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 purchased a policy from the Opposite Parties in the year, 2019 which was continued till 26.05.2023. On 06.05.2023, the complainant went to Civil Hospital, Zira with a complaint of throat pain and Woth c/o Hoarseness since the last 1/2 months H/O Vocal Abuse present and hypothyroidism, so on the advise of Dr.Hardeep Singh Osahan, (ENT) Surgeon, the complainant got conducted some tests and paid Rs.1020/- to the Arsh Clinical Laboratory, Kot Ise Khan, District Moga and got medicines from the Osahan Hospital, Zira and paid Rs.345/- to the hospital. Thereafter on 12.05.2023, the complainant went to DMC and Hospital, Ludhiana for the above said disease and doctor of DMC and Hospital got various tests of complainant and referred the complainant to PGI, Chandigarh for Speech Therapy and the said hospital charged Rs.4360/- from the complainant and amount of Rs.1125/- paid to Payal Pharmacy, Ludhiana. Thereafter on 18.05.2023 the complainant admitted at Osahan Hospita, Zira for operation of Throat and on the same day Dr.Jaswant Singh Osahan conducted the operation of complainant and discharged the complainant on 19.05.2023 and received Rs.31,109/- from the complainant. The complainant also spent Rs.4109/- on medicines. Thereafter on 28.05.2023, the complainant again went to the said hospital for routine checkup after surgery and doctor received Rs.412/- for medicines and Rs.500/- for Speech Therapy from the complainant. After discharge from the hospital, the complainant submitted entire medical bills and documents in the office of Opposite Party as per their requirement. However, the Opposite Parties rejected the claim of the complainant with remarks that “It is observed from the submitted medical records that the intimation regarding the admission was given to them only after 24 hours of hospitalization”. Due to such 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.42,980/-.
b) To pay an amount of Rs.1,00,000/- as compensation harassment and for deficiency in service.
c) To pay an amount of 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 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. Averred that the complainant availed ‘Family Health Optima Insurance Plan Policy no.P/211222/012023/001625 for the period 27.05.2023 to 26.05.2023 and in this policy, complainant, his wife Swaranjeet Kaur, his dependent Children Sukhpreet Kaur and Taranpreet Singh are insured for an amount of Rs.5 lakhs. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form and pre-existing disease was declared by the insured to the extent of ‘Hypertension and its complications only’, except this nothing have been disclosed by the insured. Averred further that the claim in dispute is fourth claim reported, previously there were three claims lodged and all three of them were settled. The present claim was registered vide claim no.CIR/2022/211222/3818600. The insured has submitted the claim documents in the present case regarding the medical reimbursement expenses towards the treatment of complainant taken by him at Osahan Hospital from 18.05.2023 to 19.05.2023 towards the treatment of TVC Polyp. Averred that it is observed from the claim documents that submitted medical records regarding the admission was given to us after 24 hours which was to be given as per terms and conditions of policy within 24 hours of hospitalization, hence the claim was rejected vide repudiation letter dated 28.07.2023 which is clear cut violation of the terms and conditions of the policy in question and came under the exclusion clause. Averred that as per condition no.1 of the policy issued to the complainant or her husband on the conditions that if there is any misrepresentation and violation made by whether the insured person or on behalf of insured person, the insurance company is not liable to pay any claim hence the claim was rejected and duly informed to 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 his case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C24.
4. On the other hand, Opposite Parties has placed on record copies of documents Ex.OP1 to OP8 and affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. as Ex.OP9.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. Availing of insurance policy bearing no.P/211222/01/2023/001625 valid from 27.05.2022 to 26.05.2023 by the complainant covering self, his wife and children and during the policy coverage, the hospitalization of complainant in Osahan Hospital for the period from 18.05.2023 to 19.05.2023 is not disputed. There is also no dispute that after discharge from the hospital, the complainant lodged the claim with Opposite Parties, but the Opposite Parties repudiated the claim of the complainant vide letter dated 28.07.2023.
7. The perusal of the record reveals that the Opposite Parties repudiated the claim of the complainant vide letter dated 28.07.2023 on the following grounds:-
“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of TVC POLYP.
It is observed from the submitted medical records that the intimation regarding the admission was given to us only after 24 hours of hospitalization.
Please note that as per policy issued to you, Condition-Standard Conditions-Clause-D- Notification of claim, the intimation has to be given within 24 hours of hospitalization.
8. In our concerted view, the ground taken by the Opposite Parties for the repudiation of the claim as mentioned above is not genuine. and this decision of ours is based upon the IRDA circular issued to the Insurance Companies stating 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.
9. Further the Opposite Parties repudiated the claim of the complainant, without getting verified its genuinenity from the hospital concerned. Had they get verified from the hospital concerned regarding fakeness or ingenuinenity of the claim, then they would have been justified in repudiating the claim, if it found fake. However, there is no document showing that they ever got verified from the hospital regarding the admission of the son of the complainant. Thus the repudiation of the claim, only on the ground of late intimation i.e. after 24 hours of hospitalization is not genuine.
10. In these circumstances, the repudiation of the genuine claim of the complainant by the Opposite Parties is unjustified.
11. From the above discussion, we allow the complaint of the complainant in part and direct the Opposite Parties to pay the claim for medical expenses incurred by complainant for his hospitalization at Osahan Hospital, Zira (which also includes pre and post hospitalization charges), subject to submission of photocopies of medical bills by 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 compliance of this order be made by the Opposite Parties within 45 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 complainants 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
