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 complainant no.1 has been availing the health insurance policy from Opposite Parties since 25.09.2020 for herself and her father, which was duly renewed time to time. Lastly the policy was renewed vide endorsement no.P/211222/01/2024/005941 for the period 25.09.2023 to 24.09.2024 with sum insured of Rs.20 lakh alongwith bonus and recharge benefit. Unfortunately, complainant no.1 suffered with Pyrexia of unknown origin (with Lymphadenopathy) suspected Hodgkins, Lymphomia and due to such problem complainant no.1 got admitted in Tata Memorial Centre (Tata Memorial Hospital) Mumbai for the period 16.02.2022 to 18.02.2022 and 10.03.2022 for regular treatment of the diagnosed problem and complainants spent Rs.1,49,000/- on the treatment and hospital authorities informed the same to Opposite Parties. Thereafter complainants have also approached the Opposite Parties and submitted the claim of medical reimbursement of complainant no.1 alongwith original medical record of said hospital and bills and Opposite Parties also issued the claim no.4025487 to complainant, but the Opposite Parties declined/repudiated the claim of the complainants. Complainant no.1 also issued legal notice dated 16.01.2024 to the Opposite Parties, but to no effect. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay a sum of Rs.1,49,000/- with interest @ 12% per annum to the complainant no.1 from the date of filing of present complaint till realization of the amount.

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

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

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 complaint is pre mature and is without any cause of action, as the claim of the complainant never denied by the answering Opposite Parties as the mentioned admission was never reported to answering Opposite Parties. Averred that the claim of the complainant was denied as per insurance policy terms and conditions. Averred further that the present complaint pertains to insurance claim under “Young Star Insurance Policy Plan’ bearing no.P/211222/01/2022/005216 valid from 25.09.2021 to 24.09.2022 covering herself 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 complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Averred that the insured has already preferred and availed eleven claims. Averred further that as per complaint copy insured is claiming Rs.1,49,000/- for hospitalization at Tata Memorial Hospital, Mumbai (non network Hospital) from period 15.02.2022 to 18.02.2022 including the post bill of 24.02.2022 and 10.03.2022, but the Opposite Parties have not received any intimation or bills against the hospitalization. In the instant case insured neither intimated the Opposite Parties-Insurance Company for hospitalization nor submitted claim documents. The Opposite Parties have already paid various 11 claims to the insured but had the insured preferred this alleged claim in accordance with rules and regulations and had submitted the claim form with all required record then the claim would have been processed so far. As per terms and conditions of the insurance policy, the insured should have provided all the documents in original to verify the hospitalization details, if any as per the alleged complaint. As per policy Condition No.2 D of Standard Conditions, upon hospitalization, notice with full particulars should have been sent to the Opposite Parties company within 24 hours from the time/date of occurrence of the event. C. For Reimbursement claims: Time limit for submission of:

As per the terms and conditions of the policy, the insured should have intimated about the hospitalization within 24 hours and should have submitted in original all the claim documents. However, the insured has failed to do same and filed the present false, frivolous complaint which is premature. Averred further that the instant complaint is neither maintainable in law nor on facts; no deficient service has been rendered by the 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.       Complainant also filed replication to the written reply of Opposite Parties denying the objections raised by Opposite Parties in their written reply.

4.       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 and Ex.C4A to Ex.C4E.

4.       On the other hand, Opposite Parties have placed on record affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. as Ex.OP1,2/A alongwith copies of documents Ex.OP1,2/1 to Ex.OP1,2/4.

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

6.       It is not a denying fact that complainant no.1 is availing health insurance policy from the Opposite Parties since, 2020. Also the complainant no.1 has availed the policy bearing no.P/211222/01/2022/005216 for the period 25.09.2021 to 24.09.2022 from the Opposite Parties covering herself for a sum of Rs.5,00,000/- is not disputed. It is also not disputed that during the above policy coverage, complainant no.1 suffered ‘Pyrexia of Unknown Origin (with Lymphadenopathy)–Suspected Hodgkin’s Lymphoma’ and got admitted in Tata Memorial Hospital on 16.02.2022 and was operated for the same and thereafter got discharged on 18.02.2022.

7.       Now, the disputed fact is qua the reimbursement of the expenses incurred on the treatment of complainant no.1/insured. Counsel for the complainants contended that complainants approached the Opposite Parties and submitted the relevant documents alongwith medical records for reimbursement of expenses incurred on the treatment for the period 16.02.2022 to 18.02.2022 including post bill of 24.02.2022 and 10.03.2022 and thereafter Opposite Parties issued claim no.4025487, but despite that Opposite Parties declined the claim of complainant no.1. On the other hand, the objection raised by Opposite Parties is that they have already paid the eleven claims of the complainant no.1 and in this alleged hospitalization period, the Opposite Parties have not received any intimation or bills, so they are unable to pay the claim of the complainant no.1. The other objection raised by Opposite Parties is that as per discharge summary, date of admission of complainant no.1 in the hospital concerned is 16.02.2022, but in the claim form date is mentioned as 24.05.2023, so there is delay of more than a year.

8.       From the submissions of the parties and as well from the arguments addressed, it is summarized that the claim of complainant no.1 has been denied not due to non submission of the claim in question rather the same has been declined due to late submission of the claim and also due to non submission of required documents. This fact is also admitted by Opposite Parties in their written reply that they denied the claim of the complainant no.1 as per terms and conditions of the policy and as per Condition no.2 the intimation has to be given within 24 hours of hospitalization. It has been gathered from the record as well been admitted by the Opposite Parties that they have already paid 11 claims of complainant no.1 pertaining to the different periods since, 2021 and the Opposite Parties are well aware about the present ailment suffered by complainant no.1 and had also paid the claim for the same. Thus, there is no doubt about the genuinenity of the claim in question. Now the only question left to be determined is with regards to the late submission of the claim, which is duly been covered under the circular of IRDA, which states that the genuine claims shall not be rejected on hyper technical grounds i.e. delay etc. which for the sake of convenience is reproduced as under:-

“INSURANCE REGULATORY AND DEVELOPMENT   AUTHORITY

Ref. IRDA/HLTH/MISC/CIR/216/09/2011 Dated:20.09.2011 CIRCULAR

To All life insurers and non-life insurers.

Re: Delay in claim intimation/documents submission with respect to

 i.         All life insurance contracts and 

ii.       All Non-life individual and group insurance contracts.

The Authority has been receiving several complaints that claims are being rejected on the ground of delayed submission of intimation and documents.

The current contractual obligation imposing the condition that the claims shall be intimated to the insurer with prescribed documents within a specified number of days is necessary for insurers for effecting various post claim activities like investigation, loss assessment, provisioning, claim settlement etc.  However, this condition should not prevent settlement of genuine claims, particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances.  

 The insurer’s decision to reject a claim shall be based on sound logic and valid grounds.  It may be noted that such limitation clause does not work in isolation and is not absolute.  One needs to see the merits and good spirit of the clause, without compromising on bad claims.  Rejection of claims on purely technical grounds in a mechanical fashion will result in policyholders losing confidence in the insurance industry, giving rise to excessive litigation.

          Thus the denial of the claim, only on the ground of late submission is not genuine. In these circumstances, the denial of the genuine claim of the complainant no.1 by the Opposite Parties is unjustified.

9.       From the above discussion, we allow the instant complaint in part and direct the Opposite Parties to pay the claim for medical expenses incurred by the complainant no.1 for the hospitalization period in dispute during the coverage period (which also includes pre and post hospitalization charges) on submission of relevant documents and medical bills by complainant no.1. Further in order to facilitate, the complainant no.1 is hereby directed to submit the relevant documents alongwith medical bills to the Opposite Parties. Opposite Parties are further directed to settle and pay the claim next within 30 days from receipt of the copies of bills/documents submitted by the complainant no.1. 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 no.1. 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 no.1 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