. for a sum insured of Rs.10,00,000/-. It is also proved on record that during the policy coverage, complainant no.2 suffered DIFFUSE CUTANEOUS SYSTEMIC SCLEROSIS and got admitted in PGI, Chandigarh for the period 23.02.2023 to 12.03.2023, 21.05.2023 to 26.05.2023 and thereafter again taken the treatment on 20.09.2023 and thereafter on 29.11.2023 i.e. four times. It is also proved on record that the complainants lodged the claim for reimbursement of the expenses incurred on the treatment and out of the four claims, first claim was paid in part, second was repudiated and third was paid and fourth is pending.
7. The complainant has filed the present complaint to get the amount of four claims i.e. Rs.2,47,193/- for first claim, Rs.63065/- for second claim, Rs.35253/- for third claim and Rs.34,353/- for fourth claim. Whereas 3rd claim is concerned. It is admitted by both the parties that it has been settled and an amount of Rs.35,253/- pertaining to third claim has already been transferred in the account of the complainant, through NEFT on 01.12.2023. It is pertinent to mention here that during the course of arguments, we came to know from the complainant that 4th claim of the complainant has also been settled and amount has been received and this fact is also admitted by both the parties.
8. Now, we have to decide the dispute regarding the first and second claim only. If we take up the first claim, the amount of which as per claim form (Ex.OP5) is Rs.2,47,193/- and out of this, the complainant has already received an amount of Rs.43,580/- from the Opposite Party. However, they approved and transferred the amount of Rs.43,580/- in the account of the complainant and has not paid the remaining amount of Rs.2,03,613/- stating that the complainant no.2/insured has taken active treatment during the first 10 days of admission only, whereas rest of days, she remained admitted in PGI, Chandigarh without any active treatment. The objection raised by the Opposite Party is quite surprising that in the institution like PGI, Chandigarh why they kept the patient in hospital without any active treatment, whereas there is heavy footfall of the patients in PGI from all over the region. It is the doctor who decides when to discharge the patient from the hospital. So, repudiation on this account is totally ingenuine and unjustified.
It is pertinent to mention here that as per Claim Form (Ex.OP5), the complainants claimed the amount of Rs.2,47,193/- regarding the first claim, but however in the ‘Bill Assessment Sheet’ (Ex.OP8), the claimed amount has been mentioned as Rs.1,08,980/- with regard to first claim of the complainants. In the given circumstances, we deem it appropriate to direct the Opposite Party to pay the left over amount after deducting the amount already paid, subject to submission of bills by the complainants.
9. Lastly the claim pertaining to second claim (the amount of which as per proposal form Ex.OP9 is Rs.Rs.63065/-), which has been repudiated by the Opposite Party on account of late intimation. It is argued by the Opposite Party that the complainant no.2/insured was admitted in the hospital on 21.05.2023 whereas the intimation regarding the admission was given on 26.06.2023 and as per policy conditions, the intimation has to be given within 24 hours of hospitalization. In our considered opinion, it is again unjustified on the part of Opposite Party when the complainants fighting for the remaining amount of 1st claim in between the second claim accrued and there is delay of mere 35 days by the complainant to file the claim, but it does not mean she has not taken any treatment. As far as the treatment of this period was concerned, the Opposite Party can enquire it from the hospital on their own. Hence, we allow the second claim of the complainants also.
10. In view of the above discussion, the instant complaint is allowed in part and direct the Opposite Party to pay the left over amount regarding the first claim of the complainants after deducting the amount already paid, subject to submission of bills by the complainants and Rs.63,065/- (Rupees Sixty Three Thousand and Sixty Five only) with regard to second claim, to the complainants. Opposite Parties are further directed to pay compository costs of Rs.15,000/- (Rupees Fifteen 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 this order, failing which, they are further burdened with Rs.10,000/- (Rupees Ten 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 cost. File be consigned to record room after compliance.
Announced in Open Commission
