BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 669 of 2019
Date of Institution : 20.11.2019
Date of Decision : 10.01.2023.
Mukul Gupta (aged about 40 years) wife of Sh. Sudhanshu Gupta son of Sh., Mahesh Chander Gupta, 4, New Housing Board Colony, Near DAV School, Bata Colony, Sirsa.
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., 1-New Tank Street, Valluvar Kottam High Road Nungambakkam, Chennai- 600034 through its Senior Manager/ Incharge Customer Care.
2. Star Health and Allied Insurance Company Ltd. Ground Floor, Rathore Tower, Near Hotel Mehak, Dabwali Road, Sirsa through its Branch Manager.
3. Star Health and Allied Insurance Company Ltd. Ground Floor, Rathore Tower, Near Hotel Mehak, Dabwali Road, Sirsa through its SM.
…….Opposite Parties
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA ……… MEMBER
Present: Sh. Rishab Goyal, Advocate for the complainant.
Sh. Mukesh Saini, Advocate for opposite parties.
ORDER
The brief and relevant facts of the present complaint are that complainant and her husband planned to purchase family health policy with the intention to cover all the members of the family. In this regard, ops no.2 and 3 being authorized Incharges of op no.1 visited to the house of complainant and stated that Star Health is one of the leading company in Indian Market. The complainant and her family were medico legally examined by the ops through their authorized doctor and thereafter, the policy was issued. It is further averred that earlier the husband of complainant purchased health policy from United India Insurance Company w.e.f. 2012 and this policy continued till 2016 and after impressing from the features of Star Health Company and upon pursuance of ops no.2 and 3, the said policy was switched over/ ported with the ops. Since 2012, complainant and her family members did not lodge any complaint for any medical ailment. The ops no.2 and 3 also assured that health insurance policy is a cashless policy and they further explained that as per newly launched scheme, there is a provision for preferential hospital for the insured person to provide better and urgent treatment all over India. Accordingly, husband of complainant purchased health policy No. P/211121/01/2020/000040 commencing from 08.04.2019 to 07.04.2020 and paid premium amount of Rs.15,287/- and complainant, her husband, son Rudransh Gupta, daughter Hitakshi Gupta were got insured by ops under the above mentioned policy. The limit of coverage was given of Rs.6.75 lakh under the scheme description 2A + 2C. That after purchasing the policy, a confirmation call was also received from ops and even physical verification was also done by ops regarding correct address and status of the complainant and thereafter ops issued customer identity card under the IRDA Registration No. 129.
2. It is further averred that complainant felt some medical problem and went to Apex Hospital and Research Centre, Sirsa where Dr. R.K. Mehta and Dr. Manisha Mehta diagnosed her on 26.07.2019. After clinically examined, she was advised for further examination i.e. blood test etc which was got done on 27.07.2019 and thereafter treating doctor advised her for surgery due to swelling in Uterus. The complainant was admitted on 01.08.2019 and after surgery, she was discharged on 03.08.2019 with the diagnose of bulky Uterus ADENONRYOSIS and doctors charged an amount of Rs.43,500/-. That before admission in the hospital, oral information was given to the ops no.2 and 3 who advised and assured to go for surgery and upon their assurances, the surgery was got done. It is further averred that ops no.2 and 3 required the investigation report for the purpose of providing the benefit of cashless policy, however, surprisingly after receiving the clinical test report, the ops issued impugned letter dated 30.07.2019 wherein hyper technical grounds were raised that “We referred to your request for approval for cashless treatment at the above referred hospital for the above diagnose disease of the insured patient. As per provided documents patient has history of/ symptom since five years, which is not provided inspite of query, moreover, patient has H/O K/C/O rheumatoid arthritis, but inquiry reply no HO rheumatoid arthritis, hence altered documents are not accepted in cashless, hence claim denied. Hence we denied the approval for cashless treatment for the above diagnose disease and you may submit the documents to us seeking reimbursement of the expenses incurred. That finding no other alternate, the husband of complainant deposited entire amount of treatment, medicines and other expenses incurred by him under proper receipt i.e.Rs.65,000/- approximately. It is further averred that ops have taken objections with the sole intention to delay and deny the claim of complainant, which reflects from their early objections taken in the letter dated 30.07.2019, whereas doctor concerned also issued letter to the effect that there is no previous history of rheumatoid arthritis to the complainant and history prepared reflects something else. The medical terms could only be understand by the professional person, but the ops through their representative without applying their mind simply repudiated the claim of complainant which amounts prejudice to the legal and valuable rights. That after discharge, the doctor concerned advised for follow up and also advised medicines for about one month and husband of complainant contacted with the ops no.2 and 3 for making payment of the entire bill of the doctor. The ops no.2 and 3 after contacting with their concerned branch advised to make the payment with the assurance and promise that they shall reimburse the same within few days after fulfillment of documentary formalities though it was made clear that after consent of ops no.2 and 3, the complainant was got admitted in Apex Hospital as a preferential patient and treatment was done there accordingly. It is further averred that ops no.2 and 3 advised the husband of complainant to submit the required documents i.e. original bills, discharge summary, original bills of medicines, surgical items etc. The husband of complainant after due authentication from the doctor concerned, sent all the original documents to the ops for early releasing of the entire amount paid by him and this fact is also clear from their letter dated 26.08.2019. The ops after going through all the documents issued a letter dated 29.08.2019 for requirement of additional documents/ information from the complainant as mentioned at Sr. No.123 and the required documents have also been sent to the ops for their satisfaction purpose.
3. It is further averred that ops could not make understand the detail history of the complainant prepared by the doctors of Apex Hospital, so under the doubt, they have required some more information, which was specifically replied by Dr. Manisha Mehta as mentioned in letter dated 30.08.2019 in which it was specifically reported that (i) there is no any history of Rheumatoid arthritis (ii) patient first time consulted on 26.07.2019, so there is no any previous consultation papers (iii) Any H/O surgical investigation and its record- No. (iv) Any post history of hospitalization- No. All these queries put by ops have duly been clarified by the doctor concerned in writing and was duly sent to the ops. It is further averred that ops again issued letter dated 18.09.2019 for requirement of additional documents/ information. The husband of complainant replied to the said letter wherein he had explained that all the required documents have duly been furnished and the doubt of previous history of RHEUMATOID ARTHRITIS is totally basis and moreover, the problem for which she underwent surgery i.e. TLH CB/C SALPINGECTOMY has no direct link with the disease RHEUMATOID ARTHRITIS. She never felt any problem in this regard and she was quite healthy prior to the admission and surgery. That thereafter husband of complainant personally contacted with ops no.2 and 3 and inquired about the status of the claim and ops no.2 and 3 assured him that claim file is in process and total amount shall be reimbursed within few days. It is further averred that however they received repudiation letter dated 14.10.2019 from ops whereby their claim was repudiated on the ground that insured is a patient of RHEUMATOID ARTHRITIS and they have not furnished required documents. The impugned non speaking decision taken by ops is totally illegal, nonest, without any reason and same is liable to be set aside as complainant and her husband have already fulfilled the requirement of ops and the act and conduct of the ops clearly amounts to deficiency in service and unfair trade practice towards the complainant. Hence, this complaint.
4. On notice, opposite parties appeared and filed written statement taking certain preliminary objections. On merits, it is submitted that true facts of the case are that branch office of answering ops at Hisar had issued the Family Health Optime Insurance Plan covering Mrs. Sudhanshu Gupta- self, Mrs. Mukul Gupta- spouse, Mr. Rudrash Gupta, baby Hitakshi Gupta dependent children for a floater sum insured of Rs.3,00,000/- for the period 03.04.2016 to 2.4.2017 and the same was renewed from 8.4.2017 to 7.4.2020. These policies were issued as per the terms and conditions of the insurance policy believing that the information provided by the insurer in his proposal form are true and correct. The policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. It is further submitted that insured patient Mrs. Mukul Gupta was admitted on 01.08.2019 at Apex Hospital and Research Centre for the treatment of fracture of Bulky Uterus with Adenomyosis. Subsequently the insured submitted claim records towards reimbursement of medical expenses. On scrutiny of the above documents, it is observed that as per consultation report dated 26.07.2017 the insured is a known case of RA. Hence, the answering ops have called for the documents related to the treatment of RA vide query letter dated 29.08.2019 and 18.09.2019 respectively. From these findings, the insured is a known case of RA, thus they called for to submit the past medical records related to RA. But the insured did not submit the required documents for further process which amounts to non submission of documents. Hence, the claim is not payable as per condition no.3 of the policy. It is further submitted that answering ops are acting as per the terms and conditions of the policy and legally rejected the claim of complainant. Remaining contents of complaint are denied to be wrong and prayer for dismissal of complaint made.
5. The complainant in order to prove her case has furnished her affidavit Ex.CW1/A and has also tendered copies of documents Ex.C1 to Ex.C36.
6. On the other hand, ops in order to rebut the evidence of complainant have furnished affidavit of Sh. Rajiv Jain, Chief Manager as Ex.RW1 and copies of documents Ex.R1 to Ex.R20.
7 We have heard learned counsel for the parties and have perused the case file carefully.
8. Admittedly, the husband of complainant namely Sh. Sudhanshu Gupta purchased health insurance policy from ops for the period 03.04.2016 to 02.04.2017 for himself, wife Mukul Gupta complainant and children Mr. Rudransh Gupta and Ms. Hitakshi Gupta and said policy was got renewed for the period 08.04.2017 to 07.04.2018, 08.04.2018 to 07.04.2019 and then from 08.04.2019 to 07.04.2020 as evident from copies of policies placed on file by ops themselves as Ex.R3 to Ex.R7. During the subsistence of the policy in question i.e. from 08.04.2019 to 07.04.2020, complainant insured was admitted in Apex Hospital, Sirsa on 01.08.2019 and she was diagnosed with Bulky Uterus with Adenomyosis as is evident from discharge card Ex.C21 of the said hospital. The complainant was operated for TLH with B/L Salpingectomy and was discharged on 03.08.2019 as per said discharge card Ex.C21. According to the complainant, her husband spent an amount of Rs.65,000/- on her treatment and as ops denied for approval of cashless treatment, the husband of complainant himself paid the said amount in the hospital for treatment and medicines etc. The ops have repudiated the claim of the complainant vide repudiation letter dated 14.10.2019 Ex.C5 while mentioning that “it is observed from the consultation report dated 26.07.2019 of above hospital, the insured patient is a known case of rheumatoid arthritis (RA). Hence we requested to furnish us treatment records and investigation reports pertaining to rheumatoid arthritis. We note that you have not furnished us the required documents. In the absence of the above documents/ details, we are not able to process your claim. As per condition No.3 of the above policy, the insured person has to submit all the required documents and details called for by us. We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim. However, Dr. Manisha Gupta of Apex Hospital in her certificate dated 30.07.2019 Ex.C10 and dated 31.08.2019 Ex.C8 have clarified that there is no any history of Rheumatoid arthritis and patient first time consulted on 26.07.2017, so there is no any previous consultation papers. Further said Dr. Manisha Mehta in her certificate Ex.C17 also certified that patient Mukul Gupta w/o Sudhanshu Gupta from Sirsa was admitted in this hospital on 01.08.2019 underwent TLH with B/L Salpingectomy. She was discharged on 30.08.2019. Since said Dr. Manisha Gupta who conducted surgery on the person of complainant have already clarified that there is no any history of Rheumatoid arthritis to the complainant, therefore, ops have wrongly and illegally denied the cashless treatment to the complainant have also illegally repudiated the genuine claim of the complainant. Although, ops have relied upon consultation report dated 26.07.2019 Ex.R16 in which it is mentioned K/C/O RA but ops have not proved on record by leading any cogent and convincing evidence that complainant was actually suffering from rheumatoid arthritis for which they have treatment records and investigation reports from the complainant. The ops have not examined said Dr. Manisha Gupta to prove the fact that actually complainant was suffering from rheumatoid arthritis or not and Dr. Manisha Gupta was the best person to explain that how RA was mentioned on the consultation paper but the ops have failed to examine her and have also failed to place on record any affidavit of Dr. Manisha Gupta in this regard. Moreover, the complainant sought reimbursement of medical expenses of surgery of Bulky Uterus with Adenomyosis which has no concern with the disease of Rheumatoid arthritis and it is also not the case of the ops that complainant concealed about the pre-existing disease of rheumatoid arthritis from the ops at the time of obtaining insurance policy in question. More so, said Dr. Manisha Mehta have also certified that complainant was not having any history of rheumatoid arthritis. So, the ops only in order to avoid from their liability to pay genuine claim amount have wrongly and illegally repudiated the genuine claim of the complainant on flimsy grounds.
9. The complainant has claimed an amount of Rs.65,000/- from the ops spent on her treatment and medicines etc. including bill of the hospital for surgery. In this regard, complainant has also placed on file copy of the receipt of the amount of Rs.43,500/- (Ex.C16) charged by Apex Hospital, Sirsa and she has also placed on file other receipts/ bills of the Apex Hospital and M/s S.B. Medicos situated in Apex Hospital, Sirsa. So, we are of the considered opinion that complainant is entitled to the amount of Rs.65,000/- spent on her treatment from ops as she has not claimed exaggerated amount.
10. In view of our above discussion, we allow the present complaint and direct the opposite parties to reimburse and pay the amount of Rs.65,000/- to the complainant alongwith interest @6% per annum from the date of filing of present complaint i.e. 20.11.2019 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. In case, ops fail to comply with this order within above stipulated period, complainant shall be at liberty to initiate proceedings under Section 71/72 of the Consumer Protection Act, 2019 against the ops. A copy of this order be supplied to the parties free of costs. File be consigned to the record room after due compliance.
Announced. Member Member President,
Dated: 10.01.2023. District Consumer Disputes
Redressal Commission, Sirsa.
