Haryana

Kurukshetra

CC/2/2021

Ashish Mehta S/o Dharampal Mehta - Complainant(s)

Versus

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

Amit bansal

03 Aug 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KURUKSHETRA

 

                                                                    Complaint No.:    02 of 2021.

                                                                   Date of institution:         01.01.2021.

                                                                   Date of decision: 03.08.2022

 

1. Ashish Mehta, aged 34 years s/o Shri Dharampal Mehta,
2. Dharampal Mehta, aged 59 years s/o Shri Daulat Ram,

Both residents of H.No.444, Sector-7, Urban Estate, Kurukshetra.

 

                                                                                                …Complainants.

                                                      Versus

 

1. Star Health and Allied Insurance Company Ltd., 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034, through its Authorized Signatory.
2. Star Health and Allied Insurance Company Ltd., SCO No.94, First Floor, Sector-17, Backside of Hotel Silver Sand, Kurukshetra.

                                                                                      ...Respondents.

 

CORAM:   NEELAM KASHYAP, PRESIDENT.    

                    NEELAM, MEMBER.

 

Present:       Shri Amit Bansal, Adv. for the complainants.

                   Shri Gaurav Gupta, Advocate for the Opposite Parties.

 

ORDER:

 

1.                This is a complaint under Section 35 of the Consumer Protection Act, 2019.

2.                It is alleged in the complaint that the complainant purchased medi-claim insurance cashless policy vide policy No.P/2111114/01/2020/000915 for the period from 05.5.2019 to 04.05.2020. Before issuance the said policy, OPs checked medically to complainant No.2. The complainant felt problem of left knee and doctor diagnosed Synovitis left knee disease. The staff of Artemis Hospital, Sukhrali applied for sanction of treatment expenses and also informed the OPs regarding the treatment and injection and amount of costs of Rs.40,000/- approx. incurred on his treatment on 14.2.2020. On 14.2.2020, OPs initially sanctioned Rs.15000/- and on 15.2.2020, complainant No.2 was admitted in the hospital and doctor injected the injection on the left knee of complainant No.2. On 15.02.2020, OPs refused to provide the cashless facility to the complainants with the pretext “we are therefore unable to approve the claim and the authorization already given for cashless treatment of above diagnosed disease stands withdrawn”. The complainant No.2 spent an amount of Rs.33674/- in that hospital and approached to OPs after submitting all the requisite documents but they wrongly and illegally repudiated the claim vide letter dated 13.03.2020 on flimsy grounds. The above act and conduct of OPs amounts to deficiency in service, causing mental agony, harassment and financial loss to them, constraining to file the present complaint against the OPs before this Commission.

3.                On receipt of notice of complaint, OPs appeared and filed their written statement admitting issuance of medi-claim policy in question to the complainant. It is submitted that the insured requested for a cashless authorization for the treatment of Synovitis Left Knee at Artemis Health Institute, Gurugram in the 5^th year of the policy, as such, OPs authorized Rs.5000/-, subject to submission of discharge summary and final hospital bill with breakup, which was submitted later and upon which, it is noted that insured patient had been admitted for the treatment of Intra-Articular Injection for knee joint (OA) and expensed for this treatment are not admissible in accordance with the exclusion No.4.22 of the policy. Hence, the authorization already given for cashless treatment was withdrawn vide letter dated 15.2.2020. The insurance submitted claim for reimbursement of medical bill of Rs.33674/-, which was not payable as per above terms and conditions of the policy and rightly rejected the same vide letter dated 13.3.2020. There is no negligence and deficiency on the part of OPs and prayed for dismissal the present complaint.  

4.                In support to support their case, complainants tendered affidavit Ex.CW1/A along with documents Ex.C-1 to Ex.C-12 and closed the evidence.

5.                On the other hand, OPs tendered affidavit Ex.RW1/A along with documents Ex.R-1 to Ex.R-14 and closed the evidence.

6.                We have learned counsel for the parties and gone through the case file carefully.

7.                Learned counsel for the complainant has argued that the complainant purchased medi-claim insurance cashless policy from the OPs. The complainant No.2 felt problem of left knee and doctor diagnosed Synovitis left knee disease. The staff of Artemis Hospital, Sukhrali applied for sanction of treatment expenses and also informed the OPs regarding the treatment and injection and amount of costs of Rs.40,000/- approx. incurred on his treatment on 14.2.2020. On 14.2.2020, OPs initially sanctioned Rs.15000/- and on 15.2.2020, complainant No.2 was admitted in the hospital and doctor injected the injection on the left knee of complainant No.2. On 15.02.2020, OPs wrongly refused to provide the cashless facility to the complainants. The complainant No.2 spent an amount of Rs.33674/- in that hospital and approached to OPs after submitting all the requisite documents but they wrongly and illegally repudiated the claim vide letter dated 13.03.2020 on flimsy grounds. The above act and conduct of OPs amounts to deficiency in service.

8.                Learned counsel for OPs has argued that the insured requested for a cashless authorization for the treatment of Synovitis Left Knee at Artemis Health Institute, Gurugram in the 5^th year of the policy, as such, OPs authorized Rs.5000/-, subject to submission of discharge summary and final hospital bill with breakup, which was submitted later and upon which, it is noted that insured patient had been admitted for the treatment of Intra-Articular Injection for knee joint (OA) and expensed for this treatment are not admissible in accordance with the exclusion No.4.22 of the policy. Hence, the authorization already given for cashless treatment was withdrawn vide letter dated 15.2.2020. The insurance submitted claim for reimbursement of medical bill of Rs.33674/-, which was not payable as per above terms and conditions of the policy and rightly rejected the same vide letter dated 13.3.2020. There is no negligence and deficiency on the part of OPs and prayed for dismissal the present complaint.  

9.                There is no dispute between the parties that the complainants took having medi-claim insurance cashless policy from the OPs initially from the year 2014 and thereafter, renewed the same from time to time and lastly for the period from 05.05.2019 to 04.05.2020 vide policy certificate Ex.C-4.

10.              The grievance of the complainants is that complainant No.2 diagnosed Synovitis left knee disease in Artemis Hospital, Sukhrali and spent an amount of Rs.33674/- in that hospital and approached to OPs after submitting all the requisite documents, but they wrongly and illegally repudiated the claim vide letter dated 13.03.2020 Ex.C-1. On the other hand, the OPs contended that complainant No.2 had taken the treatment of Intra-Articular Injection for knee joint (OA) and as per exclusion No.4.22 of the policy, the company is not liable to make any payment for that treatment. There is no dispute that the policy in question was continuing from the last five years and as per Section 45 of Insurance Laws (Amendment) Act 2015, “Insurance companies cannot reject claims made on policies over three years. According to the Section 45 no claim can be repudiated (rejected) after 3 years of the policy being in force even if the fraud is detected. So, in view of above Section, the OPs cannot reject the claim of the complainants.

11.              Moreover, we have taken out an article from the Internet Synovitis and Joint Inflammation (Joint Inflammation Specialist), of Dr. Williams of Manhattan, Brooklyn, New York as Mark-A, the disease for which complainant No.2 took the treatment, wherein the said doctor suggested that synovitis or knee inflammation may be treated with anti-inflammatory medications (NSAIDs), steroid injections, or other biologic joint injections. These injections can help decrease swelling, inflammation and can manage pain. Steroid injections can be extremely helpful in managing the symptoms of synovitis, however, it is not a cure. In the case in hand, the complainant was also suffering from the said disease/problem and as such, he also took steroid injections and submitted the claim in this regard with OPs, but they repudiated the same. The complainants are renewing the policy in question continuously from the last five years after paying the premium in this regard to the OPs, and when in the fifth year of commencement of policy in question, complainant No.2 took the treatment for said problem and submitted the claim with the OPs, they repudiated the same, which is not justifiable.

12.              At the time of arguments, learned counsel for the complainant has argued that the OPs have not supplied the terms & conditions of the policy in question to them, with the cover note. This contention of the complainant has force, because the OPs have not produced any documentary proof to establish that the terms & conditions of the policy in question were duly acknowledged to the complainants alongwith the policy cover note. Moreover, the OPs have also not produced any signed copy of the terms & conditions by the complainants, as a token of its receipt. When OPs had not supplied terms and conditions to the complainants, then how they can repudiate the claim of complainants on the ground of those so called terms and conditions of the policy. In this regard, our view is supported by the case laws titled as National Insurance Company Ltd. Vs. Rajan Narain (supra), wherein, the Hon’ble National Commission, New Delhi has held that Insured felt chest pain within 3 days of taking policy- Underwent heart surgery three weeks later- Repudiation of claim- On ground of suppression of pre-existing disease alleged- Deficiency of service alleged- Complaint allowed-Compensation awarded – Dismissal of appeal- Challenged by revision- Held, complainant was neither aware of exclusion clause nor was supplied with terms and conditions of policy at time of issuing cover note- Since, complainant having heart disease prior to taking of policy not proved- Thus, complaint rightly allowed- Order upheld- Interference declined- Revision dismissed.

 13.             So, keeping in view the above facts and circumstances of the case, we are of the considered view that the OPs are not justified in repudiating the claim of complainant No.2 to the tune of Rs.33674/-, on the flimsy grounds, mentioned above, which amounts to gross deficiency in services on their part. Hence, the OPs are liable to reimburse the said amount of Rs.33674/-, which complainant No.2 had incurred on his treatment. The OPs are also liable to compensate complainant No.2 for the mental agony and physical harassment suffered by them, alongwith litigations expenses. However, it is pertinent to mention here that since it was the complainant No.2, who had taken the said treatment, therefore, complainant No.2 is only liable to receive the claim amount along with compensation and litigation expenses from the OPs.

14.              In view of our above discussion, we accept the present complaint against the OPs and direct the OPs severally and jointly to pay the claim amount of Rs.33,674/-, to complainant No.2. The OPs are further directed to pay Rs.10,000/- to the complainant, as compensation for mental agony and physical harassment, caused to complainant No.2, due to an act of deficiency in service, on the part of the OPs, along with Rs.5,000/-, as litigation expenses. The OPs are further directed to make the compliance of this order within a period of 45 days from the date of preparation of certified copy of this order, failing which, the award amount of Rs.33,674/- shall carry on interest @6% simple per annum, from the date of this order, till its actual realization and complainant No.2 shall be at liberty to initiate proceedings under Section 71/72 of the Act, against the OPs. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

Announced in open Commission:

Dated:03.08.2022.   

 

                                                                                       (Neelam Kashyap)               

          (Neelam)                                                               President,

          Member.                                                                DCDRC, Kurukshetra.

 

Typed by: Sham Kalra, Stenographer.