DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/20/2023
Date of Institution: 22.02.2023
Date of Decision: 04.12.2024
Rajinder Singh, aged about 37 years, son of Darshan Singh resident of Bahadar Nagar, Old Radha Swami Street, Near New Peerkhana, Ward No. 8, Barnala-148101, Tehsil and District Barnala, Punjab.
…Complainant
Versus
1. Star Health & Allied Insurance Company Limited, Branch Office Bathinda, SCF No. 133, 2nd Floor, G.T. Road, Goniana Road, Bathinda-151001 through its Branch Manager.
2. Star Health & Allied Insurance Company Limited, Registered and Corporate Office, 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai 600034 through its Authorized Signatory/Responsible Person.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Dhiraj Kumar Adv counsel for complainant.
Sh. Rohit Jain Adv counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Star Health & Allied Insurance Company Limited, Branch Office Bathinda, SCF No. 133, 2nd Floor, G.T. Road, Goniana Road, Bathinda-151001 through its Branch Manager & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant obtained a cashless Young Star Insurance Policy from 24.07.2022 to 23.07.2023 of the OPs of Rs. 5,00,000/- and in this regard the OPs issued a Policy bearing No. P/211217/01/2023/002235 and the complainant got insured himself and his family through the above said policy. It is further alleged that the complainant falls on a road and feels pain in left shoulder and he was admitted at Bhim Nursing Home and Trauma Centre, Handiaya Bazar, Barnala on 28.09.2022 for his treatment and the complainant was discharged from hospital on 03.10.2022 after his treatment. It is further alleged that due to clerical mistake the name of the complainant was wrongly mentioned by the doctor as Harjinder Singh instead of Rajinder Singh on X-ray but same was rectified by the concerned when fact was come to in his knowledge and new X-ray was conducted and the complainant/concerned doctor applied for claim of Rs. 96,714/- regarding amount of treatment etc. alongwith claim form, original bills, copy of policy, original discharge summary, treatment record, original doctors prescriptions, copy of cancelled cheque, copy of PAN card, copy of Aadhar Card etc. before the Ops but the OPs rejected the claim on 29.09.2022 and on 06.12.2022 and on 13.12.2022 with wrong reason. It is further alleged that by the act and conduct of the Ops the complainant is suffering from a lot of harassment and mental agony and the complainant has issued a notice dated 05.01.2023 through his counsel to the OPs but the OPs have not bothered to reply the same. As such, the act and conduct of the opposite parties comes within the definition of the unfair trade practice as well as deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to make payment of Rs. 96,714/-alongwith interest.
- To pay Rs. 25,000/- as compensation of humiliation and harassment and pay Rs. 20,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking preliminary objections on the grounds that the complainant has no locus-standi to file the present complaint. The present complaint is not legally maintainable. The complainant has no cause of action to file the present complaint. The complainant has not come with clean hands etc.
4. On merits, it is admitted to the extent that the complainant is insured with the opposite parties under Young Star Insurance Policy vide policy No. P/211217/01/2023/002235 from 24.07.2022 to 23.07.2023 for Rs.5,00,000/-for himself, spouse and children. It is denied that the complainant fall on road and got injury on his left shoulder, however as per claim form the complainant was got admitted in Bhim Nursing home and Trauma Centre, Handiya Road, Barnala. It is further admitted that as per claim form the complainant was discharge on 03.10.2022 and submitted claim of Rs.96,714/-. It is further denied that due to clerical mistake the name of the complainant was written as Harjinder Singh instead of Rajinder Singh on X-Ray film and the same was rectified by the concerned when this fact came to his knowledge and new X-Ray was conducted. It is further alleged that this policy is ported from HDFCERGOGI (24.07.2019 to 23.07.2021) to the opposite parties from 24.07.2021 and the terms and conditions of the policy explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. Moreover it is clearly stated in the policy schedule THE INSURANCE UNDER THIS POLICY IS SUBJECT ΤΟ CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED. It is submitted that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy and the complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form. It is further alleged that the insured has requested for cashless treatment of HUMERUS FRACTURE, at BHIM NURSING HOME, BATHINDA on dated 29.09.2022 and sought for Pre Authorization Request for Cashless treatment during the 4th year of the policy and the same was denied vide letter dated 29.09.2022 stating that further evaluation is needed to ascertain the admissibility of the claim and advised the insured to come for reimbursement with all necessary documents wherein the claim might be considered on merit basis. It is further alleged that subsequently insured has submitted the claim documents towards reimbursement and on scrutiny of claim records it was observed that the following documents are necessary to process the claim. Hence, advised the insured vide our letter dated 27.10.2022 to furnish: Self declaration letter stating the circumstance of injury with time and place.
i) first aid treatment records (mandatory for further evaluation).
ii) clear pre and post Operative X-Ray records. (submitted records are not clear).
iii) Complete Operation theatre notes.
iv) all payment receipts.
It is observed that the insured has not submitted us the Complete Query Reply and the insured has not submitted the above said documents which amounts to non submission of required documents. It is further alleged that in the absence of the above documents/details, we are not able to further process your claim. Further, medicine bills are in chronological order on different dates. As per Condition No.18 of the above policy, the insured person has to submit all the required documents and details called for by the opposite parties. Further, it is noted that the discrepancy was noted in Pre Operation X-ray Films. Two Different names are noted in the same X ray Harjinder and Rajinder in claim No. -CIR/2023/211217/0857298 and CIR/2023/211217/ 0853998. Hence, the claim was repudiated vide letter dated 05.11.2022. All other allegations are denied and prayed for the dismissal of complaint.
5. The complainant has filed rejoinder to the written version of opposite parties vide which he denied the averments as mentioned in the version.
6. The complainant tendered into evidence affidavit of Rajinder Singh as Ex.C-1, copy of policy as Ex.C-2 (containing 4 pages), copy of claim form as Ex.C-3 (containing 3 pages), copies of bills are Ex.C-4 to C-17, copy of treatment record as Ex.C-18 to C- 21, copy of application to insurance company as Ex.C-22, copies of receipts are Ex.C-23 to Ex.C-25, copy of letter dated 28.09.2022 as Ex.C-26, copy of rejection of claim as Ex.C-27, copy of E mail as Ex.C-28, copy of legal notice as Ex.C-29, postal receipts are Ex.C-30 & C-31 and closed the evidence.
7. The opposite parties tendered into evidence affidavit of Sumit Kumar Sharma Manager Ex.OP-1, copy of proposal form Ex.OP-2, copy of portability form Ex.OP-3, copy of policy Ex.OP-4, copy of terms and conditions Ex.OP-5, copy of cashless request Ex.OP-6, copies of letters dated 29.9.2022 Ex.OP-7 and Ex.OP-8, copy of claim form Ex.OP-9, copy of discharge summary Ex.OP-10, copy of bill Ex.OP-11, copy of X-ray film Ex.OP-12, copy of letter dated 27.10.2022 Ex.OP-13, copy of repudiation letter Ex.OP-14, copy of bill assessment sheet Ex.OP-15 and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file.
9. It is admitted case of the opposite parties that the complainant is insured with the opposite parties under Young Star Insurance Policy vide policy No. P/211217/01/2023/002235 from 24.07.2022 to 23.07.2023 for Rs. 5,00,000/-for himself, spouse and children (as per Ex.C-2). It is further admitted case of the opposite parties that as per claim form the complainant was discharge on 03.10.2022 and submitted claim of Rs.96,714/- (as per Ex.C-3 & Ex.O.Ps-9).
10. Ld. Counsel for the complainant argued that the complainant falls on a road and feels pain in left shoulder and he was admitted at Bhim Nursing Home and Trauma Centre, Handiaya Bazar, Barnala on 28.09.2022 for his treatment and the complainant was discharged from hospital on 03.10.2022 after his treatment (as per Ex.C-20). It is further argued that due to clerical mistake the name of the complainant was wrongly mentioned by the doctor as Harjinder Singh instead of Rajinder Singh on X-ray but same was rectified by the concerned when fact was come to in his knowledge and new X-ray was conducted. It is further argued that the complainant/concerned doctor applied for claim of Rs. 96,714/- regarding amount of treatment etc. alongwith claim form, original bills, copy of policy, original discharge summary, treatment record, original doctors prescriptions, copy of cancelled cheque, copy of PAN card, copy of Aadhar Card etc. before the opposite parties but the opposite parties rejected the claim on 29.09.2022 as per Ex.C-27 with wrong reason. It is further argued that by the act and conduct of the opposite parties the complainant is suffering from a lot of harassment and mental agony and the complainant has issued a notice dated 05.01.2023 Ex.C-29 through his counsel to the opposite parties but the opposite parties have not bothered to reply the same.
11. On the other hand, Ld. Counsel for the opposite parties argued that this policy is ported from HDFCERGOGI (24.07.2019 to 23.07.2021) to the opposite parties from 24.07.2021 and the terms and conditions of the policy explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule and it is clearly stated in the policy schedule THE INSURANCE UNDER THIS POLICY IS SUBJECT ΤΟ CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC. ATTACHED. It is further argued that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy and the complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form. It is further argued that the insured has requested for cashless treatment of HUMERUS FRACTURE, at BHIM NURSING HOME, BATHINDA on dated 29.09.2022 and sought for Pre Authorization Request for Cashless treatment during the 4th year of the policy and the same was denied vide letter dated 29.09.2022 Ex.O.P-8 stating that further evaluation is needed to ascertain the admissibility of the claim and advised the insured to come for reimbursement with all necessary documents wherein the claim might be considered on merit basis. It is further argued that subsequently insured has submitted the claim documents towards reimbursement and on scrutiny of claim records it was observed that the certain documents (as mentioned in the version) are necessary to process the claim, hence advised the insured vide letter dated 27.10.2022 Ex.O.P-10 to furnish the same but the insured has not submitted the above said documents which amounts to non submission of required documents. It is further argued that in the absence of the above documents/details the opposite parties are not able to further process the claim. It is further argued that medicine bills are in chronological order on different dates and as per condition No.18 of the above policy the insured person has to submit all the required documents and details called for by the opposite parties, hence the claim was repudiated vide letter dated 05.11.2022 Ex.O.P-14.
12. We have gone through the facts and evidence produced by the parties. The allegation of the opposite parties in the present case is that it is noted that the discrepancy was noted in Pre Operation X-ray Films and Two Different names are noted in the same X-ray Harjinder and Rajinder in claim No.-CIR/2023/211217/0857298 and CIR/2023/211217/ 0853998 but to prove this fact the opposite parties have failed to place on record the copy of above said X-ray report/films in which the name of Harjinder Singh has been mentioned instead of Rajinder Singh. Moreover, the opposite parties have placed on record the copy of X-ray film i.e. Ex.O.P-12 in which the name of Rajinder Singh is mentioned. On the other hand, Ld. Counsel for the complainant argued that due to clerical mistake the name of the complainant was wrongly mentioned by the doctor as Harjinder Singh instead of Rajinder Singh on X-ray but same was rectified by the concerned when fact was came to in his knowledge and new X-ray was conducted and to prove this fact the complainant has placed on record the copy of X-ray Service Slip Ex.C-24 in which the name of Rajinder Singh is mentioned. The complainant has also produced the certificate of doctor Ex.C-21 at Page No. 2 in this regard.
13. The another allegation of the opposite parties in the present case is that despite the letter dated 27.10.2022 i.e. Ex.O.P-13 sent by the opposite parties to the complainant for requirement of additional documents/information as mentioned in the said letter but the complainant has failed to submit the required documents and as per condition No. 18 of the above policy the insured person has to submit all the required documents and details called for by the opposite parties, hence the claim was repudiated vide letter dated 05.11.2022 Ex.O.P-14. On this, the Ld. Counsel for complainant argued that after discharge from the hospital on 3.10.2022 the complainant submitted all the required documents alongwith medical record to the opposite parties as demanded by them for the reimbursement of treatment. Moreover, from the perusal of the file it shows that all the documents are already on the Court file and we are of the view that if the opposite parties required the same to settle the claim of the complainant, then they could have procure the same from the Court file but at this stage they cannot escaped from their liabilities by taking these types of unreasonable and unjustified grounds. The opposite parties alleged in repudiation letter that claim has been repudiated as per Clause No. 18 of the terms and conditions of the insurance policy. Ld. Counsel for the complainant has argued that the opposite parties have not supplied the terms and conditions of the policy to the complainant alongwith policy and the copy of insurance policy is Ex.C-2 (containing 4 pages) and the terms and conditions of the policy are not the part of the said insurance policy. On the other hand the opposite parties have also placed on record copy of insurance policy Ex.O.P-4 and the same is not containing terms and conditions of the policy. Moreover, the opposite parties have failed to prove the fact that they have supplied the terms and conditions of the policy to the complainant alongwith policy or they have explained the same to the insured when the policy was issued or renewed. Therefore, the terms and conditions on which the opposite parties relied upon are not part of the contract. The Hon'ble Supreme Court of India titled Modern Insulators Limited Versus Oriental Insurance Company Limited reported in 2000(1) CPC-596 in which Hon'ble Supreme Court held that As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclose to the appellant, respondent cannot claim the benefit of the said exclusion clause. The Hon’ble Supreme Court of India (2019) 6 SCC 212 in case titled Bharat Watch Company Through its Partner Vs National Insurance Company Limited held that Conditions of exclusion under policy document not handed over to insured by insurer and in absence of insured being made aware of terms of exclusion, held, it is not open to insurer to rely upon exclusionary clauses. So, we are of the view that at this stage the opposite parties cannot be escaped from their liabilities by raising these types of unreasonable and unjustified grounds. Ld. Counsel for the complainant also relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims.
14. Further, the complainant to prove his claim has placed on record Hospital Bill Ex.C-4 from which it shows that an amount of Rs. 92,814/- has been spent on the treatment of insured at Bhim Nursing Home, Handiaya Bazaar, Barnala. However, in the present complaint the complainant has claimed an amount of Rs. 96,714/-. On the other hand, the opposite parties in support of their case have produced the copy of Bill Assessment Sheet of Insured Patient as Ex.O.P-15 vide which the opposite parties have assessed the Final Admissible Amount as Rs. 91,003/- which is un-rebutted. So, we are of the view that the complainant is entitled to the amount of Rs. 91,003/-.
15. From the above discussion, it is proved that the claim of the complainant was repudiated by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties.
16. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 92,814/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
4th Day of December, 2024
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
