Haryana

Bhiwani

CC/230/2022

Chetan Anand - Complainant(s)

Versus

Star Health - Opp.Party(s)

Jitender Kaushik

16 Oct 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                            Consumer Complaint No. :  230 of 2022

                                                       Date of Institution            : 15.11.2022

                                                                 Date of order                   : 16.10.2024

 

Chetan Anand son of Sh. Gopal Ram R/o H.No.7, Giriraj Colony, Near Canal Rest House, Meham Road, Bhiwani.

  

           ……Complainant.

 

Versus

 

 

1. Star Health and Allied Insurance Co. Ltd., No.15, Balaji Complex, Whites Lane, 1^st Floor, Royapettah, Chennai-600014 through its Managing Director/General Manager.

 

2. Star Health and Allied Insurance Co. Ltd., Booth No.32-33, HUDA City Center, Court Road, Bhiwani through its Branch Manager.

 

…… 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. Jitender Kaushik, 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 had taken an insurance policy No.P/211128/01/2021/002443 from OP which was valid upto 16.02.2022. This insurance policy was thereafter got renewed upto 16.02.2023. It is submitted that complainant was diagnosed with heart disease and  admitted  in  AIIMS, Delhi on 18.09.2021 and  undergone bypass surgery on 22.09.2021 and was discharged on 04.10.2021. It is submitted that OP was intimated well in advanced through e-mail about such surgery.  Claim reimbursement documents for Rs.1,11,900/- were prepared from the concerned hospital but the OP refused to receive the documents on one pretext or the other despite issuance of legal  notice dated 29.08.2021. 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.1,11,900/- alongwith interest @ 12% per annum from the date of accrual till its realization, further to pay Rs.1.00 lac towards compensation for harassment etc.

2.                 Upon notice, OPs appeared through counsel and tendered reply raising preliminary objections qua maintainability of complaint, locus standi, and deficiency in service, cause of action and suppression of material facts. On merits, it is admitted that complainant was covered under the policy Family Health Optima Revised 2017 for a sum of Rs.5.00 lac with OPs on the alleged period of treatment subject to certain terms and conditions of the policy. It is submitted that on claim intimation of the hospitalization, the complainant was asked to furnish all relevant and prerequisite documents required for processing of the claim but despite various reminders dated 19.02.20231, 04.10.2021 and 19.10.2021, complainant failed to submit the required documents which were necessary as per conditions no.2 of the policy. As such, claim of complainant was repudiated vide letter dated 03.11.2021. 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-6 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-6 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-6), the claim was denied to complainant for want of “duly completed claim form alongwith discharge summary, investigation reports, hospital bills, payment receipts, prescriptions, medical bills etc. Even after reminders, you have not sent the documents, therefore, presuming that you are not interested in performing the claim and therefore, the same was rejected.”

7.                 Complainant to prove that he was under treatment and incurred a sum of Rs.1,11,900/- on his treatment has placed on record bills/documents Annexure C-3 & Annexure C-4 and the grievance of complainant is that the amount was not released by the Ops despite intimating them which has caused him financial loss as well as mental pains and physical harassment.

8.                 After hearing learned counsels for the parties and going through the record, we have observed that complainant has incurred a sum of Rs.1,11,900/- for his heart treatment at AIIMS, Delhi but the amount was not reimbursed to the complainant despite intimating the OP. Therefore, it is concluded that OP insurance company has repudiated the claim of complainant in a casual manner without mentioning any cogent and convincing reason thereof and such practice has compelled the complainant to knock the doors of the Consumer Commission. It is also observed that by deficiency in service on the part of OPs, complainant must have suffered monetary loss as well as mental and physical pains. So, he is also entitled to get compensation for harassment from the OPs. Hence, 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.1,11,900/- (Rs. One lac eleven thousand nine hundred) to the complainant so incurred by him on treatment alongwith simple interest @ 9% per annum from the date of filing of complaint till actual realization.

(ii)      To pay Rs.20,000/- (Rs. Twenty thousand) as compensation  for  harassment. 

3. To pay Rs.5000/- (Rs. Five thousand) as litigation expenses.

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

                    Further, 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.  Certified copies of this order be sent to the parties concerned, free of costs, as per rules.  File be consigned to the record room, after due compliance. 

Announced.

Dated:16.10.2024.