Chandigarh

DF-I

CC/37/2023

DILVEEN KAUR CHADHA - Complainant(s)

Versus

STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED - Opp.Party(s)

SUDHIR GUPTA & R. C. GUPTA ADVOCATES

02 Nov 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/37/2023
Date of Institution	:	23.1.2023
Date of Decision	:	2/11 /2023

 

Dilveen Kaur Chadha wife of Sh. Parminder Singh Chadha, resident of House No.43, West Avenue Road, West Punjabi Bagh, West Delhi, New Delhi-110026.

… Complainant(s)

V E R S U S

1.       Star Health & Allied Insurance Company Limited Area Office, SCO 5A, Second floor, Madhya Marg, Sector 7-C, Chandigarh 160019 through its in-charge.

2.       Star Health & Allied Insurance Company Limited, Sri Balaji Complex, 15 Whites Roads, Chennai 600014 through its in-charge.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

                                               

ARGUED BY	:	Sh. Nitin Gupta, Advocate proxy for Sh. Sudhir Gupta, Advocate for complainant
	:	Sh. Inderjit Singh, Advocate for OPs

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by the complainant under Section 35 of the Consumer Protection Act 2019 against the opposite parties  (hereinafter referred to as the OPs). The brief facts of the case are as under :-

1. It transpires from the averments as projected in the consumer complaint that  the agent/officer of the OPs approached the complainant and her husband Parminder Singh Chadha  to subscribe a medi-claim insurance policy and accordinglythe OPs insurance company on being satisfied about the health conditions and all other parameters, sold the mediclaim insurance policy  bearing NO. P211100/01/2022/008072 (herein after to be referred as subject policy) valid from 7.3.2022 to 6.3.2023. During the policy period the complainant  fell ill and she was diagnosed as COVID19  positive and was admitted in Max Health Care, Max Super Sociality Hospital, Shalimar Bagh, New Delhi on 6.8.2022 and after treatment was discharged on 10.8.2022.  The hospital raised a bill of Rs.64,029/- and request for cashless treatment was made to OP No.1 from the desk of the hospital through their TPA. However, the OP insurance company vide communication dated 10.8.2022 rejected authorization for cashless treatment  on false and flimsy grounds in an arbitrary manner and the said act of OPs amounts to deficiency in service and indulgence in unfair trade practice.  The complainant was admitted in the treating hospital on the advice of highly qualified and expert doctors of the treating hospital as there was threat to the life of the complainant on account of her illness. The copy of admission  and discharge card of the hospital is Annexure C-2 and the bills are Annexure C-3(colly) whereas Annexure C-4 is denial of cashless treatment by the OPs. The complainant issued legal notice to the OPs vide Annexure C-5 but to no avail.  OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action  and also that the complaint is premature as the complainant has not submitted the claim alongwith requisite documents. It is admitted that the subject policy purchased by the complainant and her husband was valid at the relevant time. It is alleged that the  complainant has no cause of action against the  answering OPs. It was stated that if the complainant submits the claim alongwith requisite documents then the answering OPs were ready to consider the same on merits. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant reiterated  the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that  complainant and her husband had purchased the subject policy Annexure C-1 copy of which is also proved on record by Ops as Annexure R-3 and the same is valid from 7.3.2022 to 6.3.2023, however, when the complainant remained admitted  in the treating hospital  on 6.8.2022 and  was diagnosed as COVID 19 positive and after her treatment discharged on 10.8.2022 and treating hospital had raised a bill of Rs.64,029/- and the same was not paid by OPs and also that the complainant was admitted on 6.8.2022 and discharged on 10.8.2022 and Annexure C-3 is the bill raised by the hospital and paid by the complainant from her own pocket and further cashless authorization was denied vide denial letter Annexure C-4,  the case is reduced to a narrow compass as it is to be determined if  the OPs are  unjustified in rejecting the claim of the complainant and the complainant is entitled for the relief as prayed for as is the case of the complainant or the complaint is premature and is liable to be dismissed as is the defence of the OPs.
   2. In the back drop of the foregoing admitted and disputed facts on record, it is clear that the entire case of the parties is revolving around   the terms and conditions of the subject policy, medical record and the rejection of authorization for cashless treatment letter, having been relied upon by both the parties in the present case and the said documents tendered by the parties are required to be scanned carefully in order to set at rest the real controversy between the parties.
   3. Perusal of Annexure C-4 the rejection of  authorization for cashless treatment  indicates that the OPs on finding that the hospitalization of the patient is not convincing rejected her request for cashless treatment vide letter Annexure C-4. The relevant portion of the said letter is as under:-

 

       Similarly discharge summary Annexure C-2 clearly indicates that the patient was admitted with the complaint’s intermittent fever, acute onset, moderate grade, associated with the headache, cold cough Myalgia and generalized weakness since two days etc. and she was found positive in COVID RT PCR and accordingly medication was given to her. The relevant portion of the discharge summary is as under:-

 

4.  Another document Annexure R-4  having been relied upon by the parities, is the terms and condition of the policy wherein under the head of coverage Section 1 of Hospitalization speaks about the entitlement  of insured in case of hospitalization and the relevant portion of whereof is, as under:-

 

 

 

 

5. Perusal of the aforesaid document clearly indicates that the complainant was firstly diagnosed as
   COVID19 positive and thereafter when she was brought to the treating hospital, she was complaining of intermittent fever, acute onset, moderate grade, associated with the headache, cold cough Myalgia and generalized weakness since two days and was also having difficulty in swallowing  since two days both for liquid and solids. The expert doctor of the treating hospital after examining the condition of the complainant advised her hospitalization and accordingly the complainant was admitted in the treating hospital and she was given treatment. It is further clear from the discharge summary that the condition of the complainant only improved during her hospitalization  and on her improvement the hospital had decided to discharge her on 10.8.2022. Thus, as it has come on record that the complainant was hospitalized only on the advice/decision of the expert doctors of the treating hospital as is also evident from discharge summary  and the said evidence has not been rebutted by the OPs in order to prove that the complainant was normal and no hospitalization was required, it thus is safe to hold that the rejection of cashless treatment by OPs vide Annexure C-4  is against the terms and conditions of the policy and the aforesaid act of OPs amounts to deficiency in service especially when Section 1 of the  subject policy itself says during the period stated in the schedule that in case the insured person shall contract any disease or suffer from any illness or sustain bodily injury through  accident and if such disease or injury shall require the insured person, upon  the advice of a duly qualified medical practitioner to incur hospitalization expenses for medical/surgical treatment at any nursing home/hospital in India as an in patient, the company will pay to the insured person the amount of such expenses.    The defence of the OPs that the complainant had not  lodged the claim with the OPs and the complaint of the complainant is premature, devoid of merit especially when the medical record alongwith other relevant record  and claim request of the complainant is already available with the OPs and the complainant has already tendered the bill raised by the treating hospital and further that in case of cashless facility it is not for the insured to approach the treating hospital to collect the documents and further that the OPs have already collected almost all the documents from the treating hospital which have been annexed with their written version, hence, it is safe to hold that the OPs  cannot compel the complainant again and again to do the paper formalities for submitting the papers which are already available with the OPs for the settlement of the claim especially when the OPs have sufficient material with them that the treating hospital has raised bill of Rs.64029/- for the treatment of the complainant and the same has been paid by the complainant from her own pocket  as is evident from Annexure C-3, the act of OPs by not settling the genuine claim of the complainant amounts to deficiency in service and indulgence in unfair trade practice. Hence, the instant consumer complaint deserves to be allowed.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹64029/-to the complainant  alongwith interest @ 9% per annum from the date when the authorization for cashless treatment was rejected by Ops vide letter Annexure C-4 i.e. on 10.8.2022 till onwards.
2. to pay an amount of ₹10,000/-to the complainant as compensation for causing mental agony and harassment to her;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs within 45 days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed off.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 2/11/2023			Sd/- [Pawanjit Singh] President
mp
			Sd/-
			[Suresh Kumar Sardana] Member