BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.           

                                                          Consumer Complaint no. 166 of 2020                                                           

                                                          Date of Institution :    24.07.2020

                                                          Date of Decision   :    23.05.2024

Rajesh Duggal son of Sh. Mohan Lal Duggal, resident of Gali No.4, Preet Nagar, Begu Road, Sirsa, District Sirsa.

                      ……Complainant.

                             Versus.

Star Health and Allied Insurance Company Ltd., Ground Floor, Rathore Tower, near Hotel Mehak, Dabwali Road, Sirsa, through its Manager/ Auth. Person.

…….Opposite Party.

            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. Lucky Duggal,  Advocate for the complainant.

                   Sh. Ravinder Monga, Advocate for opposite party.

ORDER

                   The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred as Op).

2.                In brief, the case of complainant is that on 28.07.2019 complainant purchased a health policy namely Family Health Optima Insurance Plan bearing No. P/211121/01/2020/002169 and paid premium amount of Rs.11889/- to the ops. That there was acute Bronchitis problem to the complainant, hence he visited to Medicity Hospital, Sirsa on 24.11.2019 and got checked himself from Dr. Gurdeep Shergill M.D. (Medicine) who admitted him in his hospital and started his treatment and he remained admitted there till 26.11.2019. The complainant spent Rs.11,119/- upon his treatment including hospital charges as well as medicines. That after discharge from hospital, complainant informed the op and requested for payment of bills and also deposited all the bills and other required documents to the op on its demand but op’s office has denied for the claim whereas disease of complainant is covered under said policy and as such op has caused deficiency in service and unnecessary harassment to the complainant. Hence, this complaint.

3.                On notice, op appeared and filed written version raising certain preliminary objections. It is submitted that complainant after accepting the policy and being fully aware of terms and conditions purchased the policy in question. The op issued the policy to complainant on the basis of information disclosed by him in the proposal form be believing in complainant and assuming that information disclosed by complainant to be true in proposal form without any pre medical screening. It was fresh policy taken by complainant first time from op. It is further submitted that in the fourth month of policy, the complainant lodged the claim before the company and submitted the documents for reimbursement towards the treatment of Acute Bronchitis. On scrutiny of claim documents, it is observed that following documents are necessary to process the claim

               1.     X-ray reports mentioned as hyperinflated lung field: A letter from treating doctor stating that exact duration of lung   disease in this patient and when it was first diagnosed.

2.     Consultation papers with treatment details and investigation reports pertaining to it.

             3.       Previous chest X-ray film, CT chest report, PFT and Echo report.

4.       It is further submitted that complainant was requested to furnish the required documents, so that claim could be proceeded further but same were/ are not provided despite repeated written requests dated 06.01.2020, 21.01.2020, 05.02.2020 and 20.02.2020 and the insured sent a letter stating that he was not suffering from IHD, which is irrelevant to the query. It is further submitted that in the absence of the required documents as per terms and condition no.3 of the policy, the claim has been repudiated vide letter dated 17.05.2020. As per factual position and circumstances, the complainant is guilty of withholding and suppressing the original documents, bills which amounts to sheer violation to the terms and conditions of the policy and complaint is liable to be dismissed only on this score. 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 under the terms of the policy shall be Rs.8837/-. With these averments, dismissal of complaint prayed for.

5.       The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 and mark A to mark N.

6.       On the other hand, op has tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex. RW1/A and documents Ex.R1 to Ex.R12.

7.       We have heard learned counsel for the parties and have gone through the case file.

8.       From the policy schedule attached with letter Ex.C1, it is evident that complainant had purchased health insurance policy from op for himself, wife Jyoti and minor children Hemant and Sonam and the sum insured under the policy was Rs.three lacs and the period of policy was effective from 28.07.2019 to 27.07.2020. From the treatment record of Medicity Hospital, Sirsa placed on file by complainant as mark A, it is evident that on 24.11.2019 during the period of policy in question complainant was diagnosed with Acute Bronchitis and from the history sheet of said hospital, it is evident that complainant complained of cough and breathlessness from last three days. All the treatment record for the above said period, bill and discharge summary have been placed on file by complainant. The op has not placed on file a single document from which it could be presumed that complainant was having the above said disease prior to 24.11.2019 and therefore, the demand of op about exact duration of lung disease and previous chest x-ray film, CT chest report, PFT and echo report etc. from complainant is not justified when complainant only for the first time on 24.11.2019 was diagnosed with the above said disease and as such demand of previous record is wrong and illegal. When the complainant only felt problem three days before 24.11.2019 how he can supply his previous reports. Since the  treatment record alongwith bills have been placed on file by complainant, therefore, it cannot be said that person who has to seek reimbursement of his claim has not supplied the required documents to the insurance company.  So we are of the considered view that op has wrongly and illegally repudiated the claim of complainant on baseless ground. The complainant for such a meager amount has to file the complaint.  The complainant was entitled to an amount of Rs.8837/- from op as per bill assessment sheet Ex.R12 and non payment of the same clearly amounts to deficiency in service on the part of op.

9.                In view of our above discussion, we allow the present complaint and direct the opposite party to pay claim amount of Rs.8837/- (in round figure Rs.8800/-) to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 24.07.2020 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the op to further pay a sum of Rs.5000/- 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: 23.05.2024.                                                        District Consumer Disputes

                                                                                       Redressal Commission, Sirsa.