Haryana

Bhiwani

CC/150/2023

Ravinder Kumar - Complainant(s)

Versus

Star Health - Opp.Party(s)

Dinesh Kumar

16 Oct 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

                                                            Consumer Complaint No. :  150 of 2023

                                                       Date of Institution            : 11.07.2023

                                                                 Date of order                   : 16.10.2024

Ravinder Kumar son of Sh. Kailash Chand R/o Gujron Ki Dhani, Old Bus Stand, Naya Bazar, Bhiwani. Mobile No.9416973509.

           ……Complainant.

Versus

1. Star Health and Allied Insurance Co. Ltd., No.15, Sri Balaji Complex 1^st Floor, Whites Lane, Royapettah, Chennai-600014 having one of its Branch Office at Opposite Red Cross Bhawan, Zoo Road, Bhiwani. Email ID  
   2. Ms. Sweety Intermediar through Hisar Branch at Plot No.71-72 Kamla Nagar, Near Kotak Mahindra Bank, Red Square Market, Hisar-125001. Email ID Anuj Bansal son of Subash Bansal R/o 342/1 Bagh Kothi, Street No.5, Bhiwani. Mobile No.9261555580.

   …… 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. Dinesh Kumar Gupta, Advocate for complainant.

                        Sh. Avinash Sardana, Advocate for OP No.1.

                        OPs No.2 & 3 exparte.

    

   ORDER:

    

   Shashi Kiran Panwar, Member:

    

   1.                 In brief, facts of this case are that complainant taken a family Health Optima Insurance Plan from OP on 18.01.2021, valid for a period of one year from the date of inception, for sum assured Rs.3.00 lac alongwith recharge benefit of Rs.75,000/-. Complainant has submitted that on 15.03.2021, Jatin-son of complainant fell ill and got examined in Bhardwaj Hospital, Bhiwani and it was diagnosed that he was suffering from cancer AML and he was advised to go Action Cancer Hospital, Delhi. Jatin remained admitted there from 16.03.2021 to 08.04.2021 and thereafter also, treatment was going on. A sum of Rs.5,00,003/- was incurred on the treatment.  As per complainant, he lodged claim with OP insurance company submitting all required documents but the claim was rejected by OP insurance company as “No Claim” for want of required documents vide letter dated 25.01.2022. 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.3.00 lac alongwith Rs.75,000/- as recharge benefit  and also to pay Rs.2.00 lac as compensation for harassment alongwith interest @ 18% from the date of accrual till the date of payment. Any other relief, to which this Commission deems fit, has also been sought.

   2.                 Upon notice, OP No.1 appeared through counsel and tendered reply 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 Jatin-son of complainant was covered under the policy on the alleged period of treatment and sum assured under the policy was Rs.3.00 lac subject to certain terms and conditions of the policy. It is submitted that complainant requested cashless authorization on 17.03.2021 for the said treatment but it was denied on 19.03.2021 while observing that complainant has contracted the above disease/condition during the first 30 days from the date of commencement of the policy. As per waiting period /exclusion no.Excl.03 of the policy, the claim is not admissible. Further, vide letters dated 26.07.2021,10.08.2021, 25.08.2021 and 09.09.2021 complainant was asked to provide some additional documents but he failed to submit, as such, claim of complainant was rejected vide letter dated 25.01.2022. In the end, denied for any deficiency in service on the part of answering OP and prayed for dismissal of the complaint with costs.

   3.                 OPs No.2 & 3 did not appear despite issuance of notices, as such, they were proceeded against as exparte vide order dated 29.08.2023.

   4.                 In evidence of complainant, his affidavit Ex.CA alongwith documents Ex. C-1 to Ex.C-23 were tendered and then closed the evidence.

   5.                 In evidence of OP No.1, affidavit of Mr. Sumit Kumar Sharma, Senior Manager of OP company as Ex. RW1/A alongwith documents Annexure R-1 to Annexure R-16 were filed and then closed the evidence.

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

   7.                 The case of complainant is that during the period of insurance policy, his son Jatin diagnosed as cancer patient and for treatment of the disease remained admitted in the concerned hospital and spent a sum of Rs.5,00,003/- but the OP insurance company did not reimburse the assured amount of Rs.3.00 lac and other benefits rather repudiated the claim of complainant vide letter dated 25.01.2022. Ld. Counsel for complainant has argued that due to such act & conduct of OPs, complainant has to suffer monetary loss as well as mental and physical harassment.

   8.                 On the other side, learned counsel for OPs has argued that as per Exclusion-Code Excl. 03 of the policy, the claim is not admissible during the first 30 days from the date of commencement of the policy. Further the complainant did not provide the documents necessary for process of the claim, despite various letters which was violation of condition no.2 of the policy by complainant. As such, complainant was not entitled to any amount from OP insurance company and claim was rightly rejected.

   9.                 It is not in dispute that on the relevant period of time complainant’s son was under the insurance cover. Complainant to prove his case has placed on record discharge summary (Ex.C-8) and bill (Ex. C-9) as well as other documents relating to the treatment. Ex.C-2 to Ex. C-7 whereby it is evident that complainant’s son Jatin was admitted in the Action Cancer Hospital, Delhi from 16.03.2021 to 08.04.2021 and incurred a sum of Rs.5,00,003/- on his treatment. Perusal of repudiation letter (Annexure R-13) reveals that claim to complainant has been denied as the complainant did not provide the required documents which as per policy was violation of its condition No.2. Prior to repudiation letter, the OPs vide their letter dated 25.08.2021 (Annexure R-12) asked the complainant to submit documents: Letter from pediatrician clarifying duration of ailment. Past Pediatric Consultation Papers and Pan card copy of insured person Ravinder Kumar.

   10.               After hearing learned counsels for the parties and going through the record, we have observed that there are sufficient material on record which has also been submitted to the OP insurance company for processing of the claim. So, the documents demanded by the OPs through the above referred letters were not specifically required for the processing of the claim. It is also observed that the exclusion clause 03 of the terms and conditions of the policy has no effect on the present case as the treatment was taken beyond 30 days of commencement of the policy period. As per insurance policy Ex. C-1, the sum insured under the policy is Rs.3.00 lac alongwith extra benefit of Rs.75,000/-. Thus 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 to the complainants.  Hence, the complaint is allowed and the OP No.1 is directed to comply with the following directions within 40 days from the date of order:-

   (i)       To pay a sum of Rs.3,75,000/- (Rs. Three lac seventy five thousand) to the complainant as sum assured and other benefits 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.11,000/- (Rs. Eleven 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 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.  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: 16.10.2024