Haryana

Bhiwani

CC/123/2022

Manju Yadav - Complainant(s)

Versus

Star Health - Opp.Party(s)

V.P Yadav

23 Oct 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                            Consumer Complaint No. :  123 of 2022

                                                       Date of Institution            : 23.06.2022

                                                                 Date of order                   : 23.10.2024

 

Smt. Manju Yadav wife of Sh. Ved Parkash R/o VPO Pahladgarh, Tehsil and District Bhiwani.

  

           ……Complainant.

 

Versus

 

 

1. Star Health and Allied Insurance Co. Ltd., No.15, Sri Balaji Complex 1^st Floor, Whites Lane, Royapettah, Chennai-600014 through its authorized signatory.

 

2. Star Health and Allied Insurance Co. Ltd. having its branch at SCF No.47, Panchayat Bhawan Pocket, Bhiwani through its Branch Manager.

 

3. Anup Kumar, Agent, Star Health and Allied Insurance Co. Ltd. R/o

SCF No.47, Panchayat Bhawan Pocket, Bhiwani.

 

…… 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. V.P. Yadav, Advocate for complainant.

                     Sh. Avinash Sardana, Advocate for OPs No.1 & 2.

                     OP No.3 given up vide order dated 21.03.2024.

 

ORDER:

 

Saroj Bala Bohra, Presiding Member.

 

1.                 In brief, facts of this complaint are that complainant taken a Family Health Optima Insurance-2017 from OP for a period from 07.05.2021 to 06.05.2022. It has been submitted that in the month of March 2022, complainant suddenly fell ill due to severe headache, giddiness and vertigo. OP No.3 was informed who suggested to get treatment from Chugh Multispecialty Hospital, Bhiwani being a panel hospital. So, complainant got admitted there from 04.03.2022 to 06.03.2022. A sum of Rs.21,110/- was spent on the treatment. Claim was submitted with the OP insurance company but it was repudiated. 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.21,110/- alongwith interest @ 24% per month up to date from 06.04.2022 till its realization. Further to pay Rs.1.00 for the losses suffered by complainant due to negligence act & conduct of OPs alongwith interest @ 18% till payment and to pay Rs.10,000/- as compensation for harassment besides Rs.5500/- as cost of litigation. Any other relief, to which this Commission deems fit, has also been sought.

2.                 Written statement on behalf of OPs filed raising preliminary objections qua maintainability of complaint, locus standi, deficiency in service, cause of action and suppression of material facts. On merits, it is admitted that during the period of treatment, complainant was covered under the policy.  It is submitted that on scrutiny of the claim of complainant, it was observed that ICP completely stereotyped and tampering was noted. Thus there was discrepancy in the records which amounts to misrepresentation of facts and as per condition no.6 of the policy, the company is not liable to make any payment in respect of such type of claim. Further, all investigation reports were within normal limit, therefore, there was no indication for hospitalization and insured could have been treated as OPD case. Hence, the claim of complainant was repudiated and intimated vide letter dated 28.05.2022. In the end, denied for any deficiency in service and prayed for dismissal of the complaint with cost.

3.                 Ld. counsel for complainant given up OP No. 3 being unnecessary, vide his separate statement dated 11.04.2023.

4.                 In evidence of complainant, his affidavit Ex.CW1/A alongwith documents Annexure C-1 to Annexure C-19 were filed and then closed the evidence on 05.05.2023.

5.                 In evidence of OPs No.1 & 2, affidavit of Mr. Sumit Kumar Sharma, Senior Manager of OP company as Ex. RW1/A alongwith documents Annexure R-1 to Annexure R-14 were filed and then closed the evidence on 24.01.2024.

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

7.                 At the outset, we have perused the repudiation letter dated 28.05.2022 (Annexure C-10) wherein it is mentioned that “the insured patient seeking reimbursement of hospitalization expenses for treatment of ACCLERATED HTN. While processing of the claim of complainant, it was observed that the indoor case records of the aforesaid treatment are completely stereotypes manner and in single handwriting and tampering is noted. Thus there is discrepancy in the records which amounts to misrepresentation of facts. As per condition no.6 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. Further, the insured patient’s vital signs were stable throughout the period of hospitalization and the investigation reports were within normal limits.”

8.                 Undisputedly, the complainant was under insurance cover during the period of treatment. As per discharge summary (Annexure C-4) she remained admitted in the hospital concerned from 04.03.2022 to 06.03.2022.  It is evident from bills (Annexure C-5, C-14 & C-15), the complainant has incurred Rs.21,110/- on her treatment.

9.                 After hearing learned counsels for the parties and going through the record, it is evident that the treatment so given to complainant was in emergency and thus necessary under the conditions of the patient, as is clear from Emergency Certificate (Annexure C-3). Therefore, we are of the view that OP insurance company arbitrarily and illegally repudiated the claim of complainant whereas the complainant was entitled to the amount so incurred by him on her treatment. As per facts and circumstances of the case, complainant is also entitled for compensation on account of mental and physical harassment due to negligent and deficient services by OPs.  Hence, the complaint is allowed and the OPs No.1 & 2, 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.21,110/- (Rs. Twenty one thousand one hundred ten) to the complainant alongwith simple interest @ 9% per annum from the date of filing of the complaint till actual realization.

(ii)      To pay Rs.10,000/- (Rs. Ten thousand) as compensation  for harassment on account of negligence and deficient services on the part of OP insurance company.   

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 concerned 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: 23.10.2024.