Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 475.
Instituted on : 04.10.2018.
Decided on : 05.07.2021.
Ayush Gupta Age 18 years s/o Sh. Subhash Chand R/o H.No.723/1, Mahajan Paraav, Rohtak.
………..Complainant.
Vs.
- Star Health & Allied Insurance Co. Ltd., registered and corporate office: 1, New Tank Street, Vallunar Kottam High Road, Nungambakkam, Chennai-600034. Through its M.D.
- Star Health & Allied Insurance Co. Ltd., No.15, Sri Balaji Complex, 1st Floor, Whites Lane, Roy Apettah, Chennai-600014, Through its M.D.
- Star Health & Allied Insurance Co. Ltd., Ashoka Plaza, 3rd Floor, Delhi Road, Rohtak, Through its Manager.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
MS. TRIPTI PANNU, MEMBER.
Argued: Sh. Pardeep Mittal, Advocate for complainant.
Sh.Gulshan Chawla, Advocate for opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Present complaint has been filed by the complainant with the averments that mother of the complainant is consumer of opposite parties since year 2015 and she continuously renewed her health insurance policy time to time wherein the complainant is also one of the insured person and thus the complainant is also consumer of opposite parties. In the year 2017 the complainant had renewed the policy from the opposite parties and the opposite parties issued policy no.P/211118/01/2017/004980. Similarly the policy was again renewed vide policy no. P/211118/01/2018/007120. On 14.10.2017 the complainant was suffering from dengue and he remained admitted in Jain Hospital & Fertility centre for his treatment w.e.f. 14.10.2017 to 20.10.2017 and he incurred Rs.37330/- on his treatment . The complainant and his parents duly gave telephonic intimation in this regard to the opposite parties and submitted the claim form with the opposite party alongwith all the requisite documents. But the opposite parties vide their letter dated 30.11.2017 had repudiated the claim of the complainant on false and flimsy ground. Complainant again requested the opposite parties to pay the genuine claim amount but to no effect. Hence this complaint and it is prayed that opposite parties may kindly be directed to pay Rs.37330/- alongwith interest compensation and litigation expenses to the complainant as explained in relief clause.
2. After registration of complaint, notice was issued to the opposite parties. Opposite parties in their reply has submitted that complainant opted for Family Health Optima Insurance Plan and the opposite party relying upon the contents of the proposal form to be true, issued the policy to the complainant, which was renewed time to time and subsequently policy no. P/211118/01/2018/007120 for the period 27.03.2018 to 26.03.2019 covering the Poonam Gupta- Self, Child-Ayush for the insured limit for Rs.625000/- was issued. It is submitted that the claim form was received in the office of the answering opposite parties for disbursement of the medical expenses incurred by the insured Ayush Gupta with Jain Hospital and Fertility Hospital and during his admission 14.10.2017 to 20.10.2017, amounting to Rs.37330/-, but the same was not paid as at the time of visit of Doctor Sh.Om Parkash Chawla on 19.10.2017, the patient was not available in the hospital and it become clear that patient is treated on the day care basis. The father of the complainant had suffered a declaration to same effect. That patient went back to home at 9:30 pm and came to hospital in the morning at about 7:30 am. Hence there was no admission of the insured with Hospital. Thus the claim of the complainant was rightly repudiated being violation of terms and conditions of the policy. As per condition No.8, if there is any misrepresentation whether by insured person or any other person acting on his behalf, the Company is not liable to make any payment in respect of any claim. Thus the claim was repudiated and the same was informed to the insured vide letter dated 30.11.2017. All the other contents of the complaint were stated to be wrong and denied. Opposite parties prayed for dismissal of complaint with costs. However, an additional plea has been taken by the opposite parties that maximum quantum of liability under the terms of the policy shall be Rs.35160/-.
3. Learned counsel for the complainant in his evidence tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C14 and has closed his evidence on dated 10.09.2019. Ld. counsel for the opposite party in his evidence has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R10 and closed his evidence on dated 26.10.2020.
4. We have heard learned counsel for the parties and have gone through the material aspects of the case very carefully.
5. In the present case, the claim of the complainant has been repudiated by the insurance company vide letter dated 30.112017(Ex.C8) on the ground that : “The patient is admitted in the hospital on 14.10.2017 and discharged on 20.10.2017; at the time of visit of our doctor on 19.10.2017, the patient was not available in the hospital; also the patient is treated on a day care basis; as per the declaration given by the husband of the patient, the patient has gone to home at 9:30pm and come back in the morning 07.30am. Thus there is discrepancy and the company is not liable to make any payment in respect of the claim”. To prove its case, opposite party has placed on record document Ex.R8, which is a declaration at page no.4, regarding authorization to the bearer to check the record of the hospital regarding the ailment of the complainant. The signatures were obtained by the concerned person and a hand written note is also mentioned on this page. As per this note the patient was not in the hospital after 9.30P.M. to 7.30 A.M. because the house of the complainant is near the hospital. However, any endorsement regarding this effect that the patient left the hospital from 9 P.M. to 7.30 A.M. has not been placed on record by the opposite parties. Moreover it seems that the signatures were obtained by the investigating person upon the declaration or not on the written notes. The investigating agency or concerned doctor, who visited in the hospital on behalf of the company should also take the statement of the treating doctor or any other hospital staff, but this type of statement has not been placed on record by the opposite parties. The claim of the complainant is repudiated on false and flimsy grounds. Hence there is deficiency in service on the part of opposite parties and opposite parties are liable to pay the claim amount as per assessment made in their report Ex.R10 amounting to Rs.35160/- to the complainant.
6 In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite parties to pay the alleged amount of Rs.35160/- (Rupees thirty five thousand one hundred and sixty only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 04.10.2018 till its realization and shall also to pay a sum of Rs.5000/-(Rupees five thousand only) as compensation and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
05.07.2021.
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Nagender Singh Kadian, President
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Tripti Pannu, Member.
