Haryana

Karnal

CC/435/2021

Amit Sachdeva - Complainant(s)

Versus

Star Health & Allied Insurance Company Limited - Opp.Party(s)

Dheeraj Sachdeva

16 Sep 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                       Complaint No. 435 of 2021

                                                        Date of instt.27.08.2021

                                                        Date of Decision:16.09.2022

 

Amit Sachdeva, resident of House no.2276, Sector-13, Urban Estate, Karnal-132001.

                                               …….Complainant.

                                              Versus

 

1.     Star Health & Allied Insurance Company Ltd. having its office at S.C.O. 242, 1^st floor, Sector-12, opposite mini Secretariat Karnal, 132001 through its Manager/Authorized person now at SCF 137, Sector-13, Nr. ICICI Bank, Urban Estate, Karnal.

 

2.     Star Health & Allied Insurance Company Ltd. Registered office at-1-New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034 through its Managing Director/Authorized person.

 

                                                                      …..Opposite Parties.

 

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

 

Before   Shri Jaswant Singh……President.

              S        hri Vineet Kaushik…..Member

      Dr. Rekha Chaudhary…..Member

           

 Argued by: Shri Dheeraj Sachdeva, counsel for complainant.

                    Shri Naveen Khetarpal, counsel for the OPs.

                   

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant purchased a medical insurance policy from OPs company on 29.02.2020 and since then the said medical health insurance policy is in continuation and renewed and the complainant is having valid medical insurance policy, vide policy no.P/211114/01/2021/013103, valid from 01.03.2021 to 28.02.2022. The premium of the said policy was Rs.13057/-. The said insurance policy was a package health plan. On 21.07.2021 in the evening at about 7.00 p.m. the upper top portion of the ring finger of left hand of complainant got badly damaged/crushed in the door/digi of the car while closing the same. The complainant immediately went to the doctor and doctor checked the finger and found that the bone exposed due to said incident and a major surgery was suggested by the doctor and it was also told that the said surgery would be conducted by Plastic Surgeon as well as orthopedic surgeon and first aid was provided by the doctor, complainant has to spend Rs.1300/- for the same including x-ray and consultation. The family members of complainant consulted with the Doctors at Aryan Hospital Gurgaon and decided to get surgery conducted at Aryan Hospital Gurgaon being an empanelled hospital of OPs. On 22.07.2021, complainant was taken to Aryan Hospital Gurgaon for surgery. The doctors at hospital got admitted for surgery and intimation for cashless claim approval was sent by the hospital for said surgery/treatment. At first instance, OPs approved an amount of Rs.25,000/- for treatment/surgery and doctors conducted the surgery on 22.07.2021 and the complainant remained admitted in the said hospital from 22.07.2021 to 24.07.2021. At the time of discharge doctor advised to follow up twice a week for checkup and dressing. The hospital sent the final bill for the treatment/surgery of the complainant for total amount of Rs.74884.50/-, but OPs had not approved the cashless claim after repeated requests made by the complainant. After waiting sufficient time of 6 hours, it was told by the doctor of the hospital that the OPs are raising query that the billed amount is at higher end and asked to raise the revised bill with lower amount upto Rs.45000/- only. After that on 25.07.2020 complainant received an email from the OPs by which OPs have been withdrawn the amount of Rs.25000/- which was initially approved by the OPs.  Thereafter, on 05.08.2021, OPs sent an email and it was mentioned that for the treatment of complainant, only Rs.63800/- has been utilized but not amount has ever been received by the complainant and all the amount of Rs.74884.50 has been paid by the complainant from his own pocket. Thereafter, on 27.07.2021, the complainant went to the follow up treatment on dated 31.07.2021, 04.08.2021, 07.08.2021, 11.08.2021 and 25.08.2021 and some medicines were suggested by the doctor. The complainant took the medicines and dressing as per instruction of doctor till 25.8.2021 and an amount of Rs.9633/- was spent. The complainant is also entitled for the said amount. The complainant continuously requested the OPs to release the abovesaid amount but OPs did not pay any heed to the request of complainant. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction and concealment of true and material facts. On merits, it is pleaded that the complainant availed Family Health Optima Insurance Plan covering Mr. Amit Sachdeva (self), Vineet Sachdeva (spouse) and Rujula Sachdeva for sum insured to the tune f Rs.5,00,000/-, vide policy no.P/211114/01/2020/013969, valid from 29.02.2020 to 28.02.2021 and the said policy was renewed till 28.02.2022.  It is further pleaded that the policy is contractual in nature and the claims arising therein are subject to the 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. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant alongwith the policy schedule. The complainant raised cashless request for hospitalization on 22.07.2021 to 24.07.2021 in Aryan Hospital Private Limited-Gurgaon towards the treatment of Crush Injury Finger. On scrutiny of the pre-authorization documents, OPs have approved an amount of Rs.25,000/- on 21.07.2021 for the treatment of above disease. The request for enhancement of amount is being examined by the office of OP, while seeking the clarification of Higher amount charged by the hospital and coordinating with the hospital to revise the Final Bill as per agreed tariff in the meantime it came to know that the complainant has paid the hospital bill and not utilized the amount approved for cashless treatment, vide hospital letter dated 25.07.2021, therefore, OPs had withdrawn the approval given earlier, vide letter dated 25.07.2021. The cashless approval is given by the OPs only on a preliminary evaluation of documents submitted by treating hospital/insured and it is subject to review upon the receipt of further details/documents from the insured patient or at any time. If amount of treatment is exceeding to cashless approval or cashless approval is denied then insured can submit his final claim for the reimbursement of the medical expenses incurred by him with the OPs with all the required documents. OPs have settled the claim according to the terms and conditions of policy. However, complainant has not submitted claim for reimbursement of medical expenses.

3.             Parties then led their respective evidence.

4.             Complainant has tendered into evidence his affidavit Ex.CW1/A, copy of insurance certificate Ex.C1, copy of x-ray bill Ex.C2, copy of OPD receipt Ex.C3, copy of admission slip of Aryan Hospital, Gurgaon Ex.C4, copy of SMS Ex.C5, copy of SMS dated 27.07.2021 Ex.C6, copy of discharge summary Ex.C7, copy of final bill of Aryan Hospital Ex.C8, copy of detail of hospital expenses Ex.C9, copies of tests reports Ex.C10 to Ex.C16, copy of SMS dated 24.07.2021  and 25.07.2021 raising query Ex.C17 and Ex.C18, copy of OPD slips Ex.C19 to Ex.C22, copy of medicines bills Ex.C23 to Ex.C25, copy of letter dated 25.07.2021 regarding withdrawal of cashless approval Ex.C26, copies of emails Ex.C27 to Ex.C29, copy of x-ray Ex.C30 and closed the evidence on 16.12.2021 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.RW1/A, copy of insurance policy Ex.R1, copy of terms and conditions of insurance policy Ex.R2, copy of proposal form Ex.R3, copy of request for cashless Ex.R4, copy of Field Visit Report Ex.R5, copy of query on authorization Ex.R6, copy of cashless authorization letter Ex.R7, copy of discharge summary Ex.R8, copy of medical bill Ex.R9, copy of letter with regard to query on enhancement of amount for cashless treatment Ex.R10, copy of cancellation letter Ex.R11, copy of withdrawal of approval letter Ex.R12 and closed the evidence on 10.05.2022 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for the complainant, while reiterating the contents of the complaint, has vehemently argued that complainant purchased a health insurance policy from the OPs. On 21.07.2021 the upper top portion of the ring finger of left hand of complainant got badly damaged/crushed in the door/digi of the car. The complainant immediately went to the doctor at Karnal and doctor checked the finger and a major surgery was suggested. Then complainant consulted with the Doctors at Aryan Hospital Gurgaon and decided to get surgery conducted in the said hospital. On 22.07.2021, the surgery was conducted  and intimation for cashless claim approval was sent by the hospital for said surgery/treatment. OPs approved an amount of Rs.25,000/- for treatment/surgery while the hospital had sent the final bill for the treatment/surgery of the complainant for total amount of Rs.74884.50/-, but OPs had not approved the cashless claim after repeated requests made by the complainant. After waiting sufficient time complainant paid the said amount to the hospital and after that  OPs have been withdrawn the amount of Rs.25000/- which was initially approved by the OPs.  Thereafter, on 05.08.2021, OPs sent another email and it was mentioned that for the treatment of complainant, only Rs.63800/- has been utilized but no amount had ever been received by the complainant. Thereafter, complainant has taken the follow up treatment from the said hospital and an amount of Rs.9633/- was spent. He further argued that after getting discharge from the hospital, complainant lodged the claim with the OPs for reimbursement of the abovesaid amount but OPs did not pay the same and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for OPs, while reiterating the contents of written version, has vehemently argued that the complainant raised cashless request for hospitalization on 22.07.2021 to 24.07.2021 in Aryan Hospital Private Limited-Gurgaon towards the treatment of Crush Injury Finger. On scrutiny of the pre-authorization documents, OPs have approved an amount of Rs.25,000/- on 21.07.2021. As the complainant has paid the hospital bill and not utilized the amount approved for cashless treatment, vide hospital letter dated 25.07.2021, therefore, OPs withdrawn the approval given earlier. The cashless approval is given by the OPs only on a preliminary evaluation of documents submitted by treating hospital/insured and it is subject to review upon the receipt of further details/documents from the insured patient or at any time. If amount of treatment is exceeding to cashless approval or cashless approval is denied then insured can submit his final claim for the reimbursement but complainant has not submitted claim for reimbursement of medical expenses and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, on 29.02.2020, complainant had purchased medical insurance policy from the OPs by paying the premium amount of Rs.13057/- and a sum insured was of Rs.5,00,000/-. It is also admitted that the policy in question was cashless policy. It is also admitted that initially an amount of Rs.25,000/- was approved by the OPs.

11.           On 21.07.2021 the ring finger of left hand of complainant got crushed and was rushed to the Virk Hospital, Karnal  and after that Bajaji Hospital Karnal and doctors of said hospitals suggested for major surgery. The complainant after consulting with the doctor of Aryan Hospital, Gurgaon and decided to get surgery conducted from the said hospital. The surgery was conducted on 22.07.2021. As per the version of the complainant, on denial of the cashless facility, he has paid Rs.74884/- to the  Aryan Hospital, Gurgaon.

12.           It is evident from the OPD Slips Ex.C2 and Ex.C3 that complainant was rushed to Virk Hospital, Karnal and Balaji Hospital and paid Rs.1300/- in that hospitals. It is also evident from the SMS Ex.C5 and Ex.C6 that the request for pre-authorization was sent and same was approved to the tune of Rs.25,000/- after raising the some queries. It is also evident from the treatment record Ex.C4 and discharge summary Ex.C7, the surgery was conducted on the left finger of complainant in Aryan Hospital, Gurgaon. It is also evident from the final bill Ex.C8 that complainant had paid Rs.74,884/- to Aryan Hospital, Gurgaon on account of his treatment.  It is also evident from the invoice bills Ex.C23 to Ex.C25, complainant spent Rs.9633/- for purchasing the medicines after discharge from the hospital.  Said bills have not been denied/rebutted by the OPs.

13.           OPs have taken a plea that on denial of the pre-authorization facility, complainant has not lodged the claim for reimbursement of the amount spent on his treatment. Learned counsel for complainant strongly had opposed the said plea of the OPs on the ground that complainant had already lodged the claim with the OPs but OPs did not approve the claim and denied the same on pretext or the other. In this regard, we are of the considered view that a person whose personal interest is involved in form of the huge claim amount, then, as to why, he would not file the claim. Hence, plea taken by the OPs has no force.        

14.  

                It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.

15.           Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OPs while denying the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

16.           The complainant claimed Rs.85,813/- and in this regard he has placed on file medical bills Ex.C2, Ex.C3, Ex.C8, Ex.C23 to Ex.C25/-. The said bills have not been rebutted by the OPs. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

17.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.85,813/- (Rs. eighty five thousand eight hundred thirteen only) to the complainant alongwith interest @ 9% per annum from the date of denial of claim till its realization. We further direct the OPs to pay Rs.10,000/- to the complainant on account of mental agony and harassment and Rs.5500/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:16.09.2022                                                                      

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)

                          Member                      Member