Punjab

Ludhiana

CC/21/437

Amandeep Samra - Complainant(s)

Versus

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

B.K.Soni Adv

15 Nov 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:437 dated 21.09.2021.                                                         Date of decision: 15.11.2023.

 

Amandeep Samra son of Rattan Chand, r/o. Village Pharwala, Distt. Jalandhar.

..…Complainant

                                                Versus

1. Star Health and Allied Insurance Company Limited, Registered and Corporate Office 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034.
2. Star Health and ALLIED Insurance company Limited, 1^st Floor, Terminal 81, Near Bus Stand, Nakodar. PIN-144040.
3. Sukhvir Singh Aged Star Health and Allied Insurance company Limited, 1^st Floor, Terminal 81, Near Bus Stand, Nakodar. PIN-144040.

.….Opposite parties.

Complaint Under Section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. B.K. Soni, Advocate. 

For OP1 and OP2          :         Sh. Rajeev Abhi, Advocate.

For OP3                         :         Exparte.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                In brief, the facts of the case are that the complainant is an Advocate by profession. The OPs approached and apprised the complainant for providing best insurance services and pressed upon him to take Family Health Optima Insurance Plan SHAHLIP21211V042021, which the complainant took through OP3 who is an agent of OP1 and OP2 insurance company. The OPs issued policy No.P/621011/01/2021/000014 dated 02.02.2021 to the complainant after complying with all the procedural and medical formalities. The complainant paid the annual premium of Rs.20,000/- through cheque. The complainant stated hat in the last week of March 2021, his wife Smt. Kamlesh Kumari suffered from symptoms of Covid-19 and was admitted in DMC Hospital, Ludhiana on 31.03.2021 were she remained admitted till 01.04.2021 and the complainant spent Rs.30,000/- as medical expenses. The complainant approached OP3 for passing the claim upon which OP3 demanded all medical bills and medicine slips from the complainant which the complainant handed over the same to OP3. However, the OPs kept on demanding more documents again and again which were already supplied to them but the OPs intentionally did not pass the claim of the complainant. Thus, the act and conduct of the OPs not honouring the claim of the complainant amounts to deficiency in service and adoption of unfair trade practice. The complainant sent a legal notice dated 25.08.2021 to the OPs but to no avail. Hence this complaint, whereby the complainant has prayed for issuing directions to the OPs to pass his claim and also to pay compensation of Rs.1,50,000/- along with litigation expenses of Rs.25,000/-.

2.                None turned up on behalf of OP3 despite service of notice through registered post and as such, OP3 was proceeded against exparte vide order dated 21.01.2022.

3.                Upon notice, the opposite parties appeared and filed joint written statement in which they assailed the complaint on the ground of maintainability; concealment of material facts; lack of jurisdiction; the complainant estopped by his own act and conduct, concealment of facts  etc. The opposite parties alleged that immediately on the receipt of the claim, it was duly registered, entertained and processed. Complainant had obtained Family Health Optima Insurance policy No.P/621011/01/2021/000014 valid from 02.02.2021 to 01.02.2022 (under portability) covering Mr. Amandeep Samra self, Mrs. Kamlesh Kumari spouse, Amita Samra and Arun Samra dependent children for a sum insured of Rs. 10,00,000/-. Insurance policy is issued on the principles uberrimae fides. The insurance policy is issued on the basis of the proposal form. The insurance

policy is a contractual in nature and the parties are bound by the terms and conditions of the policy. The claims arising therein are subject to terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form which were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the policy schedule. The OPs further stated that it was stated in the policy schedule "the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. attached." It is one of the conditions No.2 in the policy "The insured person/s shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim is based and shall also give the company such additional information and assistance as the company may require in dealing with the claim."

                   The OPs further stated that a claim was reported by the insured in the 3^rd year of continuation of the policy and first year of the insurance policy with them in respect to the medical management of Mrs. Kamlesh Kumari with diagnosis of Covid-19 pneumonia with DMC Hospital, Ludhiana. The insured requested a cashless of the medical expenses towards the treatment of Mrs. Kamlesh Kumari of Covid-19 pneumonia at DMC Hospital, Ludhiana. Immediately on the receipt of request for cashless authorization for health insurance the hospital and the complainant was called upon vide query on authorization of cashless treatment letter dated 01.04.2021 to supply the documents/details, which are reproduced as under:-

• Kindly give the exact diagnosis, CVC, other positive investigations.
• Onset, duration of ailment and its investigation, treatment plan.

According to the OPs, on scrutiny of the cashless document, it was noted that as per the submitted documents patient's general condition was stable, vitals normal, home quarantine suffice. As such, the cashless authorization was denied calling the insured for reimbursement of medical expenses and the same was communicated to the treating hospital as well as the insured vide denial of pre-authorization request for cashless treatment letter dated 01.04.2021. Subsequently, the complainant/insured submitted the claim documents for reimbursement. On scrutiny of the claim documents, it is observed that the further documentations was necessary to process the claim for Rs.23,641/-. On scrutiny of the claim documents, it was noted that the patient's vitals are normal throughout the hospitalization. As such, they advised the complainant/insured vide their letter dated 11.08.2021 followed with first reminder dated 26.08.2021 and second reminder dated 10.09.2021 to furnish the documents, which are reproduced as under:-

• Letter from the treating Doctor stating what the need for hospitalization is when the vitals are normal.
• All investigation reports taken e.g. RT PCR positive report and CT scan report.
• First and previous consultation paper of above ailments.

According to the OPs, the documents sought for were the material documents required for processing of the claim. In the absence of the above documents/details the OPs were not able to process the claim. However, the complainant / insured had failed to submit the requisite documents required by the OPs vide their letter dated 11.08.2021, 26.08.2021 and 10.09.2021 and as such the claim of the complainant was rejected by them vide their letter dated 25.09.2021 on account of non-submission of documents and the same was communicated to the complainant. The OPs further stated that as per condition No.2 of the insurance policy obtained by the complainant, the insured person had to submit all the requisite documents and details called for by the respondents. The reimbursement claim of the complainant as such was rightly rejected as no claim on legal, valid, enforceable grounds which were in accordance with terms and conditions of the policy.

                   On merits, the opposite parties reiterated the averments made in the complaint by denying the averments made in the complaint as incorrect and in the end, a prayer for dismissal of the complaint has been made.

4.                In support of his claim, the complainant firm tendered his affidavit Ex. PA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1/A is the copy of welcome letter, Ex. C1/B to Ex. C1/D are the copy of policy documents, Ex. C1/E is the copy of I-cards of the insured,  Ex. C1/F is the copy of premium receipt, Ex. C1/G is the copy of summary of important benefits, Ex. C1/H is the copy of claim form, Ex. C1/I is the copy of legal notice, Ex. C1/J are the copies of postal receipts, Ex. Mark-A is the copy of medical certificate dated 21.06.2021 issued by DMC & Hospital, Ludhiana, Ex. Mark-B is the copy of Annexure-A of undertaking by patient for home isolation dated 01.04.2021, Ex. Mark-C is the copy of Annexure-B of certificate for home isolation for COVID-19 patients dated 01.04.2021, Ex. Mark-D to Ex. Mark-F are the copies of DAMA summary dated 01.04.2021, Ex. Mark-G to Ex. Mark-N are the copies of hospital bills/receipts, Ex. C1/K is the copy of Aadhar card of Kamlesh Kumari, Ex. C1/L is the copy of Aadhar card of the complainant and closed the evidence.

5.                On the other hand, the counsel for the opposite parties tendered affidavit Ex. RA of Sh. Sumit Kumar Sharma, Senior Manager of Star Health & Allied Insurance Co. Ltd.  along with documents Ex. R1 is the copy of proposal form, Ex. R2 is the copy of policy schedule, Ex. R3 is the copy of portability form along with declaration letter Ex. R4 is the copy of policy terms and conditions, Ex. R5 is the copy of request for cashless treatment, Ex. R6 is the copy of Field Visit Report, Ex. R7 is the copy of pre-authorization query letter dated 01.04.2021, Ex. R8 is the copy of pre-authorization denial letter dated 01.04.2021, Ex. R9 is the copy of claim form, Ex. R10 is the copy of discharge summary dated 01.04.2021, Ex. R11 is the copy of medical reports, Ex. R12 is the copy of final bill, Ex. R13 is the copy of query letter dated 11.08.2021, Ex. R14 is the query of reminder letter dated 26.082021, Ex. R15 is the copy of  reminder letter dated 10.09.2021, Ex. R16 is the copy of rejection letter dated 25.09.2021, Ex. R17 is the copy of reply dated 04.10.2021, to the legal notice dated 25.08.2021 and closed the evidence.

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

7.                Perusal of documents shows that the complainant, a subscriber of cashless health insurance policy issued by the opposite parties, got his wife Smt. Kamlesh Kumar admitted with Dayanand Medical College and Hospital, Ludhiana from 31.03.2021 to 01.04.2021 i.e. during the subsistence of the policy Ex. C1/B = R2. During all the hospitalization of Smt. Kamlesh Kumar, wife of the complainant, pre-authorization for cashless claim dated 0104.2021 Ex. R5 was initiated upon which the opposite parties raised certain queries vide query letter dated 01.04.2021 Ex. R7 and the cashless facility was declined vide denial letter dated 01.04.2021 Ex. R8 due to non-receipt of the documents from complainant. The complainant was advised to file the reimbursement claim along with supportive documents.

8.                Vide letter dated 01.04.2021 Ex. R8 (addressed to the complainant), the opposite parties requested the complainant to submit the following documents:-

1. Enclosed claim form duly completed and signed by the insured.
2. Discharge summary.
3. Hospital final bill with break up details.
4. All other bills and receipts.
5. Investigation reports, X-ray, scans, etc.,
6. Prescription of the treating doctor.
7. Earlier treatment records, if any.
8. A copy of a cancelled cheque to enable us to remit the amount in settlement of the admissible claim amount to your Bank account.
9. In case the claimed amount exceeds Rs.1,00,000/- a copy of your PAN card as required by the provisions of Prevention of Money Laundering Act.

Even as per query letters Ex. R13 to Ex. R15, the opposite parties further asked the complainant to lodge the claim along with requisite documents, which are reproduced as under:-

Sr. No.	Description of documents required
1.	Letter from the treating Doctor stating what is the need for hospitalization when the vitals are normal.
2.	Al investigation reports taken e.g. RT PCR positive report and CT scan report.
3.	First and previous consultation paper of above ailments.

However, due to non-lodging of claim by the complainant with the OPs despite issuance of query letters Ex. R13 to Ex. R15, the OPs rejected the claim of the complainant vide rejection letter dated 25.09.2021 Ex. R16. The complainant has staked the claim of total Rs.23,641/- vide claim form Ex. R9, on the basis of bills submitted in his evidence. The Insurance companies do despite their officers/agent for procurement of business at the doorsteps of person(s) to be insured but at the time of settling the claims, the company’s officials or TPAs render little assistance to the policy holder. The insurance companies are required to be more liberal in their approach without being too technical.

9.                In this regard, reference can be made to 2022(2) Apex Court Judgment 281 (SC) in case title Gurmel Singh Vs Branch Manager National Insurance Company Ltd. whereby it has been held by the Hon’ble Supreme Court of India that the insurance company has become too technical while settling the claim and has acted arbitrarily. The appellant has been asked to furnish the documents which were beyond the control of the appellant to             procure and furnish. Once, there was a valid insurance on payment of huge sum by way of premium and the Truck was stolen, the insurance company ought not to have become too technical and ought not to have refused to settle the claim on non­submission of the duplicate certified copy of certificate of registration, which the appellant could not produce due to the circumstances beyond his control. In many cases, it is found that the insurance companies are refusing the claim on flimsy grounds and/or technical grounds. While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control. In the given set of circumstances, it would be just and appropriate if the complainant is directed to submit the above said documents as per query letters Ex. R13 to Ex. R15 to opposite parties No.1 to 4 within 15 days from the date of receipt of copy of order and thereafter, the opposite parties No.1 to 4 shall consider and reimburse claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant. 

10.              As a result of above discussion, the complaint is partly allowed with an order that the complainant is directed to submit the documents with respect to hospitalization of his wife Smt. Kamlesh Kumari w.e.f. 31.03.201 to 01.04.2021 with DMC & Hospital, Ludhiana as per query letters Ex. R13 to Ex. R15 to the opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties shall consider and reimburse the claims of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant.  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.

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

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

 

Announced in Open Commission.

Dated:15.11.2023.

Gobind Ram.