M/s. Star Health and Allied Insurance Company Limited, No.1, New Tank Street, Valluvar Kottam High Road, Nungambakkarr, Chennai-34, www.starhealth.in. …..Opposite parties
Complaint Under Section 12 of the Consumer Protection Act, 1986.
QUORUM:
SH. K.K. KAREER, PRESIDENT
SH. JASWINDER SINGH, MEMBER
COUNSEL FOR THE PARTIES:
For complainants : Sh. Rakesh Kumar Gupta, Advocate
For OPs : Sh. Rajeev Abhi, Advocate.
ORDER
PER K.K. KAREER, PRESIDENT
1. Shorn of unnecessary details, the case of the complainants is that complainant No.1 was a holder of Happy Family Floater Policy Schedule of Oriental Insurance Company which was valid from 21.11.2013 to 20.11.2014 and was renewed from time to time up to 20.11.2017. In the last policy issued by Oriental Insurance Company, the sum assured was Rs.2,00,000/-. On the insistence of the OPs, the complainant purchased a policy titled as Family Health Optima Insurance Plan in which basic floater sum insured was Rs.4,00,000/- under scheme 2A plus 2C. In the policy, 30 days waiting period was also waived and first year exclusion and two year exclusion were also waived while pre-existing disease was also covered. The complainant No.2 was suffering from irregular menses for which she contacted Department of Obstetrics and Gynaecology in Christian Medical College and Hospital. She was advised for treatment of hypertension on irregular medication with abnormal uterine bleeding with fibroid uterus. She was accordingly admitted in the hospital and was advised removal of uterus by surgery. The complainant lodged a pre-authorization request regarding admission of complainant No.1 on 15.03.2018, but the OPs asked for more information which was supplied by the concerned hospital. However, the OPs vide mail dated 16.03.2018 rejected the claim with the remarks that the claim was not admissible as the patient had failed to disclose the pre-existing disease of AUB (Abnormal Uterine Bleeding) in the proposal form and the claim was not payable as per the policy condition No.6. As a result, the complainant arranged for expenses of the treatment of complainant No.2 on his own. The complainant No.2 was discharged from the hospital on 25.03.2018 and sum Rs.1,03,628/- was spent on the treatment. The non-payment of the claim on the part of the OPs amounts to deficiency of services. In the end, it has been requested that the OPs be made to pay the claim of Rs.1,03,628/- along with compensation of Rs.50,000/- and litigation expenses of Rs.20,000/-.
2. The complaint has been resisted by the OPs. In the written filed on behalf of the OPs, it has been pleaded, inter alia, that the complainants obtained Family Health Optima Insurance Policy valid from 21.11.2017 to 20.11.2018 which covered the complainant Vijay Sharma, his wife Poonam Sharma, Sania Sharma and Yuvraj Sharma for a sum insured of Rs.4,00,000/-. The policy was ported from the Oriental Insurance Co. Ltd. The policy was subject to terms and conditions and exclusions clauses etc. It is further pleaded that the condition No.6 of the policy provides that the company shall not be liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be incorrect or false or such claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation etc. According to the OPs, the insured patient Poonam Sharma was hospitalized at Christian Medical College & Hospital on 15.03.2018 for treatment of AUB (Abnormal Uterine Bleeding). After the receipt of authorization request it was observed that insured patient was symptomatic since 6 months i.e. prior to the inception of the policy. Therefore, cash authorization was rejected as per condition No.6 of the policy. It has further been pleaded that only cashless authorization was submitted and no regular claim for reimbursement of the medical expenses has been submitted by the complainant till date. The cashless approval is given on preliminary evaluation of documents which is always subject to review upon the receipt of further details and documents from the insured and the claim would be considered as per terms and conditions of the policy only if the claim form duly completed and signed along with discharge summary, main hospital bill with break up, investigation reports, medical bills, indoor case papers, previous treatment records, if any are submitted. The other allegations made in the complaint have been denied as incorrect and a prayer for dismissal of the complaint has also been made.
3. In evidence, the complainant submitted her affidavit as Ex. CA along with documents Ex. C1 to Ex. C62, Ex. C8A to Ex. C8E and closed the evidence.
4. On the other hand, learned counsel for the OPs tendered affidavit Ex. RA of Sh. Rajiv Jain, Chief Manager of OPs along with documents Ex. R1 to Ex. R13 and closed the evidence.
5. We have heard the learned counsel for the parties and have also gone through records.
6. After hearing the counsel for the parties and after going through the record, it transpires that since only pre-authorization claim has been rejected by the OPs on the ground that in the proposal form Ex. R9, the insured patient did not disclose that she was suffering from any gynecological disorder such as AUB, Fibroid Uterus etc. whereas in the pre-authorization form Ex. R2 itself, it has been mentioned that the complainant was suffering from the disease for the last three months preceding 26.12.2017 i.e. before the inception of the policy which was not mentioned in the proposal form. However in our considered view, the rejection of the pre-authorization claim cannot be justified considering the fact that admittedly the original date of inception of the policy is 21.11.2013 and it continued uninterrupted since then till it was transported with the OPs. It is further pertinent to mention that at the time the policy was transported with the OPs, 30 days waiting period and first 2 year exclusion were waived and the pre-existing disease were also subject to be covered as per the document Ex. C8/C issued by the OPs. Moreover, there is no evidence that the insured patient was aware about the existence of the disease of AUB nor any evidence in this regard has been lead by the OPs. In these circumstances, the rejection of even pre-authorization claim does not appear to be justified.
7. During the course of arguments, it was argued by the counsel for the OPs that after the rejection of pre-authorization form, the complainant has not submitted the claim form along with requisite documents i.e. hospital bills, discharge summary, other treatment record etc. as stated in para No.5 of the written statement and without lodging the claim, the present complaint must be held to be pre-mature. He has further contended that without the submission of the claim form along with the requisite documents especially treatment record and the bills issued by the hospital, the OPs are not in position to settle the claim. In these circumstances, in our considered view, it would be just and proper if the complainant is directed to submit the claim for reimbursement in respect of hospitalization of complainant No.2 Poonam Sharma from 15.03.2018 to 25.03.2018 within a period of 15 days and the OPs shall settle and reimburse the claim strictly as per terms and conditions of the policy within 30 days.
8. As a result of above discussion, the complaint is allowed with a direction to the complainants to submit the claim for reimbursement in respect of hospitalization of complainant No.2 Poonam Sharma from 15.03.2018 to 25.03.2018 within a period of 15 days and the OPs shall settle and reimburse the claim strictly as per terms and conditions of the policy within 30 days from the date of receipt of the claim. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.
9. Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.
(Jaswinder Singh) (K.K. Kareer)
Member President
Announced in Open Commission.
Dated:10.11.2021.
Gobind Ram.
Vijay Kumar Vs Star Health CC.18.596
Present: Sh. Rakesh Kumar Gupta, Advocate for complainants.
Sh. Rajeev Abhi, Advocate for OPs.
Arguments heard. Vide separate detailed order of today, the complaint is allowed with a direction to the complainants to submit the claim for reimbursement in respect of hospitalization of complainant No.2 Poonam Sharma from 15.03.2018 to 25.03.2018 within a period of 15 days and the OPs shall settle and reimburse the claim strictly as per terms and conditions of the policy within 30 days from the date of receipt of the claim. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.
(Jaswinder Singh) (K.K. Kareer)
Member President
Announced in Open Commission.
Dated:10.11.2021.
Gobind Ram.
