Haryana

Ambala

CC/465/2022

PRABHJOT SINGH. - Complainant(s)

Versus

STAR HEALTH & ALLIED INSUARNCE CO.LTD. - Opp.Party(s)

C.M ATTRI.

03 May 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	465  of 2022
Date of Institution	:	13.12.2022
Date of decision	:	03.05.2024

Prabhjot Singh s/o Late Sh. Inderjit Singh, age about 42 years resident of House No.116/117, Sector-B Defence Colony Kalareheri Ambala Cantt. Tehsil and District Ambala at present # 19 Sector D Defence Colony Kalarehri Tehsil and District Ambala.

          ……. Complainant

Versus

1. Star Health and Allied Insurance Co. Ltd. through its Manager No.15, Sri Blaji Complex, 1^st Floor Whites Lane, Royapetatah, Chennai-600014.
2. Star Health and Allied Insurance Co. Ltd. through its Manager having its branch office at The Branch Manager, STAR Health and Allied Insurance Company Ltd. 1^st Floor, 5, Prem Nagar, near Post Office Prem Nagar Ambala City.

….….  Opposite parties

 Before:        Smt. Neena Sandhu, President.

                              Smt. Ruby Sharma, Member,

           Shri Vinod Kumar Sharma, Member.           

 

Present:        Shri Deepak Rana, Advocate, counsel for the complainant

                     Shri Mohinder Bindal, Advocate, counsel for the OPs.

Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Party (hereinafter referred to as ‘OP’) praying for issuance of following directions to them:-

1. To pay the medical expenses incurred on the treatment of the wife of the complainant to the tune of Rs.1,20,236/- alongwith interest @18% p.a. from the date of payment, till realization.
2. To pay Rs.50,000/-, as compensation for the mental agony, financial loss and physical harassment suffered by the complainant.  
3. To pay Rs.20,000/- as litigation expenses.

 

2.             Brief facts of this case are that in the month of March 2019 official/agent of the OPs visited the complainant and told about the health insurance plans and about the benefits of the health policy. Accordingly the complainant, in the month of March 2019, purchased a medical benefit/health risk policy from the OPs i.e. Star Health and Allied Insurance Co. Ltd. bearing no. P/211117/01/2019/004441 dated 13-03-2019. As per the said policy, the wife of complainant namely Inderjeet Kaur was also covered for all kind of medical benefits. The complainant was associated with the OPs for the last 3 years. The complainant continued paying the premium amount for the policy at regular intervals and in the year 2022. After 3 years of the said policy on 15-03-2022, the complainant along with his wife visited Indira IVF Hospital Pvt. Ltd. SCO 156-157-158-159 Sector 9-C Madhya Marg, Chandigarh and took treatment. Intimation/information regarding getting the treatment of wife of the complainant in that hospital was also given to the OPs. The complainant was assured and promised that all the expenses of the treatment will be reimbursed to the complainant upon submission of the claim. On the assurance and promise made by the OPs, the complainant got started the treatment of his wife Inderjeet Kaur from the said hospital for the period from 15-03-2022 to 29-04-2022 and spent an amount of Rs.1,77,566/-. After completion of the treatment, the complainant submitted the claim of Rs.1,77,566/- along with the relevant documents with the  OPs  along with the detail of all the expenses incurred on the treatment for its reimbursement. However, the OPs only reimbursed an amount of Rs.57,330/- out of Rs.1,77,566/- and wrongly, illegally and arbitrary did not reimburse an amount of Rs.1,20,236/-. Number of requests were made to the OPs to pay the said remaining amount of Rs.1,20,236/- but to no avail.  Hence, the present complaint.
3.           Upon notice, OPs appeared and filed written version and raised preliminary objections to the effect that this complaint is not maintainable either in law or on facts and liable to be dismissed in limine; the complainant has not approached the Commission with clean hands as he has suppressed the material facts; the present complaint is ex-facie misconceived, vexatious, untenable and devoid of any merit; the complainant has no locus standi to file the present complaint etc. On merits, it has been stated that the complainant has tried to manipulate the facts for imposing this false and frivolous complaint. As a matter of fact the wife of the complainant Mrs.Inderjeet Kaur reported to have undergone some treatment from Indira IVF Hospital, Chandigarh on 15.03.2022. The wife of the complainant submitted her claim for reimbursement of medical expenses for Rs.1,77,566/-. The said claim of the complainant’s wife was duly entertained according to the terms of the policy and after detailed perusal of the complete treatment records and the submitted treatment papers and bills, the approved amount of Rs.57,330/- was paid to the complainant accordingly which was the maximum payable amount as per the terms and conditions of the insurance policy. As per the terms qua other excluded expenses of the policy, the charges pertaining to non-payable items like Calcivoiz Nano, Capromom powder, ID brand, Inprogest Gel were not payable and pre and post not payable under Assisted Reproductive Treatment sublimit, hence the amount of Rs.6482/- and Rs.1,13,754/- was denied being not payable according to terms of the policy. The Condition no. U of the policy says:

 

“…Assisted Reproduction Treatment: The company will reimburse expenses incurred on Assisted Reproduction Treatment, where indicated, for sub-fertility subject to:

1. A waiting period of 36 months from the date of first inception of this policy with the company for the insured person. The maximum liability of the company for such treatment shall be limited to Rs.1,00,000/- for sum insured of Rs.5,00,000/- and Rs.2,00,000/- for sum insured of Rs.10,00,000/- and above for every block of 36 months and payable on renewal.

2. For the purpose of claiming under this benefit, in patient treatment is not mandatory.

3. Automatic Restoration of sum insured, Recharge benefit shall not be applicable for this benefit.

Note: To be eligible for this benefit both husband and spouse should stay insured continuously without break under this policy for every block. This coverage is available only for sum insured options of Rs.5,00,000/- and above.

Special; Exclusions: The company shall not be liable to make any payment under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of:

1. Pre and Post treatment expenses…”

In the present case, considering all the facts and after going through the entire treatment record submitted by the complainant, a total sum of Rs.57,330/- was held legally payable to the insured against the total claim bills submitted by the complainant on behalf of his wife against her aforesaid treatment. The terms of the policy shall govern the contract between the parties and they have to abide by the definition given therein and all those expressions appearing in the policy should be interpreted with reference to the terms of policy. It is a matter of contract and in terms of contract, the relation of the parties shall abide and it is presumed that when the parties have entered into a contract of insurance with their eyes wide open, they have to rely on the terms of the contract. Thus rights and liabilities of both insured and insurer are strictly governed by the policy of insurance and no relaxation or exception can be made on the ground of equity. In the present case, the claim of the complainant was settled as per the terms of the policy, however, the complainant in order to put undue pressure filed this false complaint by exploiting the process of law; hence the present complaint deserves dismissal on this score alone. The terms and conditions of the policy were served to the complainant alongwith policy schedule duly approved by the IRDA. Moreover, it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC. ATTACHED." The complainant had accepted the policy after going through the same and never objected to any of the endorsement or terms of the policy thus he is supposed to abide and legally bound by the terms and conditions of the policy. Rest of the averments of the complainant were denied by the OPs and prayed for dismissal of the present complaint with costs.

4.           Learned counsel for the complainant tendered affidavit of the complainant as Annexure CW1/A alongwith documents as Annexure C-1 to C-49 and closed the evidence on behalf of the complainant. On the other hand, learned counsel for the OPs tendered affidavit of Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Company Limited, 2^nd Floor, Daily Tej Building, 8-B, Bhadur Shah Zafar Marg New Delhi-110002 as Annexure OP-1/A alongwith documents Annexure OP-1 to OP-10 and closed evidence on behalf of the OPs.
5.           We have heard the learned counsel for the parties and have also carefully gone through the case file.
6.           Learned counsel for the complainant submitted that by deducting the amount of Rs.1,20,236/-  from the claim amount illegally, out of the total amount of Rs.1,77,566/-  spent on the treatment of the insured, the OPs indulged into unfair trade practice and are also deficient in providing service. 
7.           On the contrary, the learned counsel for the OPs submitted that the amount of Rs.1,20,236/-  was deducted strictly as per terms and conditions of the policy in question. He further submitted that the said charges were deducted because the insured was not entitled to get Pre and Post Hospitalization charges, as envisaged under exclusion clause of the policy in question.
8.           From the perusal of policy schedule Annexure C-1, it is evident that the complainant and his wife were duly insured for Rs.20,00,000/-.  Neither the treatment taken by the wife of the complainant during existence of the policy in question; nor the fact that out of total amount of Rs.1,77,566/-, the OPs paid Rs.57,330/-, after deducting the amount of Rs.1,20,236/- is in dispute, as such, the moot question which falls for consideration is, as to whether, the complainant is entitled to get any relief or not. It is significant to mention here that though counsel for the OPs have tried to justify the stand of deduction of Rs.1,20,236/- out of the total amount of Rs.1,77,566/- by placing reliance on terms and conditions, Annexure OP-3 attached alongwith letter dated 21.02.2022, allegedly sent to the complainant, perusal of Clause U-Assisted Reproduction Treatment, whereof reveals that under the Special Exclusions clause:- Pre and Post Hospitalization charges were not covered. However, on the other hand, the complainant has placed on record the same letter dated 21.02.2022, Annexure C-14 alongwith terms and conditions, Annexure C-16 but in these documents, under the Heading -Assisted Reproduction Treatment we did not find any such special exclusion clause qua:- Pre and Post Hospitalization charges.
9.           It is significant to mention here that when we compare both the letters alongwith terms and conditions i.e. Annexure OP-3 attached alongwith letter dated 21.02.2022 and letter dated 21.02.2022, Annexure C-14 alongwith terms and conditions, Annexure C-16, it is found that in the said letter Annexure C-14, wherein no exclusion clause regarding Pre and Post Hospitalization charges has been mentioned, bears the letter head of the OPs bearing the complete details of Regd. and Corporate Office of the OPs.  On the other hand, letter dated 21.02.2022 attached with terms and conditions i.e. Annexure OP-3 is neither printed on any letter of the Company nor any details qua the company have been embossed thereupon. Under these circumstances, the terms and conditions Annexure C-16 attached alongwith letter dated 21.02.2022, Annexure C-14 shall hold the field. It is therefore held that the OPs cannot deduct any Pre and Post Hospitalization charges out of the bill raised by the complainant qua the treatment taken by her insured wife.
10.           Now the next question which arises for consideration is as to what amount, the complainant is entitled for in this case for the treatment taken by his wife, it may be stated here that perusal of terms and conditions, Annexure C-16 reveals that the maximum liability of the company for the treatment in question was limited to Rs.1 lac for sum assured of Rs.5 lacs and Rs.2 lacs for sum assured of Rs.10 lacs and above. In the instant case, the sum assured under the policy was Rs.20 lacs and as such, the complainant was entitled to get claim to the extent of Rs.2 lacs spent on treatment of the insured under the policy in question. Admittedly, in the present case, an amount of Rs.1,77,566/- has been spent by the complainant on the treatment of his insured wife out of which, only an amount of Rs.57,330/- stood paid by the OPs. Under these circumstances, the OPs are liable to make payment of the remaining amount of Rs.1,20,236/- to the complainant.
11.           In view of the aforesaid discussion, we hereby allow the present complaint and direct the OPs, in the following manner:-
    1. To pay the amount of Rs.1,20,236/-  to the complainant alongwith interest @6% p.a. from the date of payment made by the complainant to the hospital for treatment of his wife, onwards.
    2. To pay Rs.5,000/-, as compensation for the mental agony and physical harassment suffered by the complainant.
    3. To pay Rs.3,000/- as litigation expenses.

 

 

The OPs are further directed to comply with the aforesaid directions within the period of 45 days, from the date of receipt of the certified copy of the order, failing which the OPs shall pay interest @ 8% per annum on the awarded amount, from the date of default, till realization. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

 Announced:- 03.05.2024.

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President