BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 41 of 2022
Date of Institution : 17.01.2022
Date of Decision : 15.05.2024
Satbir Singh Asija (aged about 59 years) son of Sh. Naranjan Singh Asija, Near Geeta Bhawan, Ward No.4, Rama Mandi, Bathinda (Punjab).
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., First Floor, Satya Sales (Samsung Showroom), RC Regency, Surkhab Chowk, Sirsa through its Branch Manager.
2. Star Health and Allied Insurance Company Ltd., No. 15, Sri Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai- 600014, through its authorized person.
…….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. R. S. Varch, Advocate for the complainant.
Sh. Ravinder Monga, Advocate for opposite parties.
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 he purchased health insurance policy namely Family Health Optima Insurance-2017 bearing No. P211121/01/2021/000891 from the ops and the last insurance policy commenced from 22.05.2020 to 21.05.2021 vide which risk of Rs. five lacs was covered in all respects and complainant lastly paid premium amount of Rs.24,143/-. The complainant was previously purchasing family health policy from other insurance company and this fact was duly intimated to the ops and the ops after verifying from the previous insurance company accepted the premium from complainant and also endorsed the previous policy no. 233200/48/2020/667. It is further averred that due to some acute problem the complainant went to Dayanand Medical College Ludhiana where he remained as indoor patient from 11.02.2021 to 16.02.2021 and the treating doctor prepared discharge summary and submitted all the documents including bills to the ops for reimbursement. The ops after examining the documents put some query and required some documents which were also supplied to them but the ops postponed the matter on one or other pretext with the assurance that claim is in process and will be reimbursed to him very shortly but thereafter vide letter dated 01.09.2020 the ops wrongly and illegally repudiated the claim of complainant as per clause 03 of the policy on the ground of non furnishing of required documents whereas complainant submitted all the required documents including previous blood test report, certificate issued by the doctor from which it was clear that he was not having any pre existing disease as alleged in the repudiation letter and the treating doctor clarified the difference between CKD and AKD. It is further averred that complainant informed the ops that the alleged base mentioned in the impugned letter on the basis of which his claim has been repudiated has no concern and cannot be treated as a pre existing disease. The ops by showing their adamancy and unilateral attitude agreed to withdraw their impugned letter dated 01.09.2021 but surprisingly they have also taken a step ahead by crossing their heights when the name of complainant deleted from the policy by cancelling and further issued fresh policy in favour of her wife alone. That complainant has contacted with the ops for a number of occasions for releasing the claim amount of Rs.1,84,189/- but ops have not paid any heed to the genuine requests of complainant and have caused deficiency in service, unfair trade practice and unnecessary harassment to the complainant. Hence, this complaint.
3. On notice, ops appeared and filed written version raising certain preliminary objections. It is submitted that no physical verification was done and the policy was issued only based on the proposal given by the insured. Although the insured had insurance policy earlier with the Oriental Insurance Company since 14.05.2019 and ported his policy with the answering ops under portability effected from 14.09.2019 to 13.05.2020. The terms and conditions were explained at the time of proposing the policy and the same was served to the complainant alongwith the policy schedule. Moreover, it is clearly stated in the policy schedule that the insurance under this policy is subject to condition, clause, warranty, exclusions etc. It is further submitted that the policy is a contractual in nature and the claim arises wherein subject to terms and conditions are forming part of the policy. The complainant after fully understanding, agreeing and aware about the terms and conditions executed the proposal form. The ops issued the policy to the complainant on the basis of information disclosed by him in the proposal form by believing in complainant and assuming that the information disclosed by complainant to be true in proposal form without any pre medical screening. It is further submitted that complainant lodged the claim before the company and submitted the documents for reimbursement towards the treatment of diabetes, mellitus, CAD, AWM1, moderate dysfunction post covid-19 acute on CKD, BPH grade-1. After carefully analyzing the documents, it was observed that the insured requested a cashless of medical expenses towards the treatment of CKD, CAD at DMC Ludhiana. On scrutiny of the cashless documents, further evaluation was required to ascertain the admissibility of the claim, hence the cashless authorization was denied and same was communicated to the treating hospital as well as insured vide copy of letter dated 16.02.2021. Subsequently, the insured submitted claim documents for reimbursement towards the treatment of diabetes, mellitus, CAD, Awmi Moderate dysfunction post covid-19 acute on CKD, BPH grade-1 for Rs.1,84,189/-. The patient had requested to furnish the required documents for the purpose of proceedings the claim. The following are necessary to process the claim:
* Submit a letter from treating Nephrologists stating the probable cause and duration of CKD and submit first and all past consultation reports, USG abdomen, RFT report since diagnosis.
* Submit all prior OPD consultation reports since onset of symptoms.
* Complete set of Indoor Case Papers with OT notes.
* Submit all past OPD consultation reports of Diabetic mellitus and hypertension.
* A letter from treating doctor stating that exact duration of heart disease and BPH.
4. It is further submitted that in this regard written letter dated 28.04.2021, 13.05.2021 and 28.05.2021 has been sent to the complainant, finally on account of non furnishing the required documents, the claim has been repudiated vide letter dated 01.09.2021. The reason mentioned in repudiation letter has been observed from the documents furnished/ supplied by the complainant and claim has rightly been repudiated with the speaking orders. It is further submitted that in case it is found that company is liable to pay the claim in terms of the contract of insurance issued to the complainant, the maximum quantum of liability under the terms of the policy shall be Rs.81,915/-. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
5. The complainant in evidence has tendered his affidavit Ex. C1 and documents Ex.C2 to Ex.C53.
6. On the other hand, ops have tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex.R1 and documents Annexures R1 to R19.
7. We have heard learned counsel for the parties and have gone through the case file.
8. From the policy schedule Ex.C4, it is evident that complainant had purchased health insurance policy from the ops for the period 22.05.2020 21.05.2021 for the sum insured amount of Rs. five lacs. The ops have also admitted that insured had insurance policy earlier from Oriental Insurance Company since 14.05.2019 and ported his policy with answering ops under portability from 14.09.2019 to 13.05.2020. From the treatment record placed on file by complainant such as discharge summary Ex.C5, it is evident that on 11.02.2021 i.e. during the period of policy in question complainant was admitted in Dayanand Medical College & Hospital, Ludhiana where he was diagnosed with Diabetes mellitus, CAD, CKD, BPH Grade 1 and procedure of coronary angiography (single vessel disease) PTCA with stenting to LAD was done and he was discharged on 16.02.2021 and complainant claims that he spent an amount of Rs.1,84,189/- on his above said treatment. The claim submitted by complainant to the ops has been repudiated by ops vide letter dated 01.09.2021 Ex.C3 as per condition no.3 of the policy on the ground of non submission of required documents i.e. documents related to kidney disease, heart disease and benign prostate hypertrophy. However, we are of the considered view that ops have wrongly and illegally repudiated the claim of complainant on the said ground of non submission of above said documents because all the documents including test reports, treatment record are on the file and it is not believable that claimant who has to seek reimbursement of his claim amount will not submit the required documents to the insurance company. The documents which were in possession of complainant have already been submitted to the ops and same have also been placed on file by complainant and therefore, demand of documents by the ops which may not be in possession of complainant is not justified. The complainant stated that he took treatment from 11.02.2021 to 16.02.2021 and all the documents regarding this treatment period have been placed on record and therefore, it cannot be said that he has not supplied the documents to the ops and demand of the ops regarding any previous record is not justified because complainant has categorically stated that he was not having any pre existing disease and he did not took any treatment of above said disease prior to his admission on 11.02.2021. Further more, ops have also failed to prove on record through any cogent and convincing evidence that complainant was having any pre existing disease and therefore, repudiation of claim of complainant on the ground of non submission of past consultation reports etc. is wrong and illegal. Further the plea of op that in case it is found that they are liable to make payment to the complainant, then maximum liability of ops shall be of Rs.81,915/- and not of Rs.1,84,189/- is also not justified and it appears that ops have made huge deduction without any basis and it is proved on record from deposit receipt dated 16.02.2021 Ex.C51 that complainant deposited an amount of Rs.1,69,938/- with Dayanand Medical College & Hospital, Ludhiana and from other bills/ receipts also it is evident that complainant has spent above said total amount of Rs.1,84,189/- on his treatment and as such he is entitled to said amount of Rs.1,84,189/- from ops. Non payment of this amount to the complainant clearly amounts to deficiency in service on the part of ops due to which complainant has suffered unnecessary harassment.
9. In view of our above discussion, we allow the present complaint and direct the opposite parties to make payment of Rs.1,84,189/- to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 17.01.2022 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.10,000/- as compensation for harassment and Rs.5000/- as litigation expenses to the complainant within above said stipulated period. 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: 15.05.2024. District Consumer Disputes
Redressal Commission, Sirsa.
