BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 211 of 2015

Date of Institution: 07.04.2015

Date of Decision: 16.10.2015 

Sukhwinder Singh, aged about 46 years, son of S.Makhan Singh, resident of 536, Gurnam Nagar, Main Bazaar, Mandir Wala Bazaar, S.W.Road, Amritsar.  

Complainant

Versus

Star Health and Allied Insurance Company Limited, SCO-25, First Floor, Ranjit Avenue, District Shopping Complex, Amritsar through its Branch Manager.

Opposite Party

Complaint under section 12 and 13 of the Consumer Protection Act, 1986 as amended upto date.

Present: For the Complainant: Sh. Nitin Madan, Advocate

              For the Opposite Party: Sh. S.S.Salaria, Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Sh.Sukhwinder Singh under the provisions of the Consumer Protection Act alleging therein that on 20.03.2013, he obtained a Health Insurance Policy titled as Medi Classic Insurance (Individual) bearing No. P/211111/01/2013/003841 for a period of one year from Opposite Party against the payment of requisite premium.  In order to continue availing the benefit of risk cover for a further period of one year, he paid the renewal premium amount and he has been issued policy bearing No.P/211111/01/2014/004202 covering the medical/ treatment expenses to the extent of Rs.2 lacs for the period from 21.3.2014 to 20.3.2015. Complainant further alleges that prior to issuing the policy in question, the medical check up of the complainant was got conducted by the Opposite Party through its empanelled doctor and the complainant was found medically fit for obtaining the present policy and it was only after thorough medical examination of the complainant that the policy in question was issued to the complainant by the Opposite Party. Under the aforesaid policy, the Opposite Party was under the obligation to indemnify the complainant in case of any medical expenses incurred during the subsistence of the aforesaid policy.   During the validity period of the present policy, the complainant fell ill with the symptoms of severe jaundice and was admitted on 22.08.2014 in B.K.Kalsi Hospital, East Mohan Nagar, Amritsar. After detailed tests and lab reports, his illness later came to be diagnosed as Liver Abscess which required immediate medical attention. The complainant remained admitted in the hospital from 22.8.2014 to 2.9.2014 and incurred more than Rs.1,28,800/- on his complete treatment. However, the various bills forwarded alongwith claim form for reimbursement as follows:

After discharge from the hospital, the complainant lodged claim with the Opposite Party and requested for reimbursement of medical expenses after providing all the necessary documents to the Opposite Party and the Opposite Party assured him that the amount of claim would be duly reimbursed shortly, but inspite of several reminders, letters and personal visits by the complainant to the office of Opposite Party, no satisfactory response has been given to the genuine claim of the complainant and repudiated the claim of the complainant on the ground that the hospital where the treatment was taken is not registered and is not under the supervision of a registered and qualified medical practitioner, as per the terms of the policy. Whereas the complainant was never supplied any such terms and conditions of the policy.    Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite party to reimburse the claim amount of Rs.1,28,850/- alongwith interest @ 18% per annum from the date of lodging the claim till payment.  Compensation and litigation expenses were also demanded.

2. On notice, Opposite Party appeared and filed written version in which it was submitted that the complainant obtained the aforesaid policies from the Opposite Party. It is stated that the complainant admitted in B.K.Kalsi Hospital, East Mohan Nagar, Amritsar on 22.8.2014 as per the certificate of treating doctor, the complainant have intake of alcohol for past 9-10 years, but the complainant had not disclosed the above mentioned details in the proposal form which amounts to misrepresentation/ non disclosure of material facts and in view of condition No.7 of the policy, if there is any misrepresentation/ non-disclosure of material facts, whether by the insured person or any other person acting on his behalf, the company is not liable to make the payment in respect of any claim and thus the claim of the complainant is not payable and otherwise also, the treating hospital was having only 10 in-patient beds available in the hospital, whereas as per the terms and conditions of the policy, the said hospital must have 15 in-patient beds and the same is also not a registered hospital and in view of this also, the claim of the complainant is not payable and same was duly repudiated and the complainant was duly informed in this regard vide letter dated 12.1.2015 and repudiation is legal and genuine. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence his affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C41 and closed the evidence on behalf of the complainant.
4. Opposite Party tendered into evidence affidavit of Sh.Rajnish Kohli, Assistant Vice President (Claims) Ex.OP1 alongwith documents Ex.OP2 to Ex.OP13 and closed the evidence on behalf of the Opposite Party.
5. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant obtained a Health Insurance Policy titled as Medi Classic Insurance (Individual) bearing No. P/211111/01/2013/003841 for a period of one year. The complainant further availed   the benefit of risk cover for a further period of one year and got issued policy bearing No.P/211111/01/2014/004202 covering the medical/ treatment expenses to the extent of Rs.2 lacs for the period from 21.3.2014 to 20.3.2015. On 22.8.2014, the complainant became ill due to severe jaundice and was admitted in B.K.Kalsi Hospital, East Mohan Nagar, Amritsar on 22.8.2014 and his disease was diagnosed as Liver Abscess. The intimation was given to the Opposite Party. The complainant was discharged from that hospital on 2.9.2014. He incurred more than Rs.1,28,800/- on his treatment as detailed above in the complaint. The claim was lodged with the Opposite Party, but the Opposite Party ultimately repudiated the claim of the complainant vide letter dated 12.1.2015 Ex.OP13 on the flimsy grounds that as per the terms and condition of the policy, the insurance company shall make the payment in respect of expenses for treatment incurred at hospital which has been either registered as hospital or nursing home with the local authorities and is under the supervision of registered and qualified medical practitioner or it has atleast 15 inpatient beds. But the complainant obtained treatment in the hospital which has only 10 beds and is also not registered one. Ld.counsel for the complainant submitted that terms and conditions of the policy were not supplied by the Opposite Party to the complainant. So, the Opposite Party has wrongly repudiated the claim of the complainant and all this amounts to deficiency of service on the part of the Opposite Party qua the complainant.         
7. Whereas the case of the Opposite Party is that the complainant obtained a Health Insurance Policy titled as Medi Classic Insurance (Individual) bearing No. P/211111/01/2013/003841 for the period from 20.3.2013 to 19.3.2014 and further policy bearing No.P/211111/01/2014/004202 valid  for the period from 21.3.2014 to 20.3.2015. The complainant was served policy alongwith its terms and conditions. The complainant was admitted in B.K.Kalsi Hospital, East Mohan Nagar, Amritsar on 22.8.2014. As per discharge summary/ treatment record Ex.C7 with history of  intake of alcohol about 100 ml to 150 ml daily for past 9-10 years as per certificate Ex.C38 issued by B.K.Kalsi Hospital, East Mohan Nagar, Amritsar, but the complainant had not disclosed these facts at the time of taking of the policy on 20.3.2014. As per the terms and condition of the policy Ex.OP2, the insurance company shall make the payment in respect of expenses for treatment incurred at hospital which has been either registered as hospital or nursing home with the local authorities and is under the supervision of registered and qualified medical practitioner or it has atleast 15 inpatient beds, whereas the treating hospital B.K.Kalsi Hospital, East Mohan Nagar, Amritsar was having only 10 inpatients beds available in the hospital. Further said hospital is also not a registered hospital. So, the Opposite Party has repudiated the claim of the complainant as per the terms and conditions of the policy and the complainant was duly informed in this regard vide letter dated 12.1.2015 Ex.OP13. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the Opposite Party.
8. From the entire above discussion, we have come to the conclusion that the complainant obtained two consecutive Health Insurance Policies titled as Medi Classic Insurance (Individual) from Opposite Party  for the period from 20.3.2013 to 19.3.2014 Ex.OP4 and for the  period from 21.3.2014 to 20.3.2015 Ex.OP5. The complainant was served  with policy document alongwith terms and conditions. The complainant has nowhere in his complaint has stated that he did not receive the policy. The policy itself contained terms and conditions of the policy, as is evident from Ex.OP2. Moreover, it can not be believed that the insured has taken two consecutive policies from the Opposite Party and he did not get the terms and conditions of the policy. So, plea of the complainant that he was not supplied with the terms and conditions of the policy, is not tenable. Moreover, it has been held by Hon’ble State Consumer Disputes Redressal Commission, Punjab Chandigarh in its latest ruling in case Bawa Singh Vs. MD India Health Care Services & Others 2015(2) CLT 418 that where in case the complainant is basing  his claim on the basis of policy taken by him there is presumption that he must have gone through the terms and conditions of the policy. The complainant became ill and he was admitted in B.K.Kalsi Hospital, East Mohan Nagar, Amritsar on 22.8.2014 and was diagnosed as a case of Liver Abscess with history of intake of alcohol about 100 ml to 150 ml daily for past 9-10 years as is evident from the  certificate Ex.C38 issued by B.K.Kalsi Hospital, East Mohan Nagar, Amritsar on 10.12.2014. Opposite Party has proved on record that said B.K.Kalsi Hospital, East Mohan Nagar, Amritsar i.e. treating hospital was having only 10 inpatient beds available in the hospital whereas as per the terms and conditions of the policy Ex.OP2, the insurance company shall make the payment in respect of expenses for treatment incurred at hospital which has been either registered as hospital or nursing home with the local authorities and is under the supervision of registered and qualified medical practitioner or it has atleast 15 inpatient beds, whereas as per the medical certificate of the treating doctor, the hospital in which the complainant was treated, having only 10 inpatient beds and  said hospital is also not a registered hospital. So, the Opposite Party was justified in repudiating the claim of the complainant as per the terms and conditions of the policy and it was conveyed to the complainant by the Opposite Party   vide letter dated 12.1.2015 Ex.OP13. Consequently we hold that the Opposite Party has rightly repudiated the claim of the complainant as per the terms and conditions of the policy. As such, there is no deficiency of service on the part of the Opposite Party.
9. Resultantly, we hold that  the complaint is without merit and the same is hereby dismissed with no order as to cost. Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 16.10.2015.                                                              (Bhupinder Singh)                                                                                               President

hrg                                                               (Kulwant Kaur Bajwa)   

Member