BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 656 of 2022
Date of Institution : 07.11.2022
Date of Decision : 12.02.2024
Deepak Sethi (aged about 32 years) son of Shri Satpal, resident of H. No. 504, Gali Khalsa School Wali, Gujran Mohalla, Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
1. Star Health & Allied Insurance Company Ltd., No. 15, Sri Balaji Complex, Ist Floor, Whites Lane, Roy Apettah, Chennai- 600014, through its Authorized person/ M.D.
2. Star Health & Allied Insurance Company Ltd., 1st and 2nd Floor, Satya Sales Samsung Plaza, Showroom Building, Adjoining RC Regency Hotel, Hisar Road, Sirsa through its Authorized person/ representative.
3. Shah Satnam Ji Specialty Hospitals, Near Shah Satnam Ji Dham, Sirsa through its Authorized person/ representative.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA……….MEMBER
Present: Sh. Vijay Sharma, Advocate for the complainant.
Sh. Ravinder Monga, Advocate for opposite parties no.1 and 2.
Sh. K.R. Taak, Advocate for opposite party no.3.
ORDER:-
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that on 25.11.2021 complainant purchased health insurance policy bearing No. P/211121/01/2022/ 009336 from op no.2 vide which ops no.1 and 2 covered the health risk of complainant, his wife Dimple Arora and his son Prathamdeep up to Rs. five lacs and the policy was effective from 25.11.2021 to 24.11.2022. The complainant paid a sum of Rs.12,621/- for the said policy for one year. That on 24.06.2022 complainant’s wife Dimple Arora suffered from NASH Non-alcoholic steatohepatitis and she was admitted at Shah Satnam Ji Specialty Hospital, Sirsa op no.3. The complainant had shown cashless card of ops no.1 and 2 to the hospital authorities but ops no.1 and 2 did not provide the cashless scheme to the said hospital authority for the reasons best known to the officials of company and ops no.1 and 2 did not co-operate despite several requests made by complainant and ultimately op no.2 refused to pay any expenses by saying that the disease NASH is not covered under their policy. It is further averred that on 25.06.2022 ops no.1 and 2 have also mentioned in their letter that insured person does not require hospitalization and he/ she could have been treated as an out door patient. That due to aforesaid refusal by op no.2 complainant got discharged his wife from the aforesaid hospital against medical advise without any further treatment as complainant was not having sufficient amount with him at that time and he was under the impression that as per policy the medical facility is cashless. It is further averred that however health of his wife decreased day by day and due to this she took further treatment from Patiala Nursing Home, Sirsa but till date she has not recovered from her said disease. The complainant has spent a huge amount of Rs.30,000/ 35,000/- on her treatment and due to discharge against medical advise, the health of wife of complainant could not be recovered and she also requires further treatment for a long period and a huge amount is yet to be sent on her treatment. That complainant at the time of admission of his wife in the hospital has duly intimated ops no.1 and 2 and also requested to pay the expenses of hospitalization etc. but the officials of ops no.1 and 2 put the queries to the complainant on some different points which were got replied from treating doctor on 25.08.2022 but despite that ops no.1 and 2 have not paid even a single penny to the complainant. The ops no.1 and 2 despite his several requests have repudiated the claim of complainant on false and frivolous grounds/ conditions on 30.08.2022 and due to the aforesaid illegal and wrongful act, the complainant has suffered mental tension, harassment. It is further averred that if his wife could be treated as an outdoor patient as per policy of ops no.1 and 2 then how op no.3 admitted his wife in the hospital and in case of any negligent act of op no.3, op no.3 may be held responsible to pay all the expenses of treatment and compensation to the complainant. That ops have caused deficiency in service and unfair trade practice towards the complainant. That complainant also got served a legal notice dated 28.09.2022 to the ops but to no effect. Hence, this complaint.
3. On notice, ops appeared. Ops no.1 and 2 filed written version raising certain preliminary objections. It is submitted that insured Dimple Arora was admitted in Shah Satnam Singh Super Specialty Hospital on 24.06.2022 for treatment of NASH (Non-Alcoholic Steato Hepatitis) and was discharged on 25.06.2022. The insured submitted claim documents for reimbursement. The insured applied for reimbursement by claiming Rs.22,440/- mentioned in claim form. On perusal of the claim documents, it is observed that the condition of the patient does not require hospitalization and he/she could have been treated as an out door patient. Subsequently insured submitted the claim documents for reimbursement for the same admission and on scrutiny of the documents, they have raised the query to submit following documents:-
(a) Patient is known case of cervical spondylosis, kindly provide treatment doctor letter for exact duration of the same.
(b) Kindly provide all past treatment record pertaining to cervical spondylosis and all investigation done during those admission.
(c) A treating doctor letter for exaction duration of NASH in this patient.
(d) A treating doctor letter for probable etiology for NASH in this patient.
4. It is further submitted that insured has not submitted the documents called for by them which amounts to non submission of required documents. As per condition 16 of the insurance policy the insured person has to submit all the required documents as detailed above and called for by the company. Hence, this claim was repudiated vide letter dated 30.08.2022 which has been rightly repudiated as per terms and conditions of the policy in consonance of the previty of the contract. It is also submitted that it is fully established that there is a direct dispute between the complainant and op no.3 and answering ops cannot be held responsible for the same and complaint is liable to be dismissed qua answering ops. It is further submitted that in case it is found that company is liable to pay the claim, the maximum quantum of liability under the terms of the policy shall be Rs.12,553/-. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint qua ops no.1 and 2 made.
5. Op no.3 also filed written version raising certain preliminary objections regarding maintainability, cause of action, locus standi and that op no.3 is neither the necessary nor proper party to the present complaint and thus same is liable to be dismissed on this score and that there is no claim against op no.3 in the present complaint, hence same cannot be entertained against op no.3. On merits, it is submitted that there is no deficiency in service on the part of answering op nor there is any negligence on its part as alleged and complainant is not at all entitled to pay any compensation as alleged. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
6. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C38.
7. On the other hand, ops no.1 and 2 have tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex. RW1/A and documents Ex.R1 to Ex.R13.
8. Learned counsel for op no.3 suffered a statement that written statement filed on behalf of op no.3 be read in evidence.
9. We have heard learned counsel for the parties and have gone through the case file.
10. Admittedly on 25.11.2021 the complainant had purchased health insurance policy from the ops no.1 and 2 for the period 25.11.2021 to 24.11.2022 by paying premium amount of Rs.12,621/- and the health risk of complainant himself, his wife Dimple Arora and son Prathamdeep were insured under the policy for the sum insured amount of Rs.5,00,000/- which fact is also proved from insurance plan Ex.R2 placed on file by ops no.1 and 2 themselves. It is also proved on record from discharge card Ex.C5 that on 24.06.2022 i.e. during the period of policy in question wife of complainant namely Mrs. Dimple Arora suffered from the disease of NASH and she was treated in Shah Satnam Ji Specialty Hospital, Sirsa but the ops no.1 and 2 did not provide cashless facility to the complainant and as such complainant incurred expenses of her treatment from his own pocket despite the fact that they were having health insurance policy. The ops no.1 and 2 denied cashless request of the complainant vide letter dated 25.06.2022 (Ex.R5) on the ground that condition of the insured patient does not require hospitalization and he/ she could have been treated as an out patient. Thereafter, complainant lodged the claim with the ops no.1 and 2 for reimbursement of the treatment expenses amount of Rs.22,440/- spent by him on her wife as is evident from claim form dated 20.07.2022 (Ex.R6) but ops no.1 and 2 vide their letter dated 10.08.2022 raised above said queries from the complainant and above said queries were duly replied by the treating doctor through certificate dated 25.08.2022 Ex.C7. The treating doctor duly replied to the above said queries of the ops no.1 and 2 through the said certificate that they do not know about cervical spondylosis, their medical officer written this in history as per patient version, she is not under their treatment for same and that second query is included in first answer. In third query the treating doctor replied that when patient was in their hospital then Gastroenterologist visited her and given his opinion about NASH on basis of raised SGPT and SGOT as there is no alcoholic history or no other drug induced history and this was an incidental finding and the treating doctor also replied that answer of fourth query is included in third answer. As such the queries raised by ops no.1 and 2 were duly replied by the treating doctor, therefore, it cannot be said that documents were not submitted by the complainant or insured patient and as such ops no.1 and 2 have wrongly and illegally repudiated the genuine claim of the complainant. The ops no.1 and 2 have failed to prove on record that what other documents were not submitted by the complainant or insured patient as the ops no.1 and 2 only raised above said queries which were duly got replied to them by the treating doctor. The ops no.1 and 2 have also wrongly denied the cashless facility to the complainant on the false and vague ground that condition of the insured does not require hospitalization and she could have been treated as out patient because seeing the condition of the insured patient the treating doctor admitted her in the hospital and she was treated as indoor patient, therefore, it cannot be said at all that she could have been treated as out door patient. The admission of the patient was necessitated as told by the concerned doctor and it was not choice and will of the patient to get admission in the hospital. The ops no.1 and 2 are liable to reimburse the expenses spent on the treatment of Dimple Arora insured patient and non reimbursement of the same and repudiation of the genuine claim of the complainant by ops no.1 and 2 clearly amounts to deficiency in service and unfair trade practice towards the complainants and they have also caused unnecessary harassment to the complainant. It is proved on record from various bills/ receipts placed on file by complainant as Ex.C9 to Ex.C31, Ex.C37 and Ex.C38 that complainant spent about Rs.24,000/- on the treatment of his wife and he lodged claim amount of Rs.22,440/- with the ops no.1 and 2 for reimbursement and as such complainant is entitled to the said amount of Rs.22,440/- from ops no.1 and 2. However, no negligence of any type of op no.3 is proved on record.
11. In view of our above discussion, we allow the present complaint qua opposite parties no.1 and 2 and direct the ops no.1 and 2 to pay above said claim amount of Rs.22,440/- to the complainant alongwith interest @6% per annum from the date of filing of present complaint i.e. 07.11.2022 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops no.1 and 2 to further pay a sum of Rs.10,000/- as composite compensation for harassment and litigation expenses to the complainant within above said stipulated period. However, complaint qua op no.3 is hereby dismissed. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 12.02.2024. District Consumer Disputes
Redressal Commission, Sirsa.
