Chandigarh

DF-I

CC/500/2023

HARMESH KUMAR GOYAL - Complainant(s)

Versus

STAR HEALTH INSURANCE COMPANY LIMITED - Opp.Party(s)

AMMISH GOEL

03 Jun 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/500/2023
Date of Institution	:	09/10/2023
Date of Decision	:	03/06/2024

 

Harmesh Kumar Goyal s/o Late Sh. Jagannath Goyal, r/o House No.5054/2, Modern Complex, Category-III, Phase-I, Manimajra (UT), Chandigarh 160101.

… Complainant

V E R S U S

1. Star Health Insurance Company Limited through its Managing Director having its registered office No.1, New Tank Street, Valluvarkottam High Road, Nungambakkam, Chennai-600034.
2. Star Health Insurance Company Limited, through its Branch Manager, having its office at SCO No.5A, Sector 7-C, Madhya Marg, Chandigarh 160019.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Ammish Goel, Advocate for complainant
	:	Ms. Surabhi Grover, Advocate for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Harmesh Kumar Goyal, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that in the month of July, 2021, representatives of OP-2 approached the complainant and explained about the various salient features of Accident Care Insurance Policy.  On their assurance, complainant purchased the “Accident Care Individual Revised-2015 policy” (hereinafter referred to as “subject policy”) on payment of requisite premium and the same was valid w.e.f. 13.8.2021 to 12.8.2022. Copy of the policy cover note alongwith terms & conditions is Annexure C-1.  On 17.6.2022, when the complainant was going to his office at morning time, he suddenly slipped nearby his society and fell down on the road and his left eye struck against some sharp object, as a result of which, he lost vision of his said eye.  In addition to the said injury, he also suffered injuries on his left ankle. Immediately he was taken to PGI, Chandigarh by the family members where he was admitted w.e.f. 17.6.2022 to 21.6.2022 and the treating doctor had performed the surgery on the left eye. Copy of registration card and medical certificate are Annexure C-2 & C-3.  After getting discharged from the PGI on 21.6.2022, complainant duly informed the OPs vide letter (Annexure C-4) about the injuries sustained by him.  Thereafter the complainant visited the PGI, Chandigarh for his routine check-up and on examining the said eye and finding some complication post surgery, the treating doctor performed another surgery of the said eye on 19.9.2022. The complainant had spent an amount of ₹65,753/- from his own pocket on account of medical expenses.  The complainant was also advised for complete bed rest for 14 weeks by the medical officer and the medical certificates issued by the hospital are (Annexure C-5 colly.).  After getting discharged from the PGI, Chandigarh, complainant brought the aforesaid facts to the notice of the OPs and submitted the documents for the medical reimbursement of ₹65,753/-, which he had spent from his own pocket and ₹2,10,000/- on account of bed rest for 14 days, total amounting to ₹2,75,753/-.  However, the complainant was shocked to know that the OPs had only approved and released the claim to the tune of ₹1,80,000/- against the claimed amount of ₹2,75,753/- by counting bed rest for 12 weeks only and thereby made deduction of ₹65,753/- spent on account of medical expenses and ₹30,000/- on account of bed rest.  In the meantime, the medical board of PGI had also given the permanent disability certificate (Annexure C-6) to the complainant on 24.1.2023 confirming that the vision of the subject eye had been got damaged to the extent of 30%. Thereafter the complainant received letter dated 5.4.2023 (Annexure C-8) from the OPs whereby his claim had been repudiated on the ground that TTD benefit, which is paid for submitted diagnosis and medical extension optional benefit is not chosen by the complainant.  In this manner, OPs had wrongly approved the claim of the complainant only partially by making illegal and arbitrary deduction and the same amounts to deficiency in service and unfair trade practice on their part. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action, concealment of facts and jurisdiction.  However, it is admitted that the subject policy was purchased by the complainant which was valid at the relevant time and also that the complainant after his treatment had submitted the documents with the OPs for reimbursement of his claim including TTD benefit for 15 weeks.  It is further alleged that TTD benefit was given to the complainant for 12 weeks and the complainant was not entitled for medical expenses as he had not taken the medical expenses extension while purchasing the subject policy. It is specifically denied that 14 weeks bed rest documents were submitted by the complainant with the OPs.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In replication, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had purchased the subject policy which was valid w.e.f. 13.8.2021 to 12.8.2022 with total sum insured of ₹1,36,00,000/- with different sum insured as mentioned in Table A  (Accidental death), Table B (Accidental death and permanent disablement) and Table C (Accidental death, permanent disablement and temporary total disablement) : (Weekly compensation) and not covered medical expenses extension since the complainant had not opted the said option and during the currency of the subject policy, complainant sustained grievous injuries on his left eye by falling on the road for which he was treated at PGI, Chandigarh through two surgeries and he remained hospitalized w.e.f. 17.6.2022 to 21.6.2022 and remained unfit to resume his duty w.e.f. 17.6.2022 to 3.10.2022, as is also evident from the medical certificates (Annexure C-3 and C-5 (Colly.) and the complainant had submitted the claim for total amount of ₹2,75,753/- i.e. ₹65,753/- for medical expenses and ₹2,10,000/- on account of bed rest and the claim of the complainant was partially disallowed by the OPs, as is also evident from the repudiation letter (Annexure C-8), the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in partially repudiating the genuine claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if OPs are justified in partially approving the claim to the tune of ₹1,80,000/- and the consumer complaint of the complainant, being not maintainable, is liable to be dismissed, as is the defence of OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, medical record and repudiation letter.
   3. Perusal of terms and conditions annexed with the subject policy (Annexure C-1) clearly indicates that the complainant had purchased the subject policy with total sum insured of ₹1,36,00,000/- covering the benefits under Table A, B & C, as discussed above, and not opted for the medical expenses extension. As the terms and conditions of the subject policy have not been disputed by the complainant, one thing is clear that since the complainant had not paid the premium for medical expenses extension, he is not entitled for the medical expenses to the tune of ₹65,753/-.
   4. It is an admitted case of the parties that the OPs have already paid an amount of ₹1,80,000/- on account of temporary total disablement by considering the temporary disablement of the complainant as at that time the permanent disability certificate (Annexure C-6) was not submitted by the complainant with the OPs.  However, when the complainant has now obtained the said disability certificate from the medical authority, Chandigarh, indicating that aforesaid authority has declared 30% permanent disability in relation to left eye of the complainant, the claim of the complainant is required to be assessed by the OPs under Table B and Table C of the terms and conditions of the subject policy as earlier the same was assessed on account of temporary total disablement and for that purpose the relevant portion of the terms and conditions of the subject policy (Annexure R-3) are reproduced below for ready reference :-

Sl. No.	Name of the Insured	Sum Insured (Rs.)				Optional Benefits opted
		Table A	Table B	Table C	Total	Medical expenses extension	Hospital cash	Home convales-cence	Winter sports
1.	HARMESH KUMAR GOYAL	2100000	10000000	1500000	13600000	No	No	No	No

                II. SCOPE OF COVER

The Company hereby agrees, subject to the terms, conditions and exclusions herein contained or otherwise expressed herein, to pay to the Insured person or his nominees or his legal heirs, a sum as compensation for any loss occurring during the Period of Insurance as described under different sections hereunder and as specified in the Schedule to the Policy.

Table-A-ACCIDENTAL DEATH: If at any time during the Period of Insurance, the Insured Person shall sustain any bodily injury resulting solely and directly from Accident caused by external, violent and visible means and such accident causes death of the Insured Person within 12 Calendar months from the date of Accident, then the Company will pay an amount as compensation 100% of the Capital Sum Insured.

Table-B-ACCIDENTAL DEATH AND PERMANENT DISABLEMENT: If the Insured Person meets with an Accident, which leads to disablement or subsequent death, the Company will provide insurance coverage to the Insured in the following manner.

1. Accidental Death of Insured Person: If following an Accident that causes death of the Insured Person within 12 Calendar months from the date of Accident, then the Company will pay an amount as compensation 100% of the Capital Sum Insured.

2. Permanent disablement of the Insured Person: If following an Accident which caused permanent impairment of the Insured's mental or physical capabilities, then the Company will pay the benefits as provided in the Table of Benefits B1 or Table of Benefits B2 mentioned herein, depending upon the degree of disablement provided that;

a) The disablement occurs within 12 Calendar months from the date of the Accident.

b) The disablement is confirmed and claimed for, prior to the expiry of a period of 60 days since occurrence of the disablement.

c) Where a covered Accident results in Permanent Disablement falling under Table of benefits B1 (Permanent Total Disablement) and under Table of benefits B2 (Permanent Partial Disablement) then the higher percentage of the sum insured will be paid,

       Table-C ACCIDENTAL DEATH, PERMANENT DISABLEMENT AND TEMPORARY TOTAL DISABLEMENT: (WEEKLY COMPENSATION)

1. Accidental Death of Insured Person: If following an Accident that causes death of the Insured Person within 12 Calendar months from the date of Accident, then the Company will pay an amount as compensation 100% of the Capital Sum Insured.

2. Permanent disablement of the Insured Person: If following an Accident which caused permanent impairment of the Insured's mental or physical capabilities, then the Company will pay the benefits as provided in the Table of Benefits B1 (Permanent Total Disablement) or Table of Benefits B2 (Permanent Partial Disablement) mentioned herein depending upon the degree of disablement provided that:

a)  The disablement occurs within 12 Calendar months from the date of the Accident.

b) The disablement is confirmed and claimed for, prior to the expiry of a period of 60 days since occurrence of the disablement

c) Where a covered Accident results in Permanent Disablement falling under Table of benefits B1 (Permanent Total Disablement) and under Table of benefits B2 (Permanent Partial Disablement) then the higher percentage of the sum insured will be paid

3. Temporary Total Disablement: If at any time during the period of insurance the insured person/s shall sustain Grievous injury arising solely and directly from an accident and resulting in hospitalization, then the insured person will be paid a sum calculated at 1% of the sum insured under Table C per completed week but not exceeding Rs.15,000/- per completed week, in all, under all Personal Accident policies, if such injury be the sole and direct cause of Temporary Total Disablement.

    This benefit is subject to a maximum period of 100 weeks from the date of such Temporary Total Disablement.

    In no case shall the compensation exceed the sun insured for this benefit.

    The payment shall be made only after the termination of such disablement.

    All the benefit under this section is subject to exclusions, as mentioned in 'General Exclusions' of this Policy.”

5. Perusal of the subject policy (Annexure R-2) further clearly indicates that the complainant had obtained the same for risks detailed under table A, B and C and as per table B, in case of permanent disablement of the insured person, the company would pay benefits as provided in the table of benefits B(1) or table of benefits B(2), making further clear that in case of permanent disability to the insured, he is not entitled for the weekly compensation as the same was only payable in case of temporary total disablement.
6. In the case in hand, as it is an admitted case of the parties that the OPs have already paid an amount of ₹1,80,000/- to the complainant on account of temporary total disablement, it is clear that the complainant was not entitled for the said amount as during the pendency of the consumer complaint, evidence has come that the complainant had suffered permanent disability and the claim of the complainant is covered under table B and not under table C.
7. In order to assess the claim of the complainant, OPs were required to take into consideration the permanent disability certificate (Annexure C-6) and the relevant portion of the same is reproduced below for ready reference :-

“He is a case of Low Vision

The diagnosis in his case is Left Eye globe Injury (status post primary repair + vitrectomy surgery)

He has 30% (in figure) Thirty percent (in words) Permanent Disability in relation to his Left Eye as per the delines (Guidelines for the purpose of assessing the extent of specified disability in a person included under RPwD 2016 notified by Government of India vide S.0. 76(E) dated 04/01/2018).”

 

8. The benefits in case of permanent total disablement and permanent partial disablement have specifically been provided in the terms and conditions of the subject policy (Annexure R-3/internal page 7) which further makes it clear that in case of total and irrevocable loss of sight of both eyes, 100% of sum insured is payable and in case of total irrevocable  loss of sight of one eye, 50% of sum insured under table B1 is payable to the insured as the said percentage has been assessed only for permanent total disablement cases.
9. Since the perusal of disability certificate (Annexure C-6) makes it clear that there is only 30% permanent disability in relation to the left eye of complainant, the case of complainant is squarely covered under permanent partial disablement, benefits of which have been tabulated in table B2, which makes it clear that in case of any other permanent partial disablement, the percentage as assessed by the medical board or by the Govt. doctor is to be considered on the percentage of sum insured which is to be payable by the insurer.  The relevant portion of Table B1 & B2 on internal page 7 of the subject policy (Annexure R-3) is reproduced below for ready reference :-

Permanent Total Disablement – Table of Benefits B1			Permanent Partial Disablement – Table of Benefits B2
Benefits	Percentage of sum insured			Benefits		Percentage of sum insured
1. xxx	xxx		1 to 9	xxx		xxx
2(xii) Sight of one eye	50%		10	Any other Permanent partial disablement	Percentage as assessed by the Medical Board or by the government doctor

Further, when it is an admitted case of parties that the sum insured under Table B is ₹1,00,00,000/- and as the medical board has declared 30% permanent disability, it is clear that complainant is entitled to 30% of the sum insured i.e. ₹30,00,000/-.  However, when it has also come on the record that ₹1,80,000/- has already been released to the complainant by the OPs, therefore, after deduction of the said amount, OPs are liable to pay an amount of ₹28,20,000/- (₹30,00,000 – ₹1,80,000) to the complainant alongwith interest and compensation etc. 

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹28,20,000/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 5.4.2023 onwards.
2. to pay ₹20,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

03/06/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member
	Sd/- [Suresh Kumar Sardana] Member