Haryana

Fatehabad

CC/243/2021

Dilip Singh Tanwar - Complainant(s)

Versus

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

Manjeet Kajla

02 Jan 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION FATEHABAD.

                                         Sh.Rajbir Singh, President.                                                      Dr.K.S.Nirania and Smt.Harisha Mehta, Members

 

                                                                    C.C.No.243 of 2021.                                                                                            Date of Instt.: 24.09.2021.                                                                                   Date of Decision: 02.01.2024.

Dalip Singh Tanwar son of Shishpal Tanwar resident of House No.129-A, Ward No.20, 340-B, Civil Hospital, Model Town c/o Gagan Memorial Hospital, Hisar.

                                                                             ..Complainant

                              Versus

1.Star Health & Allied Insurance Company Limited, 1^st Floor Himalya House, 23, Kasturba Gandhi Marg, New Delhi-110017 through its Branch Manager.

2.Star Health and Allied Insurance Company Limited, Branch Office 1^st & 2^nd floor, Satya Sales Samsung Plaza Showroom Building, adjoining RC Regency Hotel, Hisar Road, Sirsa through its Branch Manager.

                                                                   ..Opposite Parties.

Complaint U/S 35 of the Consumer Protection Act, 2019            

Present:                 Sh.Manjeet Kajla, Advocate for complainant.                                                        Sh.Sachdev Bishnoi, Advocate for Ops.                                                                                           

ORDER

SH.RAJBIR SINGH, PRESIDENT

1.                                 Brief facts of the present complaint are that the complainant had obtained an insurance policy under the name Family Health Optima Insurance Plan  bearing No.P/211121/01/2021/008431 having validity from 18.10.2020 to 17.10.2021 for a sum assured of Rs.5,00,000/-; that on 13.04.2021, Smt.Manish Tanwar, wife of the complainant felt ill and remained admitted in Gagan Memorial Hospital, Model Town, Fatehabad in emergency and discharged on 21.04.2021; that the complainant had submitted all the requisite documents with the Ops for reimbursement of the total amount of Rs.1,34,970 but despite that the amount has not been released till date; that the complainant  kept on requesting the Ops for reimbursement of the bill amount spent on the treatment of his wife but the Ops repudiated the claim vide letter dated 02.06.2021. The act and conduct of the Ops clearly amounts to deficiency in service on their part. Hence, this complaint.

2.                          On notice, Ops appeared and filed their joint written statement wherein it has been submitted that the complainant had obtained the policy in question having validity from 18.10.2020 to 17.10.2021 and the said policy was subjected to conditions, clauses, warranties, exclusion etc.; that the insured got admitted in the hospital for the period from 13.04.2021 to 21.04.2021 in the hospital namely Gagan Memorial Charitable, Hospital Fatehabad which is owned by her husband Dr.Dalip Tanwar (complainant), therefore, it is not difficult for him to manipulated a treatment record; that the claim documents submitted for reimbursement shows treatment of septicemia, hypotension, acute renal filure (ARF), Urinary tract infection (UTI) with acute pain abdomen. On scrutiny the claim documents, it was observed that indoor case records are stereotyped written in single stretch and single handwriting; multiple tampering was noted in vitals chart which amounts to misrepresentation of facts; that due to this the claim was repudiated on 02.06.2021; that on the application of the insured the claim was re-examined but the date and time of admission and discharge qua the period of hospitalization for 9 days was not found mentioned in the IPD register  and even discrepancies were found in the submitted records; that the present complaint has been filed with ulterior motive therefore, the claim was rightly repudiated vide letters dated 02.06.2021 and 05.08.2021. Other contentions have been controverted and in the end, a submission was made for dismissal of the complaint.

3.                          In evidence, learned counsel for the complainant has tendered affidavit of complainant Ex.CW1/A and documents Annexure C1 to Annexure C11 and then closed the evidence. On the other hand, learned counsel for the Ops tendered affidavits Ex.RW1/A, Ex.RW2/A with documents Annexure R1 to Annexure R16.

4.                          We have heard oral final arguments from both sides. We have also perused the case file minutely.

5.                          It is not disputed that the complainant had obtained Family Health Optima Insurance Plan bearing No. P/211121/01/2021/008431 (Annexure C4) having validity for the period from 18.10.2020 to 17.10.2021 from the Ops and also paid the premium thereof.  As per the complainant a sum of Rs.1,34,970/- was spent on the treatment of his wife Smt.Manisha Tanwar and as per the terms and conditions of the policy, so obtained by the him, the insurance company had to reimburse the amount spent on the treatment because she was hospitalized during the subsistence of the policy in question but instead of reimbursing the incurred amount, the Ops have repudiated the claim wrongly and illegally. On the other hand, learned counsel for the Ops has argued that there were many discrepancies in the record and even the date and time qua the period of hospitalization for 9 days of the insured was not found mentioned in the IPD record. It has been further argued that the insured was got admitted in the hospital which was being run by complainant, therefore, there are possibilities of managing and manipulating the records by the complainant and due to this the claim in question was rightly repudiated vide letters dated 02.06.2021 and 05.08.2021.

6.                          The material question which this Commission has to decide is as to whether the OPs have legally repudiated the claim of the complainant or not and as to whether there was any deficiency in service on the part of Ops.

7.                          It is worthwhile to mention here that health/medical insurance is a type of insurance that financially protects the insured during medical emergencies. It covers medical expenses related to illness/ hospitalization. A health/care plan covers doctor consultation fees, surgery costs, hospitalization expenses, cost of medicines, ambulance charges, day care procedures, mental healthcare and many more, thereby, protecting the insured from financial strain. In the present complaint, the motive of purchasing the policy in question from the Ops by the complainant must be the same because he had paid the premium for financially protection during medical emergencies.

8.                          Learned counsel for the appearing Ops drew the attention of this Commission towards a letters dated 02.06.2021 and 05.08.2021 (Annexure R12, Annexure R13 duly supported with document Annexure R14 (investigation report) and argued that there were number of discrepancies in the submitted record and even lots of blank pages were found in the payment receipts, therefore, the claim, on not being found to be genuine, was rightly repudiated. However, in Annexure R14 it has been mentioned that number of documents such as   Indoor papers, IPD and OPD register, Final Bill, Medicine Bill, Payment receipts, Medicine PO/Invoices, Hospital infrastructure, Hospital Registration, Degree of Treating doctor and Lab Technician, Drug License, Degree of Pharmacist, Pic & Statement of claimant and id proof, video of claimant.

9.                          After going through the material available on the case file, we have no hitch to say that the insurance company has become too technical while settling the claim of the complainant and has acted arbitrarily. The insurance company should have worked on merits and good spirit of the terms and conditions of the policy without compromising on bad claims but in the present complaint there is nothing on the record to show that as to what kind of discrepancies were found by the Ops which stopped them for settling the claim of the complainant which has been found to be genuine.  Once, there was a valid insurance on payment of huge sum by way of premium and the insured had fallen ill during the subsistence of the policy and spent amount on his treatment, the insurance company ought not to have become too technical and ought not to have refused to settle the claim without any solid and authentic reason. Undoubtedly, the insured Smt.Manisha is the wife of the complainant, who being a doctor treated his wife Smt.Manish/insured in his hospital but it cannot be a ground to repudiate the claim of the complainant. So far as the discrepancies as well as manipulation of the documents is concerned, it is pertinent to mention here that in the investigation report placed on the case file as Annexure R14, it is mentioned the complainant was found little bit confused about here complaints, treatments and days of admission. The Ops have also placed on record copy of statement of insured. Learned counsel for the Ops have drawn the attention of this Commission towards the Treatment chart and argued that there is cutting on the column of admission time. If we read this treatment chart with the statement of the insured one thing is very much clear that date in both these document is same i.e. 13.4.21. Moreover, it is matter of common sense that behaviour of a person who is ill and getting treatment for illness would get disruptive due to mental stage of fear of being sick, anxious about out of the pocket cost and alteration of lifestyle. In the present case it looks that instead of having sympathy with the patient; the Ops have repudiated the claim which is otherwise proved to be a genuine one. Hence, the plea of OPs qua managing and manipulating of documents by the complainant does not survive any more. Therefore, the end of justice would be met if we allow the complaint with a direction to the appearing Ops/insurance company to pay a sum of Rs.1,34,970/- to the complainant.

10.                         Keeping in view the above facts and circumstances of the case, this Commission is of the considered view that the present complaint deserves acceptance because the Ops have indulged in the unfair trade practice as well as dis-service to the complainant, as discussed above. Accordingly, we allow the present complaint with a direction to the appearing Ops to pay a sum of               Rs.1,34,970/- (Rs. One lac Thirty Four thousand Nine hundred seventy only) alongwith interest @ 6 % per annum from the date of filing of the complaint till its realisation. We further allow Rs.11,000/-, (Rs. Eleven Thousand) in lump sum, towards mental harassment and agony suffered by the complainant and also towards litigation expenses. The liability of the Ops is joint as well as several.  The compliance of the order be made by the appearing Ops within 45 days from today, failing which the above mentioned relief amount would carry interest @ 12 % per annum from date of filing of the present complaint till actual realization.

11.                        In default of compliance of this order, proceedings against respondents shall be initiated under Section 72 of Consumer Protection Act, 2019 as non-compliance of court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. This order be also uploaded forthwith on website of this Commission, as per rules, for perusal of parties herein. File be consigned to the record room after due compliance.     

Announced in open Commission.                                                            Dated:02.01.2024

                                                                                                        

                       (K.S.Nirania)              (Harisha Mehta)                   (Rajbir Singh)                                                  Member                       Member                                President