Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 476.
Instituted on : 04.10.2018.
Decided on : 05.07.2021.
Poonam Gupta Age 49 years w/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 complainant is consumer of respondent since year 2015 and she continuously renewed her health insurance policy time to time. In the year 2017 the complainant had renewed her health insurance policy from the respondents having product namely family health optima insurance vide policy no.P/211118/01/2017/004980. Similarly she renewed her policy vide policy no. P/211118/01/2018/007120. On 15.10.2017 the complainant was suffering from dengue and she remained admitted in Jain Hospital & Fertility centre for her treatment w.e.f. 15.10.2017 to 20.10.2017 and she incurred Rs.32060/- on her treatment . She 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 02.12.2017 had repudiated the claim of the complainant on false and flimsy ground. Lateron in the last week of April 2018 she suffered severe pain in her abdomen and remained admitted in the hospital w.e.f. 26.04.2018 to 30.04.2018 for treatment and incurred expenses of Rs.22631/- on her treatment. Complainant again filed the claim and 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.54691/-(Rs.32060/- + Rs.22631/-) 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 complainant and her child namely 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 respondent for disbursement of the medical expenses incurred by the insured Poonam Gupta with Jain Hospital and Fertility Hospital and was diagnosed with PUO with TCP, during her admission 15.10.2017 to 20.10.2017, amounting to Rs.32600/-, 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( whereas the same is husband 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 02.12.2017. The another claim form (CLI/2019/211118/0070692) was received in the office of answering opposite party for disbursement of medical expenses incurred by the insured Poona Gupta during her admission 26.04.2018 to 30.04.2018 amounting to Rs.22365/- but the same was not paid as indoor case record were written in single handwriting, relevant investigations not done and investigation also written in same handwriting in hospital note pad. Hence from the above findings, it is observed that there is discrepancy in the admission. Thus the claim of the complainant was rightly repudiated being violation of terms and conditions of the policy. All the other contents of the complaint were stated to be wrong and denied. Opposite party prayed for dismissal of complaint with costs. However, an additional plea has been taken by the opposite party that the maximum quantum of liability under the terms of policy shall be Rs.30200/- and Rs.21455/- respectively.
3. Learned counsel for the complainant in his evidence tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C16 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.R16 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 firstly vide letter dated 02.12.2017(Ex.C4/Ex.R13) on the ground that : “The patient is admitted in the hospital on 15.10.2017 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”. The second claim was repudiated vide letter Ex.C5 on the ground
that : “It is observed that indoor case records is written in single handwriting, relevant investigations not done and investigation also written in same handwriting in hospital note pad. Our medical team is of the opinion that discrepancies amounts to misrepresentation”. To prove its case, opposite party has placed on record document Ex.R11, 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 resident 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. It is observed that the other plea taken by the opposite party is that indoor case records is written in single handwriting, relevant investigations not done and investigation also written in same handwriting in hospital note pad. But to prove this fact, no expert evidence is placed on record. The claim 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.R15 & Ex.R16 amounting to Rs.30200/- and Rs.21455/- respectively 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.51655/- (Rupees fifty one thousand six hundred and fifty five 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.
