BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.      
Consumer Complaint no. 524 of 2023 Date of Institution :    13.12.2023
Date of Decision :    10.12.2024
Deepak Sethi (aged about 33 years) son of Shri Satpal, resident of H. No. 504, Gali Khalsa School Wali, Gujran Mohalla, Sirsa, Tehsil and District Sirsa. 
                      ……Complainant.
Versus
1. Star Health & Allied Insurance Company Ltd., No. 15, Sri Balaji Complex, Ist Floor, Whites Lane, Roy Apettah, Chennai- 600014, through its Authorized person/ M.D. 
2. Star Health & Allied Insurance Company Ltd., 1st and 2nd Floor, Satya Sales Samsung Plaza, Showroom Building, Adjoining RC Regency Hotel, Hisar Road, Sirsa through its Authorized person/ representative. 
…….Opposite Parties.
            Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
                    SH. OM PARKASH TUTEJA……….MEMBER
Present: Sh. Vijay Sharma,  Advocate for the complainant.
Sh. Ravinder Monga, Advocate for opposite parties no.1 and 2.
 
ORDER:-
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2.           In brief, the case of complainant is that on 25.11.2021 complainant purchased health insurance policy i.e. Family Health Optima Insurance Plan bearing No. P/211121/01/2022/ 009336 from op no.2 vide which ops no.1 and 2covered the health risk of complainant, his wife Dimple Arora and his son Prathamdeep up to Rs. five lacs and the policy was effective from 25.11.2021 to 24.11.2022. The complainant paid a sum of Rs.12,621/- for the said policy for one year. Thereafter, complainant got renewed the said policy vide Policy No. P/211121/01/2023/010408 for the period 25.11.2022 to 24.11.2023 and paid a sum of Rs.14,653/- as premium to the ops. That complainant again renewed this policy for the period 25.11.2023 to 24.11.2024. It is further averred that on 13.08.2023 wife of complainant namely Dimple had suffered from fever and she took treatment on 16.08.2023 from Holi Nursing Home for High Grade fever of three days associated with chills, severe burning micturition, frequency and dysuria and she remained admitted there up to 19.08.2023. That at the time of admission of wife of complainant in the said hospital, complainant had shown cashless card of ops no.1 and 2 upon which ops no.1 and 2 demanded the required documents of medical treatment from the concerned Hospital and thereafter all the relating documents were provided to ops but despite that ops failed to provide cashless scheme to the complainant. A sum of Rs.50,000/- has already been spent by complainant on the treatment of his wife but op no.2 refused to pay any expenses and repudiated the claim of complainant on the false ground that as per discharge summary, the insured patient was admitted from 16.08.2023 to 19.08.2023 but as per documents and details available with them, the insured patient was treated under day care basis and thus there is discrepancy in the records which amounts to misrepresentation of facts. It is further averred that wife of complainant is still under treatment as an outdoor patient and is taking medicines from the concerned Hospital and a huge amount is yet to be spent for her further treatment. That ops without any specific reason have denied the cashless facility to the complainant despite uploading/ providing of requisite documents by the concerned hospital and thereafter ops again repudiated the claim of complainant on 17.08.2023 and thereafter on 12.10.2023 without any sufficient reasons and have caused deficiency in service, adopted unfair trade practice and have also caused unnecessary harassment to them. Hence, this complaint. 
3.          On notice, ops appeared and filed written version taking certain preliminary objections. It is submitted that complainant filed two claims on account of treatment of his wife i.e. from 24.06.2022 to 26.06.2022 and from 16.08.2023 to 19.08.2023 and complainant had already filed another complaint for seeking claim for treatment of his wife from 24.06.2022 to 26.06.2022. It is submitted that regarding claim for treatment from 16.08.2023 to 19.08.2023, it is observed from the discharge summary that insured patient was admitted from 16.08.2023 to 19.08.2023 but as per documents and details available with them, the insured patient was treated under day care basis. Thus there is discrepancy in the records which amounts to misrepresentation of facts. As per terms and condition no.1 of the policy, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim. Hence, claim was rejected and conveyed to insured vide letter dated 12.10.2023. It is further submitted that plea taken in the present complaint is self contradictory from the previous complaint, so an adverse inference could easily be drawn only on this score. The complainant had failed to furnish any medical advice, opinion to support his version and claim of complainant has been rightly and lawfully repudiated with speaking order. It is further submitted that in case it is found that company is liable to pay the claim in terms of the contract of insurance, then the maximum quantum of liability shall be limited to as per terms and conditions of the policy for both the claims. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
4.        The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C38. 
5.        On the other hand, ops have tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex. RW1/A and documents Ex.R1 to Ex.R19. 
6.        We have heard learned counsel for the parties and have gone through the case file.
7.         In the present complaint, the complainant has sought reimbursement of the amount spent by him on the treatment of his wife Dimple i.e. insured for the period 16.08.2023 to 19.08.2023 under the policy taken by him from ops for the period 25.11.2022 to 24.11.2023 as she remained admitted in Holy Nursing Home, Sirsa from 16.08.2023 to 19.08.2023. The ops have denied cashless request and have repudiated the claim of complainant on the ground that from the discharge summary, the insured patient was admitted from 16.08.2023 to 19.08.2023 but as per documents and details available with them, the insured patient was treated under day care basis and thus there is discrepancy in the records which amounts to misrepresentation of facts. However, we are of the considered opinion that ops have wrongly and illegally repudiated the claim of complainant on wrong and false ground because the complainant has also placed on file treatment record,  treatment chart of the Holy Nursing Home, Sirsa from 16.08.2023 to 19.08.2023 as well as discharge summary as Ex.C1 to Ex.C6 and Ex.C9, the perusal of which reveals that Mrs. Dimple wife of complainant remained admitted in the Holy Nursing Home from 16.08.2023 to 19.08.2023 as she was having High Grade fever from three days associated with chills, severe burning micturation and dysuria and there is nothing on file to prove any discrepancy in the treatment record and misrepresentation of facts. The complainant lodged his claim for reimbursement of the amount of Rs.27020/- from ops and it is duly proved on record that complainant has spent this amount of Rs.27020/- on the treatment of his wife as is evident from bills/ receipts Ex.C15 to Ex.C32. It is unbelievable and not possible that complainant who is paying such huge premium amounts of Rs.12,621/- and Rs.14,653/- to the ops will seek false reimbursement of such petty amount of Rs.27,020/- from ops and as such ops have adopted unfair trade practice while rejecting the genuine claim of complainant. However, complainant is not entitled to any other amount than Rs.27020/- as receipt of the amount of Rs.2600/- Ex.C37 issued by Haryana Basic Lab is dated 22.08.2023 and receipt of Rs.2600/- Ex.C38 issued by Haryana Basic Lab is of dated 12.08.2023 whereas complainant has sought reimbursement of the claim for the treatment of his wife from 16.08.2023 to 19.08.2023 and has also lodged claim amount of Rs.27,020/- with the ops. 
8.         In view of our above discussion, we allow the present complaint and direct the ops to pay above said claim amount of Rs.27,020/- to the complainant alongwith interest @6% per annum from the date of filing of present complaint i.e. 13.12.2023 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.10,000/- as composite compensation for harassment and litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.   

Announced. Member Member President,
Dated: 10.12.2024.                                  District Consumer Disputes
             Redressal Commission, Sirsa.