Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 53
Instituted on : 27.01.2023
Decided on : 24.07.2023
Arun Kumar son of Shri Sube Singh resident of House No. 800/27, Medical More, Rohtak.
………..Complainant.
Vs.
- Star Health and Allied Insurance Company Limited, Branch Office at IInd Floor, Ashoka Plaza, Rohtak through its Branch Manager.
- Star Health and Allied Insurance Company Ltd. Registered Office at KRM Centre, VI Floor, no 2, Harington Road, Chetpet, Chennai-600031 through its authorized person/Managing Director.
……….Opposite parties
COMPLAINT U/S 35 OF CONSUMER PROTECTION ACT,2019.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR.VIJENDER SINGH, MEMBER.
Present: Sh. Kunal Juneja, Advocate for the complainant.
Sh. Gulshan Chawla, Advocate for opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case, as per the complainant are that he had purchased a health policy namely Family Health Optima Insurance Plan vide policy No. P/211118/01/2017/004646 for a period of 09.03.2017 to 08.03.2018 from opposite parties. He paid valuable consideration i.e. premium of Rs.19,372/- for sum assured value of Rs.15,00,000/- for two adults and two children. The opposite party was given Member ID No. 6711836-1, 6711836-2, 6711836-3 and 6711836-4 in the name of Arun Kumar, Tripti, Tejas and Advitya. The said policy was continued and renewed from time to time by the complainant and lastly he got renewed the same vide policy no. P/211118/01/2022/013682 from 12.03.2022 to 11.03.2023 for sum assured of Rs.15,00,000/- + bonus Rs.6,75,000/-, total coverage of Rs.21,75,000/- and paid total premium of Rs.24,279/-. At the time of policy and even after its renewal’s it was assured by the opposite parties that the policy holder will be entitled for all the bills, including tests, path labs reports and other kinds of bills/expenses done by the policy holder in case of any treatment. In the month of January 2022, the son of the complainant Advitya had some problem in left foot and it was found that it’s a case of deformity left foot. On 27th February, 2022 the son of the complainant was admitted in Medanta, the Medicity, Gurgaon, for tendon transfer surgery but due to fever his surgery was deferred and he was discharges on 28th February, 2022. Thereafter, on 08.03.2022, the son of the complainant was again admitted and on 09.03.2022 his surgery was done. On 11.03.2022, the son of the complainant was discharged. Again on 20.03.2022, son of the complainant was admitted in Medanta, for suture removal and as such he was discharged on 21.03.2022. The above said information regarding treatment of the son of the complainant was brought to the notice of the officials of the opposite parties timely and they assured that after completion of the treatment, all the amount spent will be reimbursed to him. The complainant spent Rs.2,86,680/- which were paid to the Medanta vide various bills and other treatments and tests. After discharge, the complainant approached the opposite party for reimbursement of the expenses and submitted all the requisite documents as required by them and again they assured that all the amount will be reimbursed within 15 days. Thereafter the complainant again visited the opposite parties but they lingered on the matter on one pretext or the other. The act of the opposite parties is wrong & illegal and there is deficiency in service on the part of opposite parties. Hence this complaint and it is prayed that opposite party may kindly be directed to pay the claim amount of Rs.2,86,680/- alongwith interest., to pay a sum of Rs.1,00,000/- as compensation and also to pay Rs.55,000/- as litigation charges alongwith 18% per annum interest to the complainant.
2. After registration of complaint, notices were issued to the opposite parties. Opposite parties in their reply has submitted that complainant has reported two claims of the insured Mr. Advitya during the 5th year of the policy and the details are as follows:
Claim No. | Name of the hospital | Period of Hospitalization | Diagnosis | Reason for repudiation |
CIR/2022/211118/ 3913128 | Medanta The Medicity | 27.02.2022 | Deformity left foot | Pre Auth Denied: the insured patient has been admitted for treatment of Left foot deformity. Expenses for this treatment are not admissible in accordance with exclusion no.20 |
CIR/2022/211118/ 3962622 | Medanta The Medicity | 08.03.2022 to 24.03.2022 | Deformity left foot | Pre Auth Denied: the insured patient has been admitted for treatment of Left foot deformity. Expenses for this treatment are not admissible in accordance with exclusion no.20 |
The complainant had submitted the claim records toward reimbursement of medical expenses of Rs.286680/- vide claim no. CIR/2022/211118/3962622.. On scrutiny of the claim records submitted by the complainant, a letter was served to the complainant on 04.06.2022 to provide the following documents i.e.
1. Letter from the treating Doctor regarding when CTEV(deformity of foot) was first diagnosed with the duration and prior consultation reports with the treatment details.
2. Complete set of indoor case papers.
3. Original payment receipts for final bill.
The reminders letter dated 21.06.2022 and 06.07.2022 were served requesting to provide the documents required for adjudication of the claim on merits. Getting no response from the complainant, closure letter dated 24.07.2022 was served upon the complainant for non-submission of the documents. The insured was again admitted in Medanta The Medicity on 20.03.2022 and raised pre authorization request for cashless treatment vide claim no. CIR/2022/211118/4011827 during the policy period of 12.03.2022 to 11.03.2023 vide policy no. P/211118/01/2022/013682. The pre authorization request for cashless treatment was denied vide letter dated 21.03.2022 stating that the insured patient has been admitted for treatment of left foot deformity. Expenses for this treatment are not admissible in accordance with exclusion no. 20. But the insured had not submitted the claim records towards the reimbursement of medical expenses. All the other contents of the complaint were stated to be wrong and denied and opposite parties prayed for dismissal of complaint.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C38 and closed his evidence on dated 16.05.2023. At the time of arguments, ld. counsel for the complainant has also placed on record a document ‘Annexure –JN-A’. Ld. counsel for the opposite parties in their evidence has tendered affidavit Ex.RW1/A and documents Ex.R-1 to Ex. R-19 and closed the same on dated 06.06.2023.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case, the claim of the complainant has been repudiated by the insurance company vide its letter Ex.21.03.2022. The rejection letter has been placed on record by the insurance company as Ex.R19 for cashless treatment of patient namely Advitya. The main ground of the rejection was that the patient was admitted in the hospital regarding the treatment of deformity of foot and as per exclusion clause 20, the expenses of this ailment are not admissible. After that the complainant submitted all the required documents alongwtith the bills with the respondent officials. As per respondents they wrote several letters on various dates i.e. 04.06.2022 Ex.R11, 21.06.222 Ex.R12, 06.07.2022 Ex.R13 and 24.07.2022 Ex.R14. Through these letters the respondent officials have demanded 3 descriptions of documents and these are as under :-
1. Letter from the treating Doctor regarding when CTEV(deformity of foot) was first diagnosed with the duration and prior consultation reports with the treatment details.
2. Complete set of indoor case papers.
3. Original payment receipts for final bill.
6. As per complainant they have submitted all the required documents with the insurance company. We have minutely perused the documents placed on record by both the parties. But perusal of documents itself shows that it is well established that the complete set of treatment papers have already been submitted with the insurance company by the hospital and by the complainant. As per claim form dated 24.05.2022 placed on record as Ex.R7, it has been established that the complainant has demanded a sum of Rs.286680/- from the respondent officials . At the time of submission of claim form, payment receipts and discharge summary were also submitted by the complainant to the respondent officials. Now only one clarification is required i.e. “Letter from the treating Doctor regarding when CTEV(deformity of foot) was first diagnosed with the duration and prior consultation reports with the treatment details”. We have minutely perused the discharge summary placed on record as Ex.R7 page no.6/6, Ex.R8 page no.1/1, Ex. R8 page no.2/2. The history of patient namely Advitya is mentioned under the head ‘Medical history and presenting complaint’ which is as under:- “Master Advitya Nara, 5 years old boy, is follow-up case of deformity left foot. Admitted here for further management”. and another clarification is already attached by the respondent in their evidence as Ex.R9, which is as under : “Advitya is FUC of deformity L foot. He has undergone surgery for correction of deformity of left foot. The said surgery will help to maintain proper function & gait of foot. The main function of this surgery is to improve walking pattern & gait efficiency i.e to improve the function of left foot”. Through the perusal of these documents it has not been established that the son of the complainant has suffered this deformity since birth. One another clarification is also placed on record by the complainant at the time of arguments as Annexure JN-A’. As per this, another clarification has been given by the treating doctor regarding the ailment of the son of the complainant. which is as under: “Advitya Nara had complained of deformity foot for which he underwent surgery. The said deformity of foot going inwards, developed around one year prior to surgery and was not present before that and was not congenital”. After perusal of these above mentioned clarifications we came into the conclusion that the ailment of the son of complainant was not congenital and not comes under section 20 as explained in repudiation letter Ex.R19. Hence the complainant is entitled for the expenditure spent by him on the treatment of his son amounting to Rs.286680/-.
7. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite parties to pay Rs.2,86,680/-(Two lacs eighty six thousand six hundred eighty Rupees only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 27.01.2023 till its realization and shall also pay Rs.10000/-(Rupees ten thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
24.07.2023.
........................................................
Nagender Singh Kadian, President
……………………………….
Vijender Singh, Member
