Punjab

Ludhiana

CC/18/422

Kamal Dev Sharma - Complainant(s)

Versus

Star Health & Allied Ins.Co.Ltd. - Opp.Party(s)

PK Wadhera adv

01 Jul 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 422 dated 06.07.2018.                                                       

                                                Date of decision: 01.07.2021. 

Kamal Dev  Sharma aged about 42 years, s/o. Late Sh. Hira Lal Sharma, r/o. Ward No.7, Baba Roor Singh Nagar, Sahnewal, District Ludhiana, Punjab.        

                                                                                      ..…Complainant

                                                Versus

1. Star Health  And Allied Insurance Company Limited, No.15, Shri Balaji Complex, 1^st Floor, Whites Floor, Royapettah, Chennai 600014.                 
2. Area Office: Star Health And Allied Insurance Company Limited, 2716, 1^st Floor, Gagan Complex, Backside Majestic Park Plaza Hotel, Gurdev Nagar, Pakhowal Road, Ludhiana-141001.                                                                                                                          …..Opposite parties 

Complaint under Consumer Protection Act.

QUORUM:

SH. K.K. KAREER, PRESIDENT

MS. JYOTSNA THATAI, MEMBER

COUNSEL FOR THE PARTIES:

For complainant             :         Sh.  P.K. Wadhera, Advocate.

For OPs                          :         Sh. Rajeev Abhi, Advocate.

ORDER

PER K.K. KAREER, PRESIDENT

1.                Shorn of unnecessary details, the case of the complainant is that the complainant took health insurance policy for himself and his wife in the month of March 2016. The policy was renewed from time to time and was valid up to 03.03.2018. It was further got renewed on 02.03.2018 for a period of one year. On 27.02.2018 Kiran Bala, the wife of the complainant, felt breathlessness and increase in heart beat. She was taken to Asian Multispecialty Hospital, Ludhiana where ECG was conducted, which revealed some problem in the heart, which required treatment by a heart specialist. Thereafter, the complainant got his wife admitted in Fortis Escorts Hospital, Amritsar on 23.03.2018 where she was treated and discharged on 24.03.2018. As per the policy, the complainant was entitled to cashless treatment in respect of all expenses. The complainant was assured by the OPs that the payment would be reimbursed on filing the claim through Fortis Escorts Hospital, which was approved by the OPs. A self declaration was also sought from the complainant on 22.03.2018 itself. An amount of approximately Rs.62,000/- was spent by the complainant on the treatment alone. The claim filed through Fortis Escorts Hospital was, however, repudiated by the OPs vide letter dated 10.05.2018. Even a request for reconsideration was also rejected vide letter dated 19.06.2018 on flimsy and untenable grounds. The insurance claim has been repudiated on the ground that as per prescription dated 27.02.2018, the patient had consulted for the disease and had history of similar illness in the past and further that the patient had a history of hospitalization at Sidhu Hospital one year back and the documents relating to the previous treatment at Sidhu Hospital were not submitted. The OPs did not consider the fact that when the wife of the complainant was treated at Sidhu Hospital, nothing was detected in ECG conducted at the said hospital and the problem was diagnosed as mere gastric trouble. In this manner, the OPs have wrongly repudiated the claim on unsustainable grounds, which amounts to deficiency of service on the part of OPs. In the end, it has been requested that the OPs be directed to pay a sum of Rs.62,000/- along with Rs.15,000/- as litigation expenses and Rs.20,000/- as compensation for having caused harassment, mental pain and agony.

2.                The complaint has been resisted by the OPs. In the written statement field by the OPs, it has been pleaded that the complaint is not maintainable. It has been admitted that the complainant obtained family optima health insurance policy, which covered the complainant, his wife Kiran Bala and son Karan Sharma for a sum of Rs.5,00,000/-.  It has further been admitted that Kiran Bala was admitted in Fortis Escorts Hospital, Amritsar on 21.03.2018 for treatment of A VNRT. Pre authorization request for cashless treatment was also raised regarding which the OPs called upon the hospital to provide documents i.e. certificate from the treating doctor mentioning exact duration of SVT and whether the patient was a case of recurrent  SVT, ECO reports, EPS study reports. The pre-authorization request was declined vide letter dated 22.03.2018 as the complainant did not supply the information/documents despite repeated reminders. On scrutiny of the records, it was found that as per consultation report of Asian Multispecialty Hospital dated 27.02.2018, the patient was presented with sudden onset of palpitation and breathlessness and she had past history of similar episodes. Therefore, the OPs called upon the complainant to submit documents such as discharge summary of Sidhu Hospital, ECG taken at that time, ECO and EPS reports, initial assessment sheet and complete set of indoor case papers for the hospitalization at Fortis Escorts Hospital, Amritsar and Part-B claim form duly complete in all respects by the treating doctor and signed and sealed by the hospital authorities. The complainant failed to submit the documents, which were very material for processing the claim. However, in reply, the complainant submitted only self declaration dated 22.03.2018. After waiting for a sufficient long time for the receipt of the documents, the claim was repudiated and the decision was communicated to the complainant vide letter dated 10.05.2018. The complainant submitted a representation dated Nil, which was reviewed and replied to by OPs vide letter dated 19.06.2018 on the grounds that as per the prescription dated 27.02.2018, the patient had a history of similar illness in the past. She was hospitalized at Sidhu Hospital one year ago and the documents regarding treatment at Sidhu Hospital were not submitted despite requests made in this regard. Thus, there is no deficiency of service or negligence on the part of the OPs. The rest of the allegations made in the complaint have been denied as wrong and in the end, a prayer for dismissal of the complaint has also been made.

3.                In evidence, the complainant submitted his affidavit as Ex. CA along with documents Ex. C1 to Ex. C5 and closed the evidence.

4.                On the other hand, the OPs submitted affidavit Ex. RA of Sh. Rajiv Jain, Chief Manager along with documents Ex. R1 to Ex. R24 and closed the evidence.

5.                We have gone through the arguments advanced by the counsel for the parties and have also gone through records as well as written arguments submitted by OPs.

6.                As per the facts of the case, the complainant had taken health insurance policy for himself and his family including his wife Kiran Bala on 04.03.2016, which was renewed from time to time. Lastly, it was renewed from 03.03.2018 and was valid till 02.03.2019. The complainant’s wife Kiran Bala felt breathlessness and increase in her heart beat on 27.02.2018. She was taken to Asian Multispecialty Hospital, Ludhiana where her ECG was conducted which revealed some problem in her heart and she was referred to cardiac specialist. As a result, the complainant got her admitted in Fortis Escorts Hospital, Amritsar on 23.03.2018 where she was given treatment and discharged on 24.03.2018. An amount of Rs.62,000/-  was spent by the complainant on the treatment of his wife, but the claim was repudiated by the OPs vide letter dated 10.05.2018 and a request for reconsideration was also rejected vide letter dated 19.06.2018, copy of which is Ex. C5 on the file.

7.                The claim has been primarily repudiated on the ground that from the records, it has been observed as per prescription dated 27.02.2018, the patient has similar illness history in the past and as per the insured’s own statement, the patient was hospitalized at Sidhu Hospital one year back, but the documents pertaining to the treatment given at Sidhu Hospital were not supplied by the complainant to the OPs despite the requests made in this regard. It has been pointed by the counsel for the OPs that in the prescription slip Ex. R4 prepared at Asian Multispecialty Hospital on 27.02.2018, it is mentioned that Kiran Bala had a past history of similar episode of sudden onset of palpitation and breathlessness. It has also been claimed in the repudiation letter that as per insured’s statement, the patient had a history of hospitalization at Sidhu Hospital one year back.

8.                In our considered view, the rejection of the claim merely on account of the fact that the record of alleged treatment at  Sidhu Hospital was not supplied by the complainant though it was demanded does not appear to be justified. In this regard, a reference can be made to the self declaration Ex. C4 submitted by the complainant. In the self declaration, it is clearly mentioned that prior to approaching Asian Multispecialty Hospital, Ludhiana on 27.02.2018, Kiran Bala had faced breathlessness 2 or 3 times. First time, the problem was resolved within 10-15 minutes without any treatment and second time, Kiran Bala was taken to Sidhu Hospital, Doraha where her ECG was conducted, but no issue was found and the doctor advised that the problem might be due to gastric problem. It has further been stated by the complainant in self declaration Ex. C4 that the complainant does not have the reports of Sidhu Hospital as the same were misplaced. When the complainant has categorically stated that he was not having any document of treatment at Sidhu Hospital, the question of supply of the said document did not arise. On the contrary, it was a duty of the OPs to collect the relevant information, if any, from Sidhu Hospital, Doraha, but no such efforts have been made by the OPs. In these circumstances, the rejection of the claim merely on account of non supply of the documents pertaining to treatment of Kiran Bala at Sidhu Hospital, Doraha cannot be said to be justified. Learned counsel for the OPs has relied upon II(2019) CPJ 122(NC) in New India Assurance Co. Ltd. Vs Parmod Kumar Singh passed by Hon’ble National Consumer Disputes Redressal Commission, New Delhi whereby it has been that when a document is not produced without any explanation or reason, adverse inference has to be drawn. However, the law laid down in this case cannot be applied to the instant case as the complainant has given a reasonable explanation that the medical record pertaining to treatment of Kiran Bala of Sidhu Hospital, Doraha was not available with him and moreover, the doctor had advised that it was only a gastric problem and not heart ailment was involved. Counsel for the OPs has further relied upon I (2009) CPJ 22(NC) in Priya Gopal Stores Vs National Insurance Co. Ltd.  as well as II(2010) CPJ 237 (NC) in United India Insurance Company Ltd. Vs Sangeeta Singh passed by Hon’ble National Consumer Disputes Redressal Commission, New Delhi  on the point of non production of documents. In our considered view, the same are not applicable to this case and cannot be banked upon to repudiate the genuine claim of the complainant.

9.                As a result of above discussion, the repudiation of the claim vide letter Ex. C1 on the basis of non production of medical record of previously taken treatment of Sidhu Hospital, Doraha cannot be sustained in the eyes of law and same is hereby set aside.

10.              Accordingly, the complaint is allowed with an order that OPs shall consider and make the payment of the claim lodged by the complainant strictly in accordance to the terms and conditions of the policy within period of 40 days from the date of receipt of copy of the order. The OPs shall further pay a composite sum of Rs.10,000/- (Rupees Ten Thousand only) on account of compensation and litigation expenses to the complainant. Payment of costs and litigation shall be made within a period of 30 days from the date of the receipt of the copy of this order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room. 

11.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

                             (Jyotsna Thatai)                              (K.K. Kareer)

                    Member                                           President

Announced in Open Commission.

Dated:01.07.2021.

Gobind Ram.