Haryana

Bhiwani

CC/193/2022

Mandeep Singh - Complainant(s)

Versus

Star Health - Opp.Party(s)

Sushil Dhillon

15 Jul 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                            Consumer Complaint No. :  193 of 2022

                                                        Date of Institution           : 08.09.2022

                                                                  Date of order                  : 15.07.2024

 

Mandeep Singh son of Sh. Raj Pal Singh R/o village Alakhpura, Tehsil Bawani Khera, District Bhiwani.

  

           ……Complainant.

 

Versus

 

Star Health and Allied Insurance Company Ltd., Branch Office at SCF-47, Panchayat Pocket, Zoo Road, Bhiwani, Tehsil and District Bhiwani through its authorized signatory/Manager and Head Office at Star Health and Allied Insurance Company Limited, No.15, Sri Balaji Complex, 1^st Floor, Whites Lane, Rohapettah, Chennai-600014 through its 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. Ajay Verma, Advocate for complainant.

                    Sh. Avinash Sardana, Advocate for OP.

 

ORDER:

 

Saroj Bala Bohra, Presiding Member:

 

1.                 In brief, facts of this case are that complainant taken a health policy from OP for a period from 27.08.2021 to 26.08.2022 wherein complainant, his wife Rubina Kumari and his daughters Kavya and Ekanshi were covered. In the month of June, 2022, Ekanshi suddenly fell ill and she remained admitted in Ahuja Children Hospital, Hansi from 25.06.2022 to 28.06.2022 and Rs.10,652/- incurred on the treatment. Complainant submitted claim with OP for medical expense reimbursement, however, the claim was denied by OP vide e-mail dated 06.08.2022. Hence, the present complaint has been preferred by complainant alleging deficiency in service on the part of OP resulting into monetary loss besides mental and physical harassment.  In the end, prayer has been made to direct the OP to pay Rs.10,652/- besides Rs.1.00 lac as compensation for harassment and Rs.11,000/- towards litigation expenses. Any other relief to which this Commission deems fit has also been sought.

2.                 Upon notice, OP 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 alleged insurance policy was issued to the complainant subject to certain terms and conditions covering the complainant his abovesaid family members and sum assured under the police was Rs.5.00 lac.  It is submitted that claim submitted by complainant was scrutinized and found that discharged summary and final bill, IP/UHID number are not mentioned; lab reports are not having any seal and signature by the pathologist; the indoor case records are in stereotyped manner which amounts to misrepresentation of the facts as per condition no.1 of the policy and thus claim of complainant was repudiated on the grounds of discrepancy in the claim, vide letter dated 06.08.2022, under intimation to complainant.  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-16 were tendered and then closed the evidence.

4.                 In evidence of OP, 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 daughter of complainant was insured under the policy during the treatment period. Claim of complainant was repudiated by OP insurance company vide letter dated 06.08.2022 (Annexure R-10) on the grounds that ‘in the discharge summary and final bill, IP/UHID number are not mentioned; lab reports are not having any seal and signature by the pathologist; the indoor case records are in stereotyped man ne. Thus there is discrepancy in the records which amounts to misrepresentation of facts. Further, as per condition no.1 of the policy, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim.’

7.                 After hearing learned counsels for the parties and going through the pleading of parties supported by their respective evidence, it has come out that daughter of complainant remained admitted in the hospital from 25.06.2022 to 28.06.2022 and he incurred a sum of Rs.10,454/- on the treatment, as per medical bills on record. We have observed that the discharge slip and medical bills are duly signed by doctor of the concerned hospital, however, bills  for Rs.850/- of some tests  are not having signature of the treating doctor but these bills are mentioning name of patient, date on which it was prepared and the name of test. Further these bills are having the name of treating hospital as Ahuja Childern Hospital, Hansi, therefore, OP cannot denied that the bills were not genuine. 

8.                 In view of the above discussion, we do not see any discrepancy in the bills or record produced by complainant before OP for his medical expenses reimbursement claim rather the act & conduct of OP appears to be arbitrary, negligent and deficient in providing proper services to the complainant which definitely has caused complainant monetary loss as well as mental and physical harassment. Accordingly, the complaint is allowed and the OP is directed to comply with the following directions within 40 days from the date of order:-

(i)       To pay a sum of Rs.10,454/- (Rs. Ten thousand four hundred fifty four) 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 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 party 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: 15.07.2024