Haryana

Karnal

CC/700/2021

Sonia Singh - Complainant(s)

Versus

Star Health And Allied Insurance Company - Opp.Party(s)

Sanjay Narang

13 Jul 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No. 700 of 2021

                                                        Date of instt.15.12.2021

                                                        Date of Decision:13.07.2023

 

Sonia Singh aged about 44 years widow of late Shri Karan Singh, resident of House no.8, Bank Colony, Mall Road, Karnal. Aadhar card no.4601 3312 0773.

 

                                               …….Complainant.

                                              Versus

 

1.     Star Health and Allied Insurance Company Ltd. Branch Karnal, c/o SCO no.104, 1^st floor, Mugal Canal, Karnal, District Karnal.

 

2.     Star Health and allied Insurance Co. Ltd., Head office no.1, New Tank Street, Valluver, Kottam High Road, Nungambakkan, Chennai.

                                                                      …..Opposite Parties.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary….Member

 

Argued by:  Shri Vikram Singh, counsel for the complainant.

                    Shri Naveen Kheterpal, counsel for the OPs.

 

                    (Jaswant Singh, president)

ORDER:  

 

                The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019, against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that the husband of complainant namely Shri Karan Singh & Kanwar Karan son of Kanwar Sultan Singh had purchased a Family Health Optima Insurance Plan from the Branch Office of OP no.2 in Yamuna Nagar, through insurance agent namely Mr. Ram Kumar Singh on 14.08.2020 bearing policy no.P/211120/01/2021/004713, valid from 14.08.2020 to 13.08.2021 and the basis sum insured is of Rs.5,00,000/-. The husband of complainant paid premium of Rs.20,077/- to the OPs. The OPs assured the complainant and her husband that their family will be provided insurance cover against expenses incurred upon medical treatment, medication, hospitalization etc. for the whole family i.e. the complainant, her husband and her two children namely Arnav Singh and Ardhya Singh. Unfortunately, the husband of complainant had fallen ill and was admitted in Fortis Memorial Research Institute, Gurugram on 21.09.2020 as he was suffering from high fever and shortness of breath etc. He remained admitted in the said hospital till 30.09.2020. The complainant incurred expenses of about Rs.5 lacs on treatment of Karan Singh and thus, she immediately lodged claim with the OPs qua re-imbursement of the treatment and hospitalization expenses bearing claim no.CIR/ 2021/21120/ 2032929. After some days, the husband of complainant again started suffering from high fever and he was admitted in Medanta Medicity Hospital, Gurugram multiple times and on 26.12.2020, the husband of complainant was diagnosed with Rheumatic Heart Disease and was advised to undergo surgery for replacement of Aortic valve of heart by the doctor. As per the advice of the doctor, the husband of complainant underwent surgery for replacement of valve of heart on 07.01.2021. Unfortunately, the husband of complainant could not recover and ultimately he expired on 11.01.2021 due to multiple organ failure, while he was admitted in Medanta Medicity, Gurguram. The complainant spent Rs.30 lacs on the treatment of her husband. The intimation was sent to the OPs regarding the death of the husband of the complainant. In the meantime, the agent of the OPs demanded medical treatment record as well as discharge summary, investigation report, main hospital bills etc. of Karan Singh. The complainant duly provided all the original documents to the agents of the OPs. The agent of the OPs always assured the complainant that she will receive the insured sum as per the insurance policy provided by the OPs. But lateron, complainant came to know that her claim has been repudiated by the OPs on flimsy ground. The OPs are legally bound to reimburse the amount spent on treatment of Karan Singh, as per terms and conditions of the policy. The complainant requested the OPs several times to reimburse the medical expenses, hospital treatment, medication etc. of Karan Singh alongwith upto date interest from the date of payment of bills till its realization but OPs did not pay any heed to the request of complainant and lingered the matter on one pretext or the other. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version, raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that the insured Karan Singh availed the Star Comprehensive Policy (individual) covering Karan Singh-self and Sonia Singh-spouse, Arnav Singh and Ardhya Singh-dependant children, vide policy no.P/211120/01/2021/004713 for the period from 14.08.2020 to 13.08.2021 for the first time for the sum insured of Rs.5,00,000/-. The OPs have issued the policy to the complainant on the basis of information disclosed by complainant in the proposal form and assuming that the information disclosed by complainant to be true in proposal form without any Pre Medical Screening. It was fresh policy taken by the complainant first time from the OPs. It is further pleaded that complainant submitted claim documents for reimbursement of medical expenses of Rs.2,98,273/- towards the treatment of Infective Endocarditis with CHF for the admission dated 21.09.2020 (37^th day of the policy). On scrutiny of claim documents, it is noted that:-

        As per the discharge summary, the insured was diagnosed with infective endocarditis with CHF, the insured patient got admitted with fever and breathlessness. Chest x-ray done which showed prominent bronchovascular marking seen and right CP angle blunted 2d Echo revealed LVEF=42%. Cardiology consultation as taken and advice followed repeat 2D ECHO was done which showed multiple large vegetarian seen on aortic valve cups with LVEF=55%.

Thus the opponent has called for the following documents, which are necessary to process the claim, vide letters dated 29.01.2021, 13.02.2021, 28.02.2021 and 15.03.2021 to furnish:

1.     Letter from treating doctor stating the exact duration of the presenting complaints and any past history of cardiac illness.

2.     First consultation papers and complete treatment records from the onset of symptom.

3.     Present Echo and ECG report.

4.     Complete set of indoor case papers.

5.     Past investigation reports like ECG and Echo.

In reply, the insured has only submitted the declaration letter, with treating doctor certificate and indoor case papers and has not furnished the remaining documents. As per declaration letter, the insured has already submitted first consultation report and informed that she do not have past investigation report like ECG and ECHO and we cannot provide present ECHO and ECG since the patient was expired. However, as per discharge summary, the insured underwent ECHO and further, it is not possible to rule out CHF (Congestive Heart Failure) without the investigations such as ECG and ECHO. Hence, in order to process the claim, OPs had requested insured to furnish the ECG, ECHO reports, duration of cardiac illness and the past treatment records. OPs have not furnished the required documents and details. In the absence of above documents/details, company is not able to further process insured claim. It is further pleaded that as per complaint, the insured was admitted in Medanta Hospital Gurugram on 26.12.2020 and diagnosed for Rheumatic Hearth Disease and advises Valve Replacement surgery of heart and underwent surgery on 07.01.2021 but patient could not recover and expired on 11.01.2021 due to multiple organ failure in Medanta Hospital. The OPs have neither received the intimation nor received the claims documents for the hospitalization at Medanta Hospital for the alleged admission dated 11.01.2021. It is further pleaded that as per the ICP dated 22.09.2020, the insured took 2d echo on 15.09.2020 (31^st day from date of inception of policy), shows mild non calcified aortic stenosis, IVF 45%. From all the findings it is noted that the patient Kanwar Karan Singh underwent ECHO, however the complainant was failed to submit the same. It is further pleaded that documents called for by the opponent are necessary to rule out the waiting period/non-disclosure/other exclusions. However, complainant has not submitted the same. As per condition no.3, the insured person has to submit all the required documents and details called for by company. Hence, the claim was repudiated, vide letter dated 22.11.2020. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of proposal form Ex.C1 to Ex.C3, copy of insurance policy Ex.C4, copy of letter by OP to insured Karan Singh Ex.C5, copy of Family Health Insurance Plan Ex.C6, copy of nominee details for the proposer Ex.C7, copy of details of documents for issuing the policy Ex.C8, copy of premium receipt Ex.C9, copy of summary of important documents Ex.C10, copy of detail of disease Ex.C11, copy of impatient summary running bill Ex.C12, copy of discharge summary Ex.C13, copy of admission and discharge record of Medanta Hospital Ex.C14, copy of admission and discharge record of Fortis hospital Ex.C15, copy of certificate of Dr.Parveen Gupta Ex.C16, copy of admission and discharge summary of Fortis Memorial Hospital Ex.C17, copy of discharge summary of Fortis Memorial Hospital, Gurugram, Department of Neurology Ex.C18, C19 to Ex.C24, copy of progress note Ex.C25 to Ex.C52, copy of vital signs flow sheet Ex.C53 and Ex.C54, copy of slip of Department of Neurology of Fortis Memorial Hospital, Gurugram Ex.C55, copy of outpatient summary Ex.C56, copy of impatient running bill Ex.C57, copy of death certificate Ex.C58 and closed the evidence on 17.02.2023 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.RW1/A, copy of proposal form Ex.R1, copy of insurance policy Ex.R2, copy of terms and conditions of the insurance policy Ex.R3, copy of claim form Ex.R4, copy of discharge summary Ex.R5, copy of indoor paper Ex.R6, copy of declaration letter Ex.R7, copy of final bill Ex.R8, copy of letters dated 29.01.2021, 13.02.2021, 28.02.2021, 15.03.2021, 10.05.2021 Ex.R9 to Ex.R13, copy of bill assessment sheet Ex.R14, copy of reminders dated 23.10.2020, 07.11.2020 Ex.R15 and Ex.R16,  copy of rejection letter dated 22.11.2020 Ex.R17, copy of rejection letter dated 30.01.2021 Ex.R18 and closed the evidence on 25.04.2023 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that the husband of the complainant purchased a Family Health Optima Insurance Plan from OPs on 14.08.2020 by paying premium amount of Rs.20,077/-. The the basis sum insured is of Rs.5,00,000/-. The husband of complainant had fallen ill and was admitted in Fortis Memorial Research Institute, Gurugram on 21.09.2020 as he was suffering from high fever and shortness of breath etc. He remained admitted in the said hospital till 30.09.2020 and complainant spent Rs. five lakhs on his treatment. The husband of complainant again started suffering from high fever and got admitted in Medanta Medicity Hospital, Gurugram and underwent surgery for replacement of valve of heart on 07.01.2021 but he could not survive and expired on 11.01.2021 due to multiple organ failure. The complainant spent Rs.30 lacs on the treatment of her husband. Complainant lodged the claim with the OPs and requested for reimbursement of the medical expenses, hospital treatment, medication etc. but OPs did not pay the same and rejected the claim of the complainant on the false and frivolous grounds and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that LA availed Family Health Optima Insurance Plan and the policy was issued on the basis of information disclosed by LA in the proposal form. Complainant submitted claim documents for reimbursement of medical expenses of Rs.2,98,273/- only towards the treatment of her husband. On scrutiny of the claim documents, it was observed that the insured patient is diagnosed with infective endocarditis with CHF, the insured patient got admitted with fever and breathlessness. OPs made requests to the complainant through various letters to furnish the previous hospitalization documents but complainant did not supply the same and due to non-supply of the documents, the claim of the complainant was rightly repudiated by the OPs, vide letter dated 22.11.2020 and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, the husband of complainant had availed Family Health Optima Insurance Plan from the OPs. It is also admitted that during the subsistence of the insurance policy, the husband of complainant has taken a treatment from Fortis Memorial Research Institute, Gurugram. It is also admitted that during the substance of the insurance policy, the insured was expired.

11.           The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.R17 Dated 22.11.2020 on the ground, which is reproduced as under:-

“We refer to intimation of claim dated 04.11.2020. We have advised you vide letters dated 23.10.2020 and 07.11.2020 to send to us the duly completed claim form alongwith discharge summary, investigation reports, hospital bills, payment receipts, prescriptions, medical bills etc.

Even after reminders, you have not sent us the above documents. We therefore, presume that you are not interested in preferring the claim and therefore the same is rejected”.

 

12.           In letters Ex.R15 and Ex.R16 dated 23.10.2020 and 07.11.2020, OPs have sought the following documents, which is reproduced as under:-

a.     Discharge summary.

b.     Investigation reports with x-ray films, scan reports etc.

c.      Main Hospital bills, payment receipts with break-up.

d.     Prescriptions, medical bills, investigation bills, receipts etc.

e.     Earlier treatments records, if any.

f.      If the claim is admitted, admission amount will be transferred to your account, if you so desire. Kindly, therefore, send us a cancelled cheque also alongwith the foregoing documents.

g.     Mandatory Documents: As per the provisions of the Anti-Money, laundering Act (AML), you are required to submit a copy of your PAN which is mandatory in case your claim is of value one lakh rupees and above.

                For non submission of the abovesaid documents, OPs have rejected the claim of the complainant.

13.           OPs had asked the complainant to complete the abovesaid formalities. The complainant has submitted all the requisite documents which were in her possession. In the written version, the OPs has admitted that the insured has submitted the declaration letter and has not furnished the other documents. The other documents are i) first consultation paper, ii) ECHO and ECG report, iii) complete set of indoor case papers and iv) past investigation reports. These documents except ECHO and ECG should have been in the possession of the complainant, if there were any past history or the husband of the complainant ever taken treatment being OPD patient, then how can the complainant submit these documents to the OPs. Furthermore, the Echo/ECG which the OPs are demanding is to be in the possession of the concerned/treating doctors of the husband of the complainant as the husband of the complainant has died during the treatment. If the said doctors are very much essentials for the OPs, then they should have collect the same from the concerned/treating documents as all other documents are already in their possession. As such, the other documents which the OPs are demanding are irrelevant and there is no legal hitch to decide the claim without the submission of the other documents, when the complainant had already submitted all the documents which were in her possession for settlement of the claim. Hence, the demand of abovementioned documents is unnecessary and irrelevant and just to harass the complainant and not to release the claim amount of the genuine claim of the complainant. Moreover, it is also unbelievable that an insured whose personal interest is involved for such amount why he/she will not supply the documents to the insurance company for getting his/her claim amount and will indulge himself/herself in an unwanted litigation. Hence, in view of the above, we found no substance in this contention of the OP.

14.           The OPs have denied that the complainant has spent Rs.4,25,286/- on the ground that the complainant has only submitted the claim for an amount of Rs.2,98,273/- only. The complainant has placed on file the bills for an amount of rs.2,98,273/- and Rs.1,27,013/-, then how can it possible that the complainant has not submitted the claim of Rs.1,27,013/- to the OPs. Since, the OPs can deny the genuine claim of the complainant on the basis of irrelevant documents, then the possibility of withheld the claim documents for an amount of Rs.1,27,013/- by the OPs, cannot be ruled out.

15.           Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

 16.          Keeping in view, the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, we are of the considered view that act of the OPs while repudiating the claim of the complainant amounts to deficiency and unfair trade practice.

17.           The complainant claimed Rs.5,00,000/- but  she has placed on file impatient summary running bills Ex.C12 and Ex.C57 amounting to Rs.4,25,286/- (i.e. Rs. 2,98,273/- and Rs.1,27,013/-). Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

18.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.4,25,286/- (Rs.Four lakhs twenty five thousand two hundred eighty six only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:13.07.2023                                                              

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)                (Dr. Rekha Chaudhary)

                        Member                             Member