Order by:
Smt.Priti Malhotra, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that complainant obtained health insurance policy from Opposite Party bearing master policy no.P/900000/01/2022/000039 for the period from 08.03.2022 to 07.03.2023 for a sum insured of Rs.5 lakhs by paying premium amount of Rs.19,587/-. In the second week of April, 2022 complainant suffered some problem/pain in his back and the complainant got himself checked from Dr.Sahil Batra, Guardian Hospital, Jalandhar, who advised the complainant for spine surgery. On 06.05.2022 complainant got admitted in Guardian Hospital, Jalandhar and on 07.05.2022 spine surgery of the complainant was done and on 09.05.2022 complainant was discharged from the said hospital. The complainant spent approximately Rs.1,25,000/- on his treatment. Thereafter, the complainant lodged the claim with Opposite party, but they repudiated the claim of the complainant on the ground “For not providing past consultation papers and investigation reports.” The repudiation of the claim of the complainant on the above said ground is illegal, against law and even is against the rules of natural justice. Hence this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite party may be directed to pay an amount of Rs.3 lakhs i.e. Rs.1,25,000/- as expenses incurred on medical treatment and Rs.1,75,000/- as damages and compensation along with interest @ 12% p.a.
b) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite party appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complaint being pre-mature and false is not maintainable; the complainant has not come with clean hands; he has not disclosed the entire true facts; the complainant has also suppressed the material facts from this Commission as well as from the answering Opposite Party. Further averred that insured availed Star Group Health Insurnace Policy- Gold (For Bank Customers) covering Sudesh Majithia self and Kamla Sehgal spouse (PED- All treatment related to varicose veins & their complications/All Arthritis and its Complications) for a sum insured Rs.5,00,000/- vide policy no. P/21122/01/2022/009850 for the period from 08.03.2022 to 07.03.2023. It is clearly stated in the policy schedule that “The insurance under this policy is subject to conditions, clauses, warranties, exclusions etc.” Further averred that the policy is contractual in nature and the claim 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. The insured was hospitalized on 06.05.2022 at Guardian Multi Specialty Hospital, Jalandhar for the treatment of L5 S1 Spondylosis and discharged on 09.05.2022. The insured complainant raised a pre-authorization to avail cashless facility for the treatment of LEG pain at Guardian Multi Specialty Hospital, Jalandhar on 06.05.2022. On perusal of the claim documents, the pre-authorization request was denied stating that the clarification/information provided by the insured is not sufficient for admissibility of the claim. Hence, requested the insured to come for reimbursement of medical expenses vide copy of letter dated 08.05.2022. Subsequently, the insured submitted medical documents in support of his claim for reimbursement of medical expenses. On scrutiny of claim documents it reveals that “the insured patient is suffering from pain in left leg since 2 months and there is no prior history of any back or leg pain.” Therefore, query was raised vide letter dated 28.05.2022 to submit the following documents:
Exact duration of the present ailments, all past consultation papers and investigation reports to process.
Subsequently reminder letter was sent on 12.06.2022 to submit the above mentioned documents and the same was not submitted by the insured. As per specific condition no.13 of the policy, the insured person shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim is based and shall also given the company such additional information and assistance as the company may require in dealing with the claim. Hence, the claim was repudiated and communicated to the insured vide letter dated 21.06.2022. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. Complainant also filed replication to the written reply of Opposite party, vide which, all the objections raised by the Opposite party in the written reply are denied.
4. In order to prove his case, complainants tendered in evidence affidavit of complainant no.1 Ex.C1 alongwith copies of documents Ex.C2 to Ex.C13.
5. To rebut the evidence of the complainant, Opposite party tendered in evidence affidavit of Sh.P.C. Tripathy, Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1/A alongwith copies of documents Ex.OP1/1 to Ex.OP1/20.
6. We have heard the counsel for the parties and also gone through the documents placed on record.
7. The case of the complainant is that he obtained health insurance policy bearing no.P/900000/01/2022/000039 from Opposite Party for the period from 08.03.2022 to 07.03.2023 for a sum insured of Rs.5 lakhs. In the second week of April, 2022 complainant suffered some problem/pain in his back and the complainant got himself checked from Dr.Sahil Batra, Guardian Hospital, Jalandhar, who advised the complainant for spine surgery. On 06.05.2022 complainant got admitted in Guardian Hospital, Jalandhar and on 07.05.2022 spine surgery of the complainant was done and he was discharged from the hospital on 09.05.2022. During the hospitalization, the complainant spent approximately Rs.1,25,000/- on his treatment. Thereafter, the complainant lodged the claim with Opposite party, but they repudiated the claim of the complainant.
8. Ld. Counsel for the Opposite Party repelled the aforesaid contention of ld. Counsel for the complainant on the ground that complainant obtained ‘Star Group Health Insurnace Policy- Gold (For Bank Customers), covering himself and Kamla Sehgal spouse for a sum insured of Rs.5,00,000/- vide policy no. P/21122/01/2022/009850 for the period from 08.03.2022 to 07.03.2023. Further contended that complainant was hospitalized on 06.05.2022 at Guardian Multi Specialty Hospital, Jalandhar for the treatment of L5 S1 Spondylosis and discharged on 09.05.2022. The insured complainant raised a pre-authorization to avail cashless facility for the treatment of LEG pain at Guardian Multi Specialty Hospital, Jalandhar on 06.05.2022 and his pre-authorization request was denied as the clarification/information provided by the insured was not sufficient for admissibility of the claim. Hence, it requested the complainant to come at the time of reimbursement of medical expenses vide letter dated 08.05.2022. Subsequently, the insured submitted medical documents in support of his claim for reimbursement of medical expenses. On scrutiny of claim documents it reveals that “the insured patient is suffering from pain in left leg since 2 months and there is no prior history of any back or leg pain.” Therefore, query was raised vide letter dated 28.05.2022 to submit the document relating to “Exact duration of the present ailments, all past consultation papers and investigation reports.” Thereafter, reminder letter was sent on 12.06.2022, but the complainant failed to submit the documents demanded by it and as per specific condition no.13 of the policy, the claim was repudiated vide letter dated 21.06.2022.
9. After due consideration to the admitted and proved facts on record, we have also considered the rival contentions of ld. Counsel for both the parties and have gone through the record. Perusal of the contention of ld. Counsel for the Opposite Party shows that they repudiated the claim of the complainant due to non submission of “exact duration of the present ailment, all past consultation papers and investigation reports”. Now, it is to be determined that whether the demand of documents raised by the Opposite party is genuine or not. We have perused the certificate issued by treating doctor of Guardian Hospital, Jalandhar, placed on record by Opposite Party Ex.OP1/6 in which it is clearly mentioned that “patient suffering from pain in left leg since 2 months no prior history of any back or leg pain’. We are of the concerted view that the certificate so issued by the treating doctor is sufficient enough to prove that complainant has no prior history of any back or leg pain. Moreover, perusal of the record reveals that the complainant has been obtaining the policy from the Opposite Party since the year, 2019 without any break, meaning thereby that the policy in question is in its 3rd year of continuation, so it cannot be said that complainant is suffering from pre-existing disease. So, the demand of Opposite Party for submission of documents i.e. all past consultation papers and investigation reports appears to be baseless and in-genuine. Not only that but also the repudiation based upon the said fact of non submission of documents is absurd and not sustainable in the eyes of law.
In view of the above, it is hereby concluded that the repudiation of genuine claim of the complainant is bad and by rejecting the genuine claim of the complainant , the Opposite Party rendered deficient services, thus is liable not only to pay the medical expenses incurred under the policy but also liable to pay compensatory cost besides litigation expenses.
10. Now come to the quantum of amount to be awarded to the complainant. The complainant has placed on record copy of Final Bill Ex.C9, beside this he placed on record copies of bills Ex.C10 amounting to Rs.21,152/-, Rs.542 and Rs.100/- respectively, Ex.C11 amounting to Rs.3600/-, Rs.2000/-, Rs.400/-, Rs.200/- and Rs.400/- respectively totaling Rs.1,35,044/-. Hence, we allow the same.
11. From the above discussion, we partly allow the complaint of the complainant and direct the Opposite Parties to pay an amount of Rs.1,35,044/- (Rupees One Lakh Thirty Five Thousand Forty Four only) to the complainant for the expenses incurred by him on his treatment. Opposite Party is further directed to pay compository costs of Rs.10,000/-(Rupees Ten Thousand only) as compensation and litigation expenses to the complainant. The compliance of this order be made by the Opposite Parties within 30 days from the date of receipt of copy of this order, failing which, they are further burdened with additional amount of Rs.10,000/-(Rupees Ten Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission
