BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 201 of 2017
Date of Institution : 4.8.2017
Date of Decision : 5.4.2018.
Prem Mehta aged 43 years son of Sh. Radha Krishan Mehta, A-119, MSG Complex, near Dera Sacha Souda, Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
- Star Health & Allied Insurance Co. Ltd., Old Civil Hospital Road, near Talian Wali Gali, Sirsa 125055, through its Branch Manager.
- M/s Star Health & Allied Insurance Co. Ltd., (zonal office) 23, First Floor, Himalya House Building, Kasturba Gandhi Marg, New Delhi- 110001.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SH. MOHINDER PAUL RATHEE …… MEMBER.
Present: Sh. Amit Goyal, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
The case of the complainant in brief is that complainant purchased a health insurance policy for himself and for his family members including his wife namely Geeta Mehta from opposite party no.1 with a payment of Rs.11,828/- vide mediclaim policy no.P/211121/01/2017/000104 on 14.5.2016 (previous policy no.9202552825002202) for a period of one year i.e. from 20.5.2016 to 19.5.2017. The customer code is AA0003523512 and sum assured is Rs.5,00,000/-. That the wife of complainant namely Geeta Mehta suffered with disease Anemia and the complainant intimated the ops in this regard on even date. On 5.9.2016, wife of complainant got admitted for her treatment at Shah Satnam Ji Specialty Hospital, Sirsa and after treatment she was discharged on 9.9.2016. The complainant incurred a total amount of Rs.27,000/- on her treatment at aforesaid hospital at Sirsa including hospital charges as well as medicine bills. The complainant has submitted all the medical records as well as other necessary documents as required by the ops time to time to their satisfaction. The complainant on the demands of the ops has also submitted the certificate from Dr. Meenakshi (MBBS, MD) i.e. treating doctor at above said Hospital at Sirsa who has certified that “Mrs. Geeta Mehta wife of Sh. Prem Mehta (The complainant) aged 39 years, female, resident of A-119, MSG Complex, Sirsa, Haryana, Patient ID 271513, C.R. No.37584, admitted on 5th September, 2016. I am stating that patient was suffering from anemia that caused from Vit B12 deficiency, S.Iron deficiency and Hypothyroidism.” It is further averred that thereafter, the complainant submitted the claim to the ops alongwith original bills as well as medical summary etc. alongwith detailed expenditure incurred by him on treatment i.e. Rs.27,000/- excluding loss of income and expenses incurred by the complainant on special diet and medicines after discharge. It is further averred that later on, the complainant provided all the relevant documents as demanded by the ops for verification and for settlement of medical claim and the ops started lingering on the matter on one pretext or another and finally refused to entertain the claim of complainant on unreasonable ground without passing any speaking order. The complainant has complied with the terms and conditions of the policy but to no effect. That the complainant has been paying premium under Health insurance policy for more than last 15 years continuously. However, the pre-conditions or a waiting period if any is not applicable in the case of complainant. That the complainant also got sent a legal notice to the ops on 19.4.2017 but to no effect. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement taking certain preliminary objections. It is submitted that true facts of the case are that Branch Office of answering op has issued Family Health Optima Insurance Policy vide policy No.P/211121/01/2017/000104 for the period 20.5.2016 to 19.5.2017 covering Prem Mehta self, Ms. Geeta Mehta spouse, Kartik Mehta and Jagrit Mehta dependent children for the sum insured of Rs.5,00,000/-. The insured patient, Geeta Mehta was hospitalized at Shah Satnam Ji Specialty Hospital, Sirsa on 5.9.2016 for the treatment of Anemia with DM/ Hypothyroidism and submitted claim records for reimbursement of medical expenses. On scrutiny of the claim records, it is observed that as per discharge summary, the insured was admitted on 5.9.2016 with the complaints of Anemia, giddiness, DM since 2½ years, hypothyroidism since six months and diagnosed as Anemia with DM with Hypothyroidism. The treating doctor certificate which is submitted in response to their query, states that the patient was suffering from anemia, cause from Vitamin B12 deficiency, Serum iron deficiency and hypothyroidism. The indoor case records of above hospital revealed that the insured patient was mainly treated for anemia and nutritional deficiency. It is further submitted that as per Exclusion No.6 of above policy, the company is not liable to make any payment in respect of any expenses for treatment of nutritional deficiency. Upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy, its terms have to be strictly construed to determine the extent of liability of the insurer. Hence, the claim was repudiated and same was communicated to the insured vide letter dated 12.1.2016. The preliminary objections regarding suppression of material facts, cause of action, intricate question of law and facts are also taken. It is also submitted that the registered and corporate office of the answering op is situated in Chennai and no cause of action arose at Sirsa, so this Forum has no jurisdiction to try and entertain and decide the present complaint. It is also submitted that complainant has disclosed the policies from 2012 only, hence the contentions the complainant has insurance policy since 15 years is not acceptable. It is further submitted that both parties are bound to act according to the terms and conditions of the policy and there is no violation of terms and conditions of the policy on the part of answering ops. It is further submitted that op further submits that the policy issued to the complainant under which the dispute has been raised is governed by limits of liability as per various clauses. That without any prejudice to whatever has been stated earlier in this written statement, even admitting without conceding that company is liable to pay t he claim in terms of the contract of insurance issued to the claimant and that the maximum quantum of liability is Rs.23,524/-. Remaining contents of the complaint are also denied.
3. The complainant produced his affidavit Ex.CW1/A, affidavit of Smt. Geeta Mehta as Ex.CW2/A, copy of legal notice Ex.C1, postal receipts Ex.C2, copy of claim form Ex.C3, copies of policy schedule Ex.C4 to Ex.C11 and status of intimation Ex.C12 and coy of certificate of doctor Ex.C13. On the other hand, ops produced affidavit of Sh. N.Gopalan Ex.RW1, copy of investigation form Ex.R1, copy of claim form Ex.R2, copy of discharge card Ex.R3, copy of report Ex.R4, copy of policy Ex.R5, copy of literature regarding Nutritional Deficiencies, copy of proposal form Ex.R7, copy of discharge report Ex.R8, copy of policy schedule Ex.R9, copy of repudiation letter dated 12.1.2017 Ex.R10 and copy of certificate of doctor Ex.R11.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. The complainant in order to prove his case has furnished his affidavit Ex.CW1/A wherein he has reiterated all the averments made in his complaint. He has also furnished affidavit of his wife Smt. Geeta Mehta as Ex.CW2/A in which she has also supported the version of complainant. The complainant has also placed on record copies of documents Ex.C1 to Ex.C13 as mentioned above. On the other hand, the opposite parties have furnished affidavit of Sh. N.Gopalan, Chief Manager as Ex.RW1 in which he has reiterated the averments of the written statement. The ops have also furnished copies of documents as Ex.R1 to Ex.R11.
6. It is undisputed fact between the parties that complainant purchased Family Health Optima Insurance Policy from the opposite parties vide policy No.P/211121/01/2017/000104 for the period 20.5.2016 to 19.5.2017 covering himself, his wife Smt. Geeta Mehta and children Kartik Mehta and Jagrit Mehta for the sum insured of Rs.5,00,000/-. It is also undisputed fact between the parties that prior to the purchase of present policy, the complainant was holding health insurance policy of Reliance General Insurance company for himself and his above said family members as is evident from copies of schedule Ex.C5 to Ex.C11. It is also admitted fact between the parties that insured Geeta Mehta wife of complainant was hospitalized at Shah Satnam Ji Specialty Hospital, Sirsa on 5.9.2016 for the treatment of Anemia with DM/ Hypothyroidism i.e. during the subsistence of the policy in question purchased from the opposite parties for the period 20.5.2016 to 19.5.2017. The complainant lodged the claim with the opposite parties for an amount of Rs.27,000/- which has been repudiated by the opposite parties vide repudiation letter dated 12.1.2017 Ex.R10 by mentioning that “We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of anemia with diabetes mellitus/ hypothyroidism. It is observed from the medical certificate dated 31.12.2016 issued by the treating doctor submitting in response to our query that the insured patient has undergone treatment for nutrition related anemia. As per Exclusion No.6 of the above policy, the company is not liable to make any payment in respect of any expense for treatment of nutritional deficiency. We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.” The record reveals that Smt. Geeta Mehta was treated for anemia with DM with hypothyroidism. The anemia disease is a condition in which the blood does not have enough health red blood cells. The hypothyroidism disease is a condition in which the thyroid gland does not produce enough thyroid hormone. The opposite parties while repudiating the claim of the complainant has relied upon the copy of certificate of Dr. Meenakshi, MBBS, MD i.e. treating doctor of Shah Satnam Ji Specialty Hospital, Sirsa in which it is certified that the patient was suffering from anemia, that caused from Vit B12 deficiency, S.iron deficiency and hypothyroidism. Therefore, from the perusal of the above said certificate, it cannot be said that Smt. Geeta Mehta was only treated for nutritional deficiency rather it is evident that she was having problem of thyroid also. Besides this from the medical record placed on file, it is also evident that she was also treated for diabetes mellitus. Further, it has also been observed from the record placed on file by ops themselves that there was heavy bleeding during menstruation period as mentioned in Ex.R1 (page 16). On page 13 (of Ex.R1) under the head “chief complaints”, it has been mentioned that “C/o Weakness and giddiness”, on page 15 under the head “Impression”, it has been mentioned ‘Anemia with DM and hypothyroidism.’ When all the above facts are seen in toto, the cause of anemia appears heavy bleeding during menstruation due to deficiency in blood i.e. HB 9.00 gm. on 5.9.2016, the patient was feeling weakness and giddiness and that appears to be the major cause and nutrition deficiency may be the minor cause of her such condition. Under such circumstances, providing of some medicines for vitamins and iron does not mean that she was only treated for nutritional deficiencies. In our considered view, the opposite parties have wrongly repudiated the claim of the complainant and it amounts to deficiency in service on the part of opposite parties. From the copy of claim form Ex.C3, it is evident that complainant has spent an amount of Rs.21,695/- for hospitalization and Rs.5149/- on medicines and this claim form is signed by the doctor of Shah Satnam Ji Speciality Hospital, Sirsa and thus according to the complainant he has spent an approximate amount of Rs.27,000/- on the treatment of his wife but his claim is not supported by bills of the expenses. However, the ops in para no.12 of the written statement have quantified their liability of Rs.23,524/-. Hence, we are of the considered opinion that the complainant is entitled to the claim amount of Rs.23,524/- as per the document of the ops produced by them with Ex.R8.
6. In view of the above, we allow the present complaint and direct the opposite parties to pay the claim amount of Rs.23,524/- to the complainant within a period of 30 days from the date of receipt of copy of this order, failing which the complainant will be entitled to interest @9% from the date of order till actual realization. We also direct the opposite parties to further pay an amount of Rs.3000/- as composite compensation and litigation expenses to the complainant. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:05.04.2018. Member District Consumer Disputes
Redressal Forum, Sirsa.
