Punjab

Ludhiana

CC/19/550

Vivek Rana - Complainant(s)

Versus

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

Amitaj Khera Adv.

02 Dec 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 550 dated 29.11.2019.                                                        Date of decision: 02.12.2022.

 

1. Vivek Rana aged 42 years, B-II-1332, Street No.4, Arya Mohalla, Ludhiana.                                                                
2. Naina D/o. Sh. Vivek Rana R/o.B-II-1332, Street No.4, Arya Mohalla, Ludhiana (impleaded as per order dated 16.12.2020)                                                                                                  ..…Complainants 
3.  

1. Star Health & Allied Insurance Co. Ltd., No.15, Shri Balaji Complex, First Floor, White Lane, Roy Apettah, Chennai, Through its Director/M.D.
2. Star Health & Allied Insurance Co. Ltd., Near Ansal Plaza, Ferozepur Road, Ludhiana, through its Manager.                                                                                                                         …..Opposite parties 

Complaint under Section 12 and 14 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainants            :         Sh. Amitoj Khera, Advocate.

For OP                           :         Sh. Rajeev Abhi, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of the unnecessary details, the facts stated in the complaint are that the complainants availed Family Floater Insurance Policy No.P/161114/01/2017/010313 having validity for the period from 20.03.2017 to 19.03.2018. The complainant has availed the services of the opposite parties for more than five years without any default and as per original policy, all the diseases of the complainant and his family members were covered under the policy after the completion of initial period of three years. The daughter of the complainant namely Naina suddenly fell seriously ill and she was got admitted in D.M.C. & Hospital, Ludhiana on 07.03.2018. The opposite parties were informed regarding admission of Naina in the hospital within 24 hours of the admission and lodged the claim for cashless benefit of the family but the claim was repudiated vide letter dated 17.05.2018 on the pretext that the disease was not covered under the policy. The complainant also served a legal notice dated 27.09.2019 upon the opposite parties calling upon them to make the payment of the claim within 15 days from the date of receipt of notice but nothing was done on the part of the opposite parties. The complainant also stated that he has suffered humiliation, harassment, anguish and mental trauma owing to the conduct of the opposite parties. The complainant has prayed for payment of claim amount along with compensation of Rs.1,00,000/- and litigation expenses of Rs.11,000/-.

2.                Upon notice, the opposite parties filed written statement and took preliminary objection that the complaint is not maintainable as on the receipt of the claim, it was duly registered, entertained and processed. It is further stated that the complainant had obtained Family Health Optima Insurance Plan covering Vivek Rana self, Mrs. Anju Rana spouse, Naina Rana and Anshul Rana as dependent children for a sum insured of Rs.5,00,000/- vide policy No.P/161114/01/2017/010313 for the period from 20.03.2017 to 19.03.2018 which is in continuation since 20.03.2010. The claim was lodged in the 8^th year of the policy. It was also stated that the terms and conditions of the policy were explained to them and the complainant had accepted the policy being fully aware of the terms and conditions and one of the exclusion clause No.6 of the policy “the company is not liable to make any payment in respect of any expenses for treatment of psychiatric, mental and behavioral disorders”. However, it is admitted that Naina Rana was admitted in Dayanand Medical College & Hospital, Ludhiana on 07.03.2018 for medical management with the diagnosis of anxiety neurosis with known case of celiac disease and request for cashless authorization treatment of Rs.22,743/-. The cashless authorization request was made on behalf of the insured by Dayanand Medical College & Hospital, Ludhiana but after seeing the treatment/medical record of patient Naina Rana who has undergone treatment primarily for anxiety neurosis, hence the cashless claim was denied vide letter dated 17.05.2018 on the ground that the same is not payable as per exclusion clause No.6 since the policy does not cover the  expenses incurred on the treatment of psychiatric, mental and behavioral disorder and conveyed to the complainant. It was further alleged that the claim was rightly repudiated. The opposite parties also took objection that the complaint is bad for non-joinder of necessary parties and it has also been asserted that the Civil Court has jurisdiction to try the present case. On merits, the aforesaid facts were reiterated in the different paras of written statement and even service of the legal notice was denied. The opposite parties have further alleged that the claim was rightly repudiated as per the policy terms and conditions. Prayer of the complaint has also been denied and in the end, a prayer for dismissal of the complaint has been made.

3.                In support of their claim, the complainants tendered affidavit of Sh. Vivek Rana as Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainants also tendered documents Ex. C1 as copies of medical bills, Ex. C2 is the bill of AMC Bassi Hospital, Ex. C3 is the discharge summary of DMC & Hospital, Ex. C4 is the copy of legal notice dated 27.09.2018, Ex. C5 and Ex. C6 are the copies of postal receipts and closed the evidence.

4.                On the other hand, the counsel for the opposite parties submitted affidavit Ex. RA of Sh. P.C. Tripathy, Zonal Manager of the opposite parties along with documents Ex. R1 is copy of policy terms and condition, Ex. R2 is copy of proposal form, Ex. R3 is copy of request letter for enhance sum insured, Ex. R4 is the copy of pre authorization request, Ex. R5 is copy of field visit report, Ex. R6 is copy of patient notes (ICP), Ex. R7 is copy of pre authorization query letter dated 08.03.2018, Ex. R8 is the copy of pre authorization rejection letter dated 09.03.2018, Ex. R9 is the copy of indoor case papers, Ex. R10 is the copy of claim form, Ex. R11 is the copy of discharge summary, Ex. R12 is the copy of final bill, Ex.C13 I the copy of repudiation letter dated 17.05.2018, Ex. R14 is the copy of billing assessment sheet and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, written statement, affidavits and annexed documents produced on record by both the parties.

6.                We have heard the counsel for the parties and also perused and examined the record and following is the point of issue which requires adjudication:-

          (i)      Whether the opposite parties were justified in disapproving the                             pre-authorization claim for cashless treatment vide Ex. R8 and                             subsequently repudiating the claim vide Ex. R13?

 

7.                The counsel for the complainant has contended that the opposite parties have wrongly repudiated the claim of the complainant by invoking clause 3.6 of the policy and the same is not applicable to the facts of the case.

8.                On the other hand, the counsel for the opposite parties while contending drawn attention of this Commission to Ex. R13 that the claim has been repudiated by observing that the patient had undergone treatment primarily for anxiety neurosis. The counsel for the opposite parties has further contended that as per exclusion clause No.6 of the policy, “the company is not liable to make any payment in respect of any expenses for treatment of psychiatric, mental and behavioral disorders”.

9.                We have examined the contents of the written statement as well where the opposite parties have themselves admitted that this policy is in continuation since 20.03.2010 and it was renewed for a period of 20.03.2017 to 19.03.2018 and the claim has been lodged in the 8^th year of the policy. This act also finds mention on the first page of Ex. R1 where it is specifically mentioned that the date of inception of the first policy was 20.03.2010 and it is the 6^th year of renewal. Ex. R1 provides for the said clause which is reproduced as under:-

“3.    During the first two years of continuous operation of insurance cover any expenses on

          a)..., b)…, c)…, d)…, e)…, f) …, g)…, h)…

4.       …

5.       …

6.       Convalescence, general debility, run-down condition or rest cure, nutritional states, psychiatric, mental and behavioral disorders, congenital external disease or defects or anomalies, venereal disease and sexually transmitted disease, intentional self injury and use of intoxicating drugs/alcohol, smoking and tobacco chewing.”

The opening lines of the clause No.3 clearly mentions that the condition enumerated in clause 3.6 of the policy are for the first two years of continuance operation of the insurance cover. As such, the exclusion clause 3.6 is not applicable from the facts and circumstances of the case as the complainants had been availing insurance policies since 2010. The record of the hospital refers the illness to be 4-5 years old and even if it is assumed to be true still it would be deemed to have occurred during the continuance of the policy. Therefore, the act of the opposite parties for not approving the pre-authorization for cashless treatment and subsequently repudiating the claim is unjustified and is against the letter and spirit of the policy as well as law. The opposite parties have also submitted the bill assessment sheet and hospital payment (Ex. R14) according to which after making deductions as applicable, in the policy itself, the claim of Rs.16,917/- is admissible. As such, it would be just and appropriate if the opposite parties are directed to pay Rs.16,917/- to the complainant along with interest @8% per annum from 17.05.2018 i.e. from the date of repudiation of claim till actual  payment along with composite cost and compensation of Rs.7,000/-.

10.              As a result of above discussion, the complaint is allowed with direction to the opposite parties to pay Rs.16,917/- to the complainant along with interest @8% per annum from 17.05.2018 i.e. from the date of repudiation of claim till actual payment. The opposite parties shall also pay a composite compensation of Rs.7,000/- (Rupees Seven Thousand only) to the complainant. Compliance of order be made within 30 days from the date of receipt of copy of the 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.

 

(Monika Bhagat)                    (Jaswinder Singh)             (Sanjeev Batra)                          Member                                      Member                            President         

 

Announced in Open Commission.

Dated:02.12.2022.

Gobind Ram.

Vivek Rana Vs Star Health Allied Insurance                   CC/19/550 

Present:       Sh. Amitoj Khera, Advocate for complainants.

                   Sh. Rajeev Abhi, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is allowed with direction to the opposite parties to pay Rs.16,917/- to the complainant along with interest @8% per annum from 17.05.2018 i.e. from the date of repudiation of claim till actual payment. The opposite parties shall also pay a composite compensation of Rs.7,000/- (Rupees Seven Thousand only) to the complainant. Compliance of order be made within 30 days from the date of receipt of copy of the order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)                    (Jaswinder Singh)             (Sanjeev Batra)                          Member                                      Member                            President         

 

Announced in Open Commission.

Dated:02.12.2022.

Gobind Ram.