DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SHAHEED BHAGAT SINGH NAGAR

Consumer Complaint No.    57/ 2022

Date of Institution:             : 07.07.2022

Date of Decision               :  07.10.2022    

Sunil Sharma s/o Sh. Satya Nand Sharma r/o Toor Colony, Saloh Road, District Shaheed Bhagat Singh Nagar.

….. Complainant

Versus

1.       Head Office, Star Health and Allied Insurance Co. Ltd., 1, New Tank Street, Valluar Kottam High Road, Nungambakkam, Chennai- 600034, Phone 044 28288800.

2.       Head Office, Star Health and Allied Insurance Co. Ltd. No.15, Sri Balaji Complex, Ist Floor, Whites Lane, Royapettah, Chennai 600014.

3.       Branch Office, Star Health and Allied Insurance Co. Ltd., EH 198, 2^ND Floor, Nirmal Complex, G.T Road, Jalandhar Punjab 144001, Ph no. 0181- 4606268/460636.

4.       Sarabjit Singh, Branch Manager, Star Health and Allied Insurance Co. Ltd., LIC Office, 1 Floor Above Blueberry Spa, Banga Road, Nawanshahr, Punjab 144514 , Ph. 9888828683/9888828683.

                                                                         …..Opposite parties

(Complaint under the provision of Consumer Protection Act)

QUORUM:

SH.KULJIT SINGH, PRESIDENT

SH.YADWINDER PAL SINGH BAATH, MEMBER

SMT. RENU GANDHI, MEMBER

COUNSEL FOR THE PARTIES:

For complainant             :         Sh.Parnav Miglani, Advocate

For OPs                          :         Sh.P.S Bakshi, Advocate

Per : KULJIT SINGH, PRESIDENT

1.                 The brief facts of the complaint are that OP no.4 being agent of OPs allured the complainant that Star Health Insurance Company Ltd provided all the treatments of  person and his family cover under policy, If he obtain the same and also disclosed that all  the body parts and diseases  are covered under the policy. On the assurance of agent/OP no.4 of OPs no.1 to 3, the complainant obtained insurance policy  and paid full premium and OPs issued policy no. P/161125/01/2022/005656 with sum assured of Rs.5,00,000/- which is valid from 30.11.2021 to midnight of 29.11.2022.  The complainant was diagnosed with TRIGERMINAL NEURALGIA and had undergone surgery from PGI Chandigarh on 20.12.2021 and he had disclosed regarding treatment/surgery to OP no.4 and on his demand. The complainant handed over  all the bills to Sarabjit Singh /OP no.4 and he assured to complainant that whole amount would be transferred in his account.  The complainant was surprised to see that out of total bills of Rs.1,67,601/- , OPs accepted only Rs.72,470/- . OPs are deliberately and intentionally not paying the balance amount to him  and rejected the other bills.  The complainant also served notice dated 23.04.2022 upon OPs calling upon OPs to make the payment of Rs.95,131/- but OPs rejected  the claim of the complainant. OPs have failed to provide the adequate services to the complainant. Due to act and conduct of OPs, the complainant has filed the instant complaint and prayed that the OPs be directed to pay Rs.95,131/-  along with interest @ 12% per annum till the actual realization and Rs.50,000/- as damages.

2.                 Upon notice, OPs appeared and filed joint written reply and contested the claim of the complainant by raising preliminary objections that  no cause of action has arisen to file the complaint. There is no deficiency in service on the part of OPs. The complaint is baseless and flagrant. On merits, it was averred that all the conditions under the policy were fully understood by the complainant before taking the policy and explained to the complainant at the time of processing of the policy and same was served to the complainant along with policy schedule.  A claim for re-imbursement was received along with documents for the treatment of complainant  who was hospitalized at PGIMER on 13.12.2021 to 25.12.2021  for the treatment of Trigerminal Neuralgial. The claim was processed and amount of Rs.72470/-  was approved and paid to the insured through NEFT No.73221873719728 dated 14.03.2022. The certain deductions as per policy conditions were made as under :-

1. As per other excluded expenses of the policy, the charges pertaining to Extra Room Charges not payable, hence amount of Rs.1500/- are not payable.
2. As per other excluded expenses of the policy, the charges pertaining to Audiometry, HIV , HCV, HBSAG, Grouping and Cross Mathcing not payable, Ferritin, Iron Profile not payable/ General investigation- No break up hence 20% disallowed, hence amount of Rs.5870/- are not payable.  
3. As per other excluded expenses of the policy, the charges pertaining in DURAGEN, SANITISER, THERMOMETER, GLOVES, STRIPS, LANCETS, CANNULA, IV SET, BAND, KIT, FILTER, VACCUSUCK, IV SET, CANNULA, MICROSHIELD, BANDAGE, SOLUTION, DRAPE, NOT PAYABLE CRANIO CLAM 20% DEDUCTED /PERFORATOR, DRILL BIT NOT PAYABLE, hence amount of Rs.78405/- are not payable.
4. As per the other excluded expenses of the policy, the charge towards- BILL DATED 23/9 EXCEEDS 60 DAYS OF PRE HOSPITALIZATION HENCE DISALLOWED. Hence amount of Rs,5900/- are not payable (being pre hospitalization deduction).
5. As per the other excluded expenses of the policy, charge towards PIRAMAPORE, CAP not payable and amount of Rs.631/- are not payable (being post hospitalization deductions).

Thus, the total amount of Rs. 1,67,601/- an amount of Rs.95,131/- was deducted and maximum payable of Rs.72470/-  has been already paid to complainant. OPs denied any deficiency in service on their part and prayed for dismissal of the complaint.

3.                The complainant has tendered in evidence his affidavit Ex.CW-1 along with copies of documents Ex.C-1 to Ex.C-37 and closed the evidence. On the other hand, OPs tendered in evidence affidavit of P.C Tripathi Zonal Manager as Ex.OP-1/A along with copies of documents Ex.R-1 to Ex.R-8 and closed the evidence.

4.                The learned counsel for the complainant alleged that the complainant obtained insurance policy bearing no. P/161125/01/2022/005656 on the assurance of agent/OP no.4 with sum assured of Rs.5,00,000/- , which is valid from 30.11.2021 to 29.11.2022.  The complainant further alleged that the OPs only accepted Rs.72,470/- out of total bill of Rs.1,67,601/-.

5.                On the other hand, OPs refuted the allegations of the complainant and pleaded that they paid Rs.72,470/- to complainant as per terms and conditions of the policy. OPs further pleaded that they processed the claim amount of Rs.72470/-  out of the total amount of Rs.1,67,601/-. It was denied that there has been any negligence in service by OPs.

6.                It is an established fact that the complainant obtained the insurance policy from OPs and OPs paid Rs.72470/- to the complainant instead of Rs.1,67,601/-. Now, main controversy involved in this case is whether OPs are  liable to pay the remaining amount of Rs.95131/- or not. OPs sent letter Ex.C-7 to complainant that please select the room as per your eligibility stipulated in policy to avoid additional payment from your pocket towards proportionate increase which would invariably be charged by the hospital for the higher room category occupied. From perusal of this letter, it seems that OPs are ready to pay the room charges as per eligibility of the complainant and on the other hand, OPs rejected the room charges claimed by the complainant. The policy in question valid from 30.11.2021 till 29.11.2022, this fact is clear from perusal of copy of insurance policy placed on the record. We have also examined copies of bills Ex.C-11 to Ex.C-35 placed on the record. The complainant was diagnosed with TRIGERMINAL NEURALGIA and undergone surgery from PGI Chandigarh on 20.12.2021 during currency period of the policy. From perusal of discharge summary prepared by PGI Chandigarh, this fact is clear that the complainant admitted in the hospital on 13.12.2021 and discharged on 25.12.2021 as indoor patient and diagnose of Trigerminal Neuralgial was given to the complainant. We have also perused the terms and conditions of the policy Ex.R-3 placed on the record. In Column B of the policy, it has been specifically mentioned that :- the limit of room Single Standard A/C Room . B- Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees. C. Anesthesia, Blood, Oxygen, Operation theatre charges, ICU charges, surgical appliances, medicines and drugs, Diagnostic material and x-ray, diagnostic imaging modalities, dialysis, chemotherapy, radiotherapy, cost of pacemaker, stent and similar expenses. With regard to coronary stenting, medicines, implants and such other similar items the company will pay cost of stent as per the Drug Price Control Order (DPCO)/National Pharmaceuticals Pricing Authority (NPPA) Capping. I. Consultant fees, diagnostic charges, medicines and drugs wherever recommended by the Hospital/Medical Practitioner, where the treatment was taken.

Similarly, in COLUMN No. 14 – It has been specifically mentioned that company with prior approval of IRDA  may revise  or modify  the terms of the policy including the premium rates. The insured person shall be notified three months before the charges are effected.

We have also perused the items which are to be subsumed into cost of treatment  as follows:-

1. Admission/Registration Charges.
2. Nutrition planning charges- Dietician charges – Diet charges.
3. HIV KIT
4. Scrub Solution/Sterillium
5. Glucometer & Strips
6. Cotton Bandage
7. Surgical drill
8. Eye drape
9. X-ray film

7.                From perusal of above said terms and conditions of the policy, we are of the considered view that the OPs wrongly rejected the claim of the complainant. The terms and conditions binding upon both the parties and no one wriggle out from the same. We cannot add or subtract in the conditions of the policy.  It was duty of the OPs to prove that such terms and conditions with exclusion clause were explained to the insured when cover note was issued. Once the insurer/OPs failed to prove this fact, it cannot take any benefit from such an exclusion clause. The insurer/OPs duty bound to inform its policyholders/complainant  about the limitation.

8.                 The learned counsel for the complainant relied upon citations in support of his case titled as Oriental Insurance Co. Ltd. Versus  Dr.Deepak Raje by Chattisgarh State Disputes Redressal Commission Raipur reported in Appeal no. 118 of 2011 decided on 10.10.2011 that insurance contract is a contract like nay other contract. Terms and conditions of the insurance policy are binding upon both the parties. Nobody can add or subtract any condition in policy document after finalization of contract of insurance. Terms of contract can be changed only if there is binding effect of any law or unless both parties give consent regarding exclusion or including of any condition or at least when policy decision has been taken by Insurance Company.  The case tiled as National Insurance Co. Ltd  and another vs. Vinay Narain Calla by Rajasthan State Consumer Disputes Redrssal Commission Jaipur reported in Appeal no. 1112 of 2006 decided on 2.11.2006 that benefit of exclusion clause- claimed by insurer and liability denied. Exclusion clause included in terms of policy was neither part of contract of insurance between the parties nor disclosed by insurer to insured. We have also perused the other citations placed on record by learned counsel for the complainant. Further case titled as National Insurance Company Ltd vs. Mohan Ohri and another by Hon’ble Punjab State Consumer Disputes Redressal Commission, Pb. Chandigarh reported in First Appeal no. 1583 of 2005 decided on 25.03.2011 that it was settled by Apex Court that when insurance companies want to apply Exclusion Clause to deny insurance claim, they have to prove that Exclusionary Clause was duly communicated to insured. Deficiency in service established.

9.                From perusal of entire record on the file, we are of the considered view that the OPs wrongly rejected the claim of the complainant for balance amount. The complainant contacted OPs for settlement of his claim as per terms and conditions of the policy. However, OPs failed to settle the claim of the complainant as per terms and conditions of the policy.  The contract should be in consonance with its aims and objects. Interpretation should not be grammatical or literal, same should always be logical and liberal. True intention of statute or contract is the guiding principle. As per terms and conditions of the policy, OPs are liable to pay the balance amount to complainant but OPs intentionally rejected the claim of the complainant on wrong footings.

10.              Mostly, the insurance companies are only interested in earning the premiums and find ways and means to decline the claims. All conditions which generally are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. We find deficiency in service and unfair trade practice attributed on the part of OPs for not settling the claim of the complainant. The insurance companies ought not to have become too technical and ought not to have refused to settle the claim The Hon’ble Apex Court has decided this issue in case titled as Gurmel Singh vs. Branch Manager, National Insurance Co. Ltd. Reported in Civil Appeal No. 4071 of 2022that “there is  need for the insurance company has become too technical while settling the genuine claims. The insurance companies ought not to have become too technical and ought not to have refused to settle the claim. Hon’ble Apex Court observed that it is found that insurance companies are refusing the claim on flimsy grounds and /or technical ground while settling the claim.” The Apex Court in above titled is clear that insurance companies should not reject the claim on flimsy ground. At the time of issuance the insurance policy, Insurance companies shows rosy pictures to its customers OPs for purchasing the policies.

11.              In the light of our above discussion, we allow the complaint of the complainant and OPs are directed to pay balance amount of Rs.95,131/- with interest @ 4% from the date of filing the claim till its realization to complainant, which has wrongly rejected by OPs. The OPs are further directed to pay Rs.5000/- as compensation for mental harassment and Rs.3,000/- as cost of litigation.

12.              The compliance of the order be made within 45 days from receipt of copy of this order. Copies of the order be supplied to the parties free of costs.

13.              File is ordered to be sent back to the record room.

 Dated:07.10.2022                     (Kuljit Singh)

                                               President

(Yadwinder Pal Singh Baath)                            (Renu Gandhi)

               Member                                                       Member

.         .