Haryana

Bhiwani

CC/343/2023

Atul Kumar - Complainant(s)

Versus

Star Health Ins. - Opp.Party(s)

Deepanshu Tutega

30 Sep 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                            Consumer Complaint No. :  343 of 2023

                                                       Date of Institution            : 20.11.2023

                                                                 Date of order                   : 30.09.2024

 

Atul Kumar son of Sh. Bishan Sarup R/o H.No.283 Bagh Kothi, Gali No.3, Bhiwani, Tehsil and District Bhiwani, Haryana.  

  

           ……Complainant.

 

Versus

 

 

1. Star Health and Allied Insurance Co. Ltd., Branch Office: SCF 47, 1^st Floor, Panchayat Bhawan Pocket, Bhiwani, Haryana-127021 through its Branch Manager.

 

2. Star Health and Allied Insurance Co. Ltd., Registered and Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai -600034 through its Authorized Person.

 

…… 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. Deepanshu Tuteja, Advocate for complainant.

                     Sh. Avinash Sardana, Advocate for OPs.

 

ORDER:

 

Saroj Bala Bohra, Presiding Member:

 

1.                 In brief, facts of this case are that complainant taken a family Health Optima Insurance Plan from 2019 and the same was renewed time to time. In this regard, complainant on 04.05.2022 paid renewal premium of Rs.27,164/- for a period from 06.05.2022 to 05.05.2023 in which sum insured was Rs.10.00 lac. It is alleged that complainant feeling unwell on 22.02.2023 and was admitted in Nitesh Goel Heart & Poison Hospital, Meham Chowk, Bhiwani. He was diagnosed as Enteric Fever and was discharged on 24.02.2023. A sum of Rs.28,458/- was incurred on the treatment. Claim was lodged with the OPs but it was repudiated on the grounds that patient could have been treated as outpatient and hospitalization was not warranted. As per complainant, he approached the treating doctor and apprised the situation, who issued a certificate against the grounds of repudiation of the claim of complainant. 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.28,458/- alongwith interest @ 18% per annum from the date of admission till its realization, further to pay Rs.51,000/- towards compensation for harassment besides Rs.21,000/- as litigation expenses. Any other relief, to which this Commission deems fit, has also been sought.

2.                 Upon notice, OPs appeared through counsel and tendered reply raising preliminary objections qua maintainability of complaint, estoppal against complainant, locus standi, deficiency in service, cause of action and suppression of material facts. On merits, it is admitted that complainant was covered under the policy on the alleged period of treatment. Complainant submitted claim his treatment of Eneteric Fever and going through the medical treatment history, it was observed that insured patient’s vitals are stable throughout the hospitalization. The medical team of OP company opined that as per Exclusion-Code Excl 36 of the policy, the OP company is not liable to pay the expenses of any hospitalization. So, claim of complainant was rightly repudiated vide letter dated 16.03.2023 under intimation to him. In the end, denied for any deficiency in service and prayed for dismissal of the complaint with costs.

3.                 In evidence of complainant, his affidavit Ex.CW1/A alongwith documents Ex. C-1 to Ex.C-7 were tendered and then closed the evidence.

4.                 In evidence of OPs, affidavit of Mr. Sumit Kumar Sharma, Senior Manager of OP company as Ex. RW1/A alongwith documents Annexure R-1 to Annexure R-9 were filed and then closed the evidence.

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

6.                 At the outset, it is not in dispute that complainant was under insurance cover during the period of treatment. As per pleadings and claim repudiation letter (Annexure R-9) by OPs, the claim was denied to complainant on the ground that for the treatment taken by complainant was not required hospitalization. Complainant to rebut the grounds of repudiation of the claim has placed on record a certificate issued by the doctor concerned (Ex. C-7) whereby it is crystal clear that hospitalization of the patient was necessary when brought to the hospital.

7.                 After hearing learned counsels for the parties and going through the entire record, we have observed that the OP insurance company has  arbitrarily denied claim to the complainant whereas the complainant was entitled to get reimbursed of the amount so incurred on  his treatment.  It is pertinent to mention here that whether a person is required indoor treatment or outdoor depends on situation of the illness and upon the wisdom of a doctor whereas patient has only follow the instructions of the treating doctor. From Discharge Certificate Ex. C-3, complainant was admitted in the hospital from 22.02.2023 to 24.02.2023 and as per bill (Ex. C-4) incurred Rs.28,458/- on his treatment are sufficient to prove the case of complainant.

8.                 In view of the above discussion, we are of the view that 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 OPs, jointly and severally, are directed to comply with the following directions within 40 days from the date of order:-

 

 (i)      To pay a sum of Rs.28,458/- (Rs. Twenty eight thousand four hundred fifty eight) to the complainant so incurred by him on his treatment 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 parties 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: 30.09.2024