Haryana

Karnal

CC/686/2021

Sunil Kumar - Complainant(s)

Versus

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

Jain Kumar

30 Aug 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.686 of 2021

                                                        Date of instt. 08.12.2021

                                                        Date of Decision: 30.08.2024

 

Sunil Kumar son of Om Parkash, resident of Village Badarpur, Tehsil Indri, District Karnal.

 

                                               …….Complainant.

                                              Versus

 

1.     Star Health and Allied Insurance Company Limited Regd and Corporate Office 1, New Tank Street, Valluvar Kotlum High Road, Nungambakkarm Chennai, 600034 through its authorized person.

2.     Star Health and Allied Insurance Company Limited SCF 137, Sector-13, Market, Karnal, through its authorized person.

 

                                                                      …..Opposite Parties.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

 

Before   Shri Jaswant Singh……President.     

      Smt.Sarvjeet Kaur………Member

          

 Argued by: Shri Jain Kumar, counsel for complainant.

    Shri Mohit Goyal, counsel for 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 complainant purchased a Corona Rakshak Policy and got insured himself through the OPs in Health Insurance vide policy No.P/211114/01/2021/012498 dated 17.02.2021 valid from 18.02.2021 to 02.06.2021. As per terms and conditions of the policy, the OPs are liable to pay Rs.2,50,000/- to the complainant beside the expenses of treatment of Corona disease. On 20.03.2021, the complainant fall ill due to corona disease and got admitted in Amrit Dhara Hospital, Karnal, where he remained admitted from 20.03.2021 to 25.03.2021 there and he was treated properly and same was intimated to the OPs at that time, officials of OP gave assurance that the OPs will pay Rs.2,50,000/- to the complainant but till today the OPs have not paid the same to the complainant. Thereafter, the complainant submitted all the bills and other documents to the OPs vide claim No.CLR/2022/211114/2415891. Complainant visited the office of OPs time and again but the OPs postponing the matter on one pretext or the other and now on 19.05.2021, the OPs rejected the claim of the complainant on false and flimsy grounds. In this way, there is deficiency in service and unfair trade practice on the part of the OPs. Hence the present complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections regarding maintainability. It is also submitted that the insurance policy is purely a contract like any other commercial contracts under which insurer takes coverage of risk subject to policy terms and conditions against the premium paid by the insured for the time prescribed by the policy schedule. Thus, there is no scope for any other commitment/obligation beyond the insurance policy terms and conditions and no other can change or add any condition in that contract, both parties are bound with the conditions of insurance contract. On merits, it has been pleaded that vide claim No.CIR/2022/211114/2415891 the complainant has lodged the claim but the OPs were unable to settle the claim of the complainant under above policy, therefore, the same was repudiated. The decision has been taken as per the terms and conditions of the policy and based on the claim details/documents submitted.  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 policy Ex.C1, copy of COVID 19 test report Ex.C2, copy of repudiation letter Ex.C3, copy of legal notice Ex.C4, copy of postal receipts Ex.C5 and Ex.C6, Hospital records Ex.C7 and closed the evidence on 04.05.2023 by suffering separate statement.

5.             On the other hand, learned counsel for OPs has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager, Star Health and Allied Insurance as Ex.OPW1/A, copy of policy Ex.OP1, copy of terms and conditions Ex.OP2, copy of proposal form Ex.OP3, copy of claim form Ex.OP4, copy of Indoor Progress Report Ex.OP5, copy of discharge summary Ex.OP6, copy of CT Throax report Ex.OP7, copy of final bill Ex.OP8, copy of repudiation letter Ex.OP9 and closed the evidence on 30.05.2024 by suffering separate statement.

6.             We have heard the learned counsel for complainant and learned counsel for the OPs and have gone through the record available on the file carefully.

7.             Learned counsel for complainant while reiterating the contents of complaint, has vehemently argued that the complainant purchased a Corona Rakshak Policy and as per the said policy, the OPs are liable to pay Rs.2,50,000/- to the complainant beside the expenses of treatment of Corona disease. On 20.03.2021, the complainant fall ill due to corona disease and got admitted in Amrit Dhara Hospital, Karnal, and after discharge, the complainant lodged his claim and submitted all the bills and other documents to the OPs but the OPs repudiated the claim of complainant on false and flimsy 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 the claim lodged by the complainant was rightly repudiated by the OPs on the basis of terms and conditions of the policy, thus, there is no deficiency in service and unfair trade practice on the part of OPs and lastly prayed for dismissal of complaint.

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

10.           Admittedly, complainant purchased a Corona Rakshak Policy from the OPs. It is also admitted that during the subsistence of the insurance policy complainant was hospitalized in Amritdhara Hospital due to covid-19. It is also admitted that the sum insured under the policy is Rs.2,50,000/-.

11.           The claim of the complainant has been repudiated by the OPs vide claim repudiation letter Ex.C3/OP9 dated 19.05.2021, on the following ground which is reproduced as under:-

“We have processed the claim records relating to the above insured patient seeking lump sum benefit towards treatment of acute febrile illness, chest infection, COVID 19 positive.

It is observed from the indoor case records of the above hospital that the insured patient’s oxygen saturation is around or below 90% but there is no evidence of oxygen supplementation given; the investigation reports does not correlate with the clinical findings in the indoor case records; the indoor case records are written at single stretch with single handwriting. Thus, there are discrepancies in the records which amounts to misrepresentation of facts.

As per terms and conditions of the policy issued to you, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim.

We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.”

 

12.           The claim of the complainant has been denied by the OPs on the above mentioned grounds. The onus to prove its version was relied upon the OPs but OPs have miserably failed to prove the same by leading any cogent and convincing evidence. Rather as per treatment record Ex.C7 and discharge summary, complainant was hospitalized on 20.03.2021 and discharged on 25.03.2021 for the treatment of Covid-19 positive, high fever, cough, dyspnoea and G.Weakness. Further, if there are any discrepancies in the record on the hands of the treating doctor for that complainant cannot be blamed. OPs have alleged that there is no evidence of Oxygen Supplementation given to the complainant. If the investigation report does not correlate with the clinical findings in the indoor case record for that it is the Doctor who decide where Oxygen Supplementation was required to be given to the patient. Thus, it is well proved on record complainant had suffered from Covid-19. Hence, the repudiation of the claim of complainant is unjustified and not tenable in the eyes of law. Moreover, nowadays, it has become the routine practice of the insurance companies to reject the genuine claim on minor technicality.  Hence, the repudiation of the claim of complainant is unjustified, arbitrary and not tenable in the eyes of law.

13.          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”.

 

14.           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 amounts to deficiency in service and unfair trade practice while repudiating the claim of the complainant, which is otherwise proved genuine.

15.           As per Corona Rakshak Policy Ex.C1/Ex.OP1 dated 18.02.2021, the insured amount is of Rs.2,50,000/-. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

16.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.2,50,000/- (Rs.two lakhs fifty thousand) as sum insured 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.20,000/- to the complainant on account of mental agony and harassment and Rs.5500/- 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: 30.08.2024

                                                          President,

                                             District Consumer Disputes

                                             Redressal Commission, Karnal.

 

(Sarvjeet Kaur)

                             Member