Haryana

Bhiwani

CC/279/2023

Amit Kumar - Complainant(s)

Versus

Star Health Ins. - Opp.Party(s)

Pankaj Sharma

14 Oct 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                            Consumer Complaint No. :  279 of 2023

                                                       Date of Institution            : 19.09.2023

                                                                 Date of order                   : 14.10.2024

 

Amit Kumar son of Sh.Ramesh Chander Sharma R/o Lokmanya Street Near Kirori Mal Mandir, Bhiwani, Tehsil and District Bhiwani.

  

           ……Complainant.

 

Versus

 

 

1. Star Health and Allied Insurance Co. Ltd., Branch Office Rohtak Ashoka Plaza, 3^rd Floor Delhi Road, Rohtak-124001.

 

2. J.B. Gupta, Hospital, Chiriya Ghar Mor, Bhiwani.

…… Opposite Parties.

 

COMPLAINT U/S 35 OF CONSUMER PROECTION ACT, 2019.

 

BEFORE:       Mrs. Saroj Bala Bohra, Presiding Member.

  Ms. Shashi Kiran Panwar, Member.

 

Present:-        Sh. Pankaj Sharma, Advocate for complainant.

                     Sh. Avinash Sardana, Advocate for OP No.1.

 Sh.Amit Kumar, Advocate for OP No.2 (defence struck of vide

 order dated 19.01.2024).

 

ORDER:

 

Shashi Kiran Panwar, Member:

 

1.                 In brief, facts of this case are that complainant was insured with OP insurance company under Family Health Optima Insurance Plan for Rs.10.00 lac, for a period from 13.06.2022 to 12.06.2023.  Complainant has submitted that his daughter Nandini Kaushik got admitted in the hospital of OP No.2 for Acute Viral Hepatitis from 22.05.2023 to 27.05.2023 and Rs.37,744/- incurred on the treatment. Claim for reimbursement of the amount was lodged with the OP insurance company but it was rejected. So, legal notice dated 25.08.2023 was served upon the OP but of no avail.  Hence, the present complaint has been preferred by complainant alleging deficiency in service on the part of Ops resulting into monetary loss besides mental and physical harassment. In the end, prayer has been made to direct the OPs to pay Rs.37,744/-, further to pay Rs.1.00 lac as compensation for harassment besides Rs.27,000/- as cost of litigation. Any other relief, to which this Commission deems fit, has also been sought.

2.                 Upon notice, OP No.1 appeared through counsel and tendered reply raising preliminary objections qua maintainability of complaint, estoppal against complainant, locus standi, deficiency in service and suppression of material facts. On merits, it is admitted that complainant and his family members were covered under the policy on the alleged period of treatment. It is submitted that as per discharge summary, the insured was admitted and diagnosed with Acute Viral Hepatitis and thus the patient was not admitted in emergency. It is submitted that the OP hospital is an excluded provider hospital by the OP insurance company on 10.08.2022. It is urged that the insured was admitted on 22.05.2023 and the claim was intimated on 09.06.2023 which was after 18 days after the admission which is violation of the terms and conditions of policy. If the insured would have intimated the claim within 24 hours of the admission then, the OP would have informed about the OP hospital as Excluded Provider.  Hence, the claim of complainant was rejected and intimated vide letter dated 17.06.2023. In the end, denied for any deficiency in service and prayed for dismissal of the complaint with costs.

3.                 OP No.2 did not file written statement despite availing sufficient opportunities, as such, defence of OP No.2 was struck of vide order dated 19.01.2024.

4.                 In evidence of complainant, his affidavit Ex.CW1/A alongwith documents Ex. C-1 to Ex.C-20 were tendered and then closed the evidence.

5.                 In evidence of OP No.1, affidavit of Mr. Sumit Kumar Sharma, Senior Manager of OP company as Ex. RW1/A alongwith documents Annexure R-1 to Annexure R-11 were filed and then closed the evidence.

6.                 We have heard learned counsels for the contesting parties and perused the record carefully.

7.                 Initially, it is not in dispute that daughter of complainant was under insurance cover during the period of treatment. As per pleadings of OP insurance company and claim repudiation letter (Annexure R-9), the claim was denied to complainant on the ground that “…..it is observed from the submitted records that the insured patient was admitted and treated in an excluded provider (hospital).  As per Exclusion No.(11), Excluded Providers-Code Excl 11 of the policy, the expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the insurer and disclosed in its website /notified to the policyholders are not admissible.”

8.                 After hearing learned counsels for the parties and going through the entire record, we have observed that as per Annexure R-10, OP insurance company has assessed Rs.35,340/- as final admissible amount towards the claim of complainant.  Further, there is no record on file which could show that the OP hospital was not an approved hospital for the OP insurance company. In view of the above, we have concluded that the OP insurance company has arbitrarily and illegally denied reimbursement claim to the complainant whereas the complainant was entitled to get reimbursed of the amount so incurred on the treatment of his daughter being insured at the time of admission. From Discharge Summary Annexure C-14, insured Nandini Kaushik remain admitted in the OP hospital from 22.05.2023 to 27.05.2023 and as per bills (Ex. C-15 & Ex. C-16) incurred Rs.37,444/- on the treatment, are sufficient to prove the case of complainant. As such, the complainant is entitled to get reimbursed Rs.35,340/- from the OP insurance company.

9.                 As a sequel to above, the OP insurance company is deficient and negligent in providing proper services to the complainant resulting into monetary loss as well as mental and physical harassment. Accordingly, the complaint is allowed and the OP No.1insurance company is directed to comply with the following directions within 40 days from the date of order:-

 (i)      To pay a sum of Rs.35,340/- (Rs. Thirty five thousand three hundred forty) to the complainant so incurred by him on the treatment of her daughter alongwith simple interest @ 9% per annum from the date of filing of complaint till actual realization.

(ii)      To pay Rs.5,000/- (Rs. Five thousand) as compensation   for  harassment. 

3. To pay Rs.5500/- (Rs. Five thousand five hundred) as litigation expenses.

                    In case of non-compliance, all the awarded amounts shall attract simple interest @ 12% per annum for the period of default. 

                    The complainant shall be entitled to the execution petition under section 71 of Consumer Protection Act, 2019 and in that eventuality, the opposite party No.1 may also be liable for prosecution under Section 72 of the said Act which envisages punishment of imprisonment, which may extend to three years or fine upto rupees one lac or with both.  Copies of this order be sent to the parties concerned, free of costs.  File be consigned to the record room, after due compliance. 

Announced.

Dated: 14.10.2024