BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 93 of 2021
Date of Institution : 19.04.2021
Date of Decision : 08.05.2024
Rohtash Kumar aged about 61 years son of Sh. Jarnail Singh, resident of village Nathore, Tehsil Rania, District Sirsa.
……Complainant.
Versus.
Star Health and Allied Insurance Company Limited (IRDAI REGISTRATION NO. 129) Branch Office at Ground Floor, Opposite Shakti Motors, near IDBI Bank, Sirsa 125055 now the branch office at near R.C. Regency (near Tulla Ram Dharamshala), Sirsa through its Manager/ Office Incharge/ authorized signatory.
…….Opposite Party.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
Present: Sh. S.L. Sidhu, Advocate for the complainant.
Sh. Ravinder Monga, Advocate for opposite parties.
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 complainant had purchased one health insurance policy bearing No. P/211121/01/2019/ 006439 from op for the basic floater sum insured amount of Rs.5,00,000/- which was valid/ effective from 19.03.2019 to 18.03.2020. On 21.06.2019 complainant visited hospital of Dr. Bhanwar’s Gastro & Liver Hospital, Sirsa for the treatment of his liver problem where his treatment was started. Some necessary medical tests were also conducted there and doctor diagnosed the problem of complainant as Peptic Ulcer disease with Gasteric outlet obstruction with pancreatic Mass (Pancreatico- Duodenalngroove) but the complainant could not recover from the treatment of that hospital and due to critical problem, Dr. Bhanwar Lal referred him to Higher Centre while discharging him from his hospital on 22.06.2019. Thereafter, complainant got his further treatment from Adesh Institute of Medical Sciencies and Research (AIMSR), Bathinda for the said problem. He was got admitted in this hospital on 22.06.2019 and remained admitted there for several days where his treatment was done and several tests were also got conducted there. The complainant was operated on 24.06.2019 and was discharged on 07.07.2019. That during whole of the treatment including surgical operation, huge amount of Rs.3,76,722/- was spent by him which includes fee of the doctors, testing fee of the labs, medicines etc. and besides this amount, the complainant had spent Rs.48,000/- as room rent, Rs.10270/- lab charges and Rs.90,635/- as fee of the Radiologist and in this way an amount of Rs.5,25,627/- was spent by complainant on his treatment and complainant is legally entitled to reimbursement of hospitalization expenses for his treatment. It is further averred that complainant lodged his claim for the said amount with the op and submitted all the bills and medical reports etc. but the officials of op after receipt of papers from complainant vide letter dated 22.02.2021 asked the complainant that his papers have been sent to the Head Office and after approval of the claim, the amount will be paid to him. That but after several days wait, the claim of complainant has been repudiated vide letter dated 30.09.2019 on the ground that the original documents have not been produced by complainant whereas in fact the original record relating to his treatment is with the hospital authorities but they have refused to give the original record to the complainant. In this way, the claim of complainant has been repudiated wrongly and illegally and without any justification by the op. It is further averred that complainant visited the op from time to time and met the official concerned but they did not listen him and asserted that his claim has been rightly repudiated. The complainant also got issued a legal notice dated 28.12.2020 to the op but to no effect and op has refused to admit his claim about a week ago despite several requests and demand. That these acts on the part of op amounts to deficiency in service and unfair trade practice due to which complainant has suffered unnecessary harassment. Hence, this complaint.
3. On notice, op appeared and filed written statement taking certain preliminary objections. It is submitted that insurance under this policy is subject to conditions, clauses, warranty, exclusion clause etc. The complainant after accepting the policy and being fully aware of such terms and conditions and executed the claim form with free will and consent. The complainant lodged the claim before the company and submitted the documents for reimbursement towards the treatment of Duodenal growth, gastric outlet obstruction, massive upper GI bleed and Anemia. After carefully analyzing the documents, it is found that all the medical records submitted by the insured are duplicate/ Xerox/ photostat copies. Hence, the insured was asked to furnish the original treatment record and bills. The insured despite repeated requests failed to furnish the original treatment, bills etc. as per clause 3. It is further submitted that complainant has furnished the original copy of investigation report alone, however, the original discharge summary, final bill and payment receipt is mandatory document to prove that complainant has paid the hospital bill and has not got reimbursement from any other insurance company. However, the complainant failed to produce the original documents despite repeated requests and ultimately as per terms and conditions of the policy, the claim has been repudiated vide letter dated 01.10.2019 duly informed to the complainant. The complainant while submitting his claim form before the insurance company claimed a total amount of Rs.1,83,842/- and he is now travelling beyond the factual position and by mentioning the exaggerated, excessive amount of treatment shown to be spent which is specifically denied. It is further submitted that 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. As per terms and conditions of the policy, the complainant/ insured is entitled to reimburse the payable amount and not the other bills permissible under the policy. It is further submitted that complainant is alleging about the original record not being supplied to him is a colourful story. Lastly it is submitted that if it is found that op is liable to pay any amount to the complainant, the maximum quantum of liability under the terms of the policy shall be of Rs.1,46,232/-. With these averments, dismissal of complaint prayed for.
4. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C73.
5. On the other hand, op has tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex.R1 and documents Annexures R1 to R10, CD Annexure R11 and bill assessment sheet Annexure R12.
6. We have heard learned counsel for the parties and have gone through the case file.
7. From the policy schedule Ex.C2, it is evident that complainant had purchased the health insurance policy from op for the period 19.03.2019 to 18.03.2020 for sum insured amount of Rs.5,00,000/- for himself and for his wife Smt. Santosh. It is also proved on record that during the period of policy in question, the complainant was treated in above said two hospitals from 21.06.2019 to 07.07.2019 and he has claimed to have spent an amount of Rs.5,25,627/- on his treatment of Duodenal growth, gastric outlet obstruction, massive upper GI bleed and Anemia. However, from the claim form placed on file by op as Annexure R4, it is evident that complainant lodged his claim of the amount of Rs.1,80,188/- to the op. The op vide bill assessment sheet Annexure 12 although approved the claim of Rs.146,232/- but did not pay the said amount to the complainant on the ground of non submission of original treatment record and bills and in this regard the complainant claims that hospital authorities refused to give original record to the complainant. The complainant in this regard also moved an application to the op to the effect that he has submitted all the original documents regarding claim and he has no more original documents with him. It appears that all the original documents available with the complainant have already been supplied to the op but still op is persisting its demand for supply of original documents but complainant is helpless in this regard and as such demand of op in this regard is not justified because if any documents have not been supplied to it in original then op can verify the record from photostat copies from the hospital authorities. But however, op without any justifiable reason has repudiated the claim of complainant and has not paid approved amount to the complainant and has caused unnecessary harassment and deficiency in service towards complainant who was already under mental trauma due to above said disease. The treatment record as well as bill produced on record as well as supplied to op are genuine record of the hospitals and it is not alleged by op that same is fabricated and forged and genuineness of the same could have been verified by op from hospital authorities well in time, however op has failed to do so and as such op has wrongly and illegally repudiated the claim of complainant on lame excuse. The op vide bill assessment sheet Annexure R12 assessed the claim amount of Rs.1,46,232/- after necessary deduction and thereby approved the said amount of Rs.1,46,232/- but however, op has not paid this amount also in time to the complainant and as such complainant is entitled to the amount of Rs.1,46,232/- alongwith interest.
8. In view of our above discussion, we allow the present complaint and direct the opposite party to make payment of claim amount of Rs.1,46,232/- to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 19.04.2021 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.10,000/- as compensation for harassment and Rs.5000/- as 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 President,
Dated: 08.05.2024. District Consumer Disputes
Redressal Commission, Sirsa.
