Haryana

Bhiwani

CC/90/2022

Laush - Complainant(s)

Versus

Star Health - Opp.Party(s)

Naveen Saini

25 Jun 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                             Consumer Complaint No. :  90 of 2022

                                                        Date of Institution           : 13.05.2022

                                                                  Date of order                  : 25.06.2024

 

Layush aged 7 ½ years minor son of Sh. Dharambir R/o village Kharkhari, Tehsil Loharu, District Bhiwani through his natural guardian & father Dharambir son of Omparkash.

  

           ……Complainant.

 

Versus

 

1. Star Health and Allied Insurance Co. Ltd., New Tank Street, Valluvar Kottam, High Road, Nungambakkam, Chennai through Managing Director/ authorized signatory.

 

2. Star Health and Allied Insurance Co. Ltd., Branch Office: SCF No.47, Panchayat Bhawan Pocket, Bhiwani through its Branch Manager/Authorized signatory.

 

…… 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. Naveen Saini, 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 health policy from OP on 16.08.2021 having sum insured Rs.5.00 Lac w.e.f. 16.08.2021 to 15.08.2022.  On 20.09.2021, complainant got fracture and was got admitted in Rahul Goyal Trauma and Joint Replacement, Bhiwani from 20.09.2021 to 23.09.2021 and Rs.76,243/- were incurred on the treatment.  Information qua this incident was given to OPs and also filed claim of the said amount but the OPs repudiated the claim vide letter dated 20.12.2021. 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.76,243/- alongwith interest @ 24% per annum from 23.09.2021 till realization of the amount. Further to pay Rs.50,000/- as compensation for harassment besides Rs.22,000/- 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, deficiency in service, locus standi & cause of action and suppression of material facts. On merits, it is submitted that the insurance policy was issued to the complainant subject to certain terms and conditions. It is also submitted that reimbursement claim was submitted by complainant with regard to hospitalization from 20.09.2021 to 23.09.2021. It is submitted that there were some discrepancies qua the time of discharge of patient and amount incurred on the treatment which is violation of terms and conditions of the policy as such claim was rejected vide letters dated 11.11.2021 and 20.12.2021. However, it is submitted that liability under the terms and conditions of the policy shall be Rs.33,955/-. 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 Annexure C-1 to Annexure C-8 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-12 were filed and then closed the evidence.

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

6.                 It is not in dispute that complainant was insured under the policy during the treatment period. Claim of complainant was repudiated by OP insurance company vide letter dated 11.11.2021 (Annexure R-10) on the ground as per documents, patient was discharged on 23.09.2021 at 6.00 p.m. but as per discharge card and letter of treating doctor discharge is at 10: am on 23.09.2021. Further, as per information with OP, Rs.70,000/- was paid at the time of discharge only but as per payment receipt at the hospital, total payment of Rs.86,043/- was paid in cash in three installments of Rs,25,000/- on 20.09.2021, Rs.20,000/- on 22.09.2021 and remaining balance Rs.23,403/- on the day of discharge i.e. 23.09.2021.

7.                 After going through the repudiation letter as well as pleading of the parties and evidences produced on record from both the sides, it has come out that complainant remained admitted in the hospital from 20.09.2021 to 23.09.2021 as corroborated from discharge slip Annexure C-6 and as per final bill Annexure C-2 paid Rs.68,043/- in the hospital for medical treatment. As per repudiation letter, incur of this amount on the treatment has not been denied by the OP insurance company. Thus the complainant is entitled to Rs.68,043/- as incurred on the medical treatment.

8.                 In view of the above discussion, we are of the view that OP insurance company has wrongly and illegally repudiated the claim of complainant just to cheat and harass the complainant which amounts to deficiency in service and mal-trade practice on their part 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.68,043/- (Rs. Sixty eight thousand forty three) to the complainant so incurred by him on the 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  on account of mental agony and physical harassment. 

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

                    In case of non-compliance, all the awarded amounts shall further 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.  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: 25.06.2024