PER:

Ms. Nidhi Verma Member

1        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 34, 35 and 36 against the opposite party on the allegations that the opposite party Star Health and Allied Insurance Company Limited are doing the business of insurance and opposite party No.4 is running a branch office of Star Health and Allied Insurance Company. The complainant has taken Family health insurance plan from the party No.1 on 2.6.2021 for a sum of Rs. 5,00,000/- vide policy No. P/211237/01/2022/000296 at their branch office i.e. opposite party No. 3 on the basis of annual premium installment at the rate of Rs.15000/- per year and the complainant has paid his first premium of Rs.15000/- at the same time at the branch office and the first coverage plan commencing period was started from 2.6.2021 to midnight of 1.6.2022. The premium of insurance is being paid by the complainant to opposite party. On 9.10.2021 suddenly the son of the complainant namely Karanbir Singh suffered from illness and then the complainant arranged a vehicle and he got admitted his son at Cherish Children Hospital Medicity Market, Opp. Civil Hospital Tarn Taran in emergency condition and concerned doctor has advised to the complainant for admission in Hospital for medical treatment and son of the complainant was got admitted on 9.10.2021 to 14.10.2021 and concerned doctor conducted his Digital Radiograph Chest AP View, Haematology test i.e. WBC, New#, Mon#, RBC, HGB, PLT, PCT, C-Reactive Protein, Microbiology and others from the various Lab and diagnostics centers. After treatment the son of the complainant discharged from above said Hospital and son of the complainant has come to back in house. The complainant alongwith respectable persons approached to the respondent No.4 at their branch office and also provided them the original copies of treatment of son of complainant, medical bills and the complainant lodged his claim to the opposite party No.4 and the said claim alongwith record was forwarded to their divisional office i.e. opposite party No.1 for settling the claim of son of complainant. After that the complainant has approached to the opposite party No. 3 and 4 so many times, but every time they linger on the matter from pretext one to another and respondent/opposite party No.1 has not accepted the claim and the opposite parties and have not paid the full claim amount to the complainant and full claims to complainant. The complainant is entitled to Rs. 40,380 /-. The complainant has paid his full premium of above said policy to the opposite party No.1, but the opposite party No.1 has intentionally prolonged /in-ordinarily delayed, refused, disbursement of assurance claim, putting in mental agony, depression, harassing and teasing.  The complainant has prayed that the opposite party may kindly be directed to pay damages and compensation to the tune of Rs. 50,000/- alongwith litigation expenses and Rs. 40,380/-i.e. treatment amount may also be awarded in favour of complainant and against opposite parties for unnecessary harassment, inconvenience, agony and mental tension suffered by the complainant at the hands of the opposite parties. Alongwith the complaint, the complainant has filed documents i.e. copy of policy Ex. C-1, Original Discharge Card Ex.  C-2, Copy of Treatment Chart Ex. C-3, Original Radiograph Chest A View Report dated 9.10.2021 Ex. C-4, Original Radiograph Chest AP View Report dated 14.10.2021 Ex. C-5, Original Lab Report from 9.10.2021 to 14.10.2021 Ex. C-6 Copy of Medical Bill Ex. C-7, Original receipt/ bills of health care Lab’s and ECG Centre Ex. C-8 to Ex. C-12, Original receipt/ Bills of Cherish Children Hospital Ex. C-13 to C-22, X-Ray Films of Karanbir Singh Ex. C-23 and C-24, Copy of Cover Note of Star Health and Allied Insurance Company Limited Ex. C-25, Affidavit of complainant Ex. C-26, Copy of Adhar Card of complainant Ex. C-27, Copy of Refusal order dated 16.2.2022 Ex. C-28.

2        Notice of this complaint was sent to the opposite party and opposite party appeared through counsel and filed written version by interalia pleadings that the insured availed Family Health Optima Insurance Plan vide policy No. P/211237/01/2022/000296 for the period of 2.6.2021 to 1.6.2022 covering Mr. Palwinder Singh- self, Mrs. Mandeep Kaur- spouse and two dependent children Mr. Karanbir Singh & Ms. Hargunpreet Kaur for the sum insured of Rs.5,00,000/-. The terms and conditions of the Policy were duly explained to the complainant at the time of receipt of proposal and the same was served to the complainant along with the Policy Schedule. The complainant has not come to the Commission with clean hands and has concealed material facts from this Commission, therefore, the complainant is not entitled for any relief as claimed. The insured patient Mr. Karanbir Singh was admitted at Cherish Children Hospital-Best Child Care Hospital on 09-10-2021 for the treatment of SEPSIS/PNEUMONIA and submitted medical documents for reimbursement of the claim. On perusal of the medical documents it was observed that:-

(i)      As per claim form part a date of admission is mentioned as 9.10.2021 and date of discharge as 7.09.2021, but as per part B of claim form and discharge summary date of admission is 9.10.2021 and date of discharge is 14.10.2021.

(ii)     Date of sign is tampered in discharge summary.

(iii)    Serial investigation receipt of Guru Nanak is having different dates and there is tempering on date in the investigation report.

(iv)    Treatment charts are in stereotyped and single handwritten.

Thus there is clear cut discrepancy in the medical records produced which amount to misrepresentation of fact, therefore, the claim was rejected and intimation to this affect was given to the complainant vide letter dated 16.2.2022. Keeping in view the above said facts, the claim of the complainant was rightly repudiated as per terms and conditions of the policy, the relevant clause is reproduced below: -

As per condition No-1:- The policy shall be void and all premium paid thereon shall be forfeited to the Company, in the event of mis-representation, mis-description or non-disclosure of any material fact by the policy holder.

The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same were served to the complainant alongwith the policy schedule. The complainant is estopped by his own act and conduct from filing the present complaint, as the complaint has been filed without any cause of action. The complainant has got no locus standi to file the present complaint. The complaint has been filed without any cause of action against the opposite parties and denied the other allegations of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite parties have placed on record affidavit of Sumit Kumar Sharma, Senior Manager Ex.OP1,2,3,4/1, self attested copy of Power of attorney/Authority letter Ex.OP1,2,3,4/2, self attested copy of policy Ex.OP1,2,3,4/3, self attested copy of terms and conditions Ex.OP1,2,3,4/4, self attested copy of proposal form Ex.OP1,2,3,4/5, self attested copy of field visit report (FVR) Ex.OP1,2,3,4/6, self attested copy of claim form Ex.OP1,2,3,4/7, self attested copy of discharge summary Εx.OP1,2,3,4/8, self attested copy of receipts dated 09.10.2021 and 14.10.2021 Ex. OP1,2,3,4/9(colly.), self attested copy of dial investigation reports Ex. OP1,2,3,4/10(colly.), self attested copy of indore case papers Ex.OP1,2,3,4/11(colly.), self attested final bill Ex. OP1,2,3,4/12, self attested copy of repudiation letter dated 16.02.2022 Ex.OP1,2,3,4/13. Without prejudice to whatever has been stated earlier in this written statement, even assuming without conceding that the company is liable to pay the claim in terms of the contract of insurance issued to the claimant-petitioner, it is respectfully submitted that the maximum quantum of liability under the terms of the policy shall be Rs.33,769/-, A detailed Billing Sheet is Ex.ΟΡ1,2,3,4/14).

3        We have heard the Ld. counsel for the complainant and opposite party and have carefully gone through the record placed on the file.

4        In the present case, the complainant has taken family health insurance plan from the O.P No. 1 on 02.06.2021 for the sum of Rs. 500,000/- vide policy No. P/211237/01/2022/000296  at the rate of Rs.15,000/-per year. On dated 09.10.2021 suddenly the son of the complainant namely Karanbir Singh suffering from illness and then complainant admitted his son at Cherish Children Hospital Medicity Market , Opp. Civil Hospital Tarn Taran in emergency condition , the son of the complainant was got admitted on 09.10.2021 to 14.10.2021 and concerned doctor conducted his digital radiograph chest Ap View, Haematology test i.e. WBC,NEW#, MON#, RBC , HGB , PLT, PCT , C- Reactive Protein , Microbiology and others from the various Lab and diagnostics centers. The complainant provided the original copies of the treatment of son of complainant ,medical bills and the complainant lodged his claim to the opposite party No.4. On dated 16.02.2022 O.Ps refused to accept the genuine claim of the complainant.

5        O.Ps stated in their written version that the insured patient Mr. Karanbir Singh was admitted at Cherish Children Hospital Best Child Care Hospital on 09.10.2021 for the treatment of sepsis/pneumonia and submitted medical documents for reimbursement of the claim. On perusal of the medical documents it was observed that:-

• As per claim form part A date of admission is mentioned as 09.10.2021 and date of discharge as 07.09.2021 but as per part B of claim form and discharge summary date of admission is 09.10.2021 and date of discharge is 14.10.2021.

• Date of sign is tampered in discharge summary.
• Serial investigation receipt of Guru Nanak is having different dates and there is tempering on dated in the investigation report.
• Treatment charts are in stereotyped and single handwritten.

Thus there is clear cut discrepancy in the medical records produced which amount to misrepresentation of facts, therefore the claim was rejected and intimation to this affect was given to the complainant vide letter dated 16.02.2021.

6        As a result of the above discussion we are of the considered view that there is no dispute regarding the family health insurance plan availed by the complainant from the O.Ps . There is no dispute regarding the treatment of the son of the complainant. The only dispute is regarding the medical documents produced by the complainant which amount to misrepresentation of facts and therefore, the claim was rejected by the O.Ps. As per O.Ps the claim form (Ex.Op 1to 4/7) where part A date of admission is 09.10.2021 and date of discharge is 07.09.2021 but as per part B and discharge summary date of admission is 09.10.2021 and date of discharge is 14.10.2021 , O.Ps rejected the claim on above stated ground of mismatched date of discharge . However, complainant placed on record the original discharge card (Ex.C2) where date of admission is 09.10.2021 and date of discharge is 14.10.2021 and while gone through the discharge card carefully we found in ‘weight’ column just below the date of discharge which is written as 7.9kg and it might be writing mistake that instead of discharge date one mistakenly written the weight figure in claim part A of discharge date as 07.09.2021 which clearly resembled with weight figure as 7.9kg . Moreover , it’s impossible that a person admitted in October month and discharged in September month( one month earlier) , it’s clearly a writing mistake. Which cannot be considered as the reason for the repudiation of the claim .

7        According to O.Ps the second reason for repudiation the claim of the complainant is “sign is tampered in discharge summary” if we go through the discharge summary (Ex.C2) It is not intentional but it may be a writing mistake . However, if the O.Ps is alleging that the signature is tampered they are supposed to put strict proof regarding tampering . The O.Ps are failed to prove that the signature are tampered. The correction on the discharge card is not fatal to the case of the complainant. The contention of the O.Ps is without basis. Hence, we hold that the O.Ps have selected a flimsy ground without any basis to repudiate the claim of the complainant which is ill founded.

8        According to O.Ps the third reason for repudiation the claim of the complainant is “Serial investigation receipt of Guru Nanak is having different dates and there is tempering on dated in the investigation report.” After gone through the receipts and investigation report of Guru Nanak ( Ex. C4,C5,C9,C11) we found nothing is tampering, it’s just an objection by the O.Ps to repudiate the claim of the complainant. Prudent man can easily see the tampering with naked eyes if there is any discrepancy in the bills as well as the receipts issued by the Guru Nanak  Diagnostic Center . The receipts are issued by the Guru Nanak are in continue serial numbers with different dates which may not be considered as the reason of the repudiation of the claim of the complainant .

9        According to O.Ps the fourth reason for repudiation the claim of the complainant is “ Treatment charts are in stereotyped and in single handwritten.” After gone through the treatment charts (Ex.C 3) and other documents placed on record by the complainant i.e. discharge Card ( Ex.C2) , medical bill (Ex.C7,C13 to C22) , Claim Form (Ex.C-25) all are signed by Dr. Raj Kumar Punia , which seems that Cherish Children Hospital may have only one appointed Doctor/ hospital authority namely Dr. Raj Kumar Punia , hence having only one treating doctor and treatment charts are in single handwritten cannot considered as the reason of repudiation of the claim of the complainant. If single handwritten of treatment charts is the reason by the O.Ps then they have to prove that the more consultant/ hospital authority/ treating doctors are available in the hospital but O.Ps failed to prove the same. The complainant had no control over the handwriting of the treating doctor and his staff. The complainant cannot be blamed for any similarities of the handwriting or stereotyped recording of the treatment charts . Further, if any tampering took place in the treatment charts, then without specifying as to whether or not the said tampering’s are glaring , we are not inclined to accept the version of O.Ps as a gospel truth .Merely saying that the treatment charts is in stereotyped and single handwritten is not the point to repudiate the claim of the complainant .

10      Thus, we find it a case of deficiency in service and unfair trade practice on the part of the O.Ps . O.Ps intentionally with the malafide intention are not paying the claimed amount for which they have no right to do so and due to negligence in the service by the O.Ps the complainant has been suffering a huge mental harassment.

11      Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.UshaYadav& Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these 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. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

12      In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant. The opposite Parties are directed to make the payment of Rs. 40,380/-i.e. treatment amount /insurance claim to the complainant. The complainant has been harassed by the opposite parties unnecessarily for a long time. The complainant is also entitled to Rs.10,000/- as compensation on account of harassment and mental agony and 5,000/- as litigation expenses. Opposite Parties are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.

Announced in Open Commission

11.07.2024