Haryana

Karnal

CC/52/2022

Girish Malik - Complainant(s)

Versus

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

Bhaskar Bhalla

25 Aug 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No. 52 of 2022

                                                        Date of instt.27.01.2022

                                                        Date of Decision:25.08.2023

 

Girish Malik son of Shri Harbans Lal Malik now deceased through his legal heirs

1. Bhawna widow of Shri Girish Malik. Aadhar no.3297 0454 6561
2. Shubhit Malik son of Shri Girish Malik. Aadhar no.9988 9252 2444
3. Ashmita Malik daughter of Shri Girish Malilk. Aadhar no.7365 3387 5084.

All residents of house no.220, New Ramesh Nagar, Karnal.

 

                                               …….Complainants.

                                              Versus

 

1. Star Health and Allied Insurance Co.Ltd., #SCF-137, 2^nd floor, above ICICI  Bank, Sector-13, Urban Estate, Karnal-132001, through its Branch Manager.

 

2. Star Health and Allied Insurance Co. Ltd. # no.15, Sri Balaji Complex, 1^st floor, Whites Lane, Roy apettah, Chennai-600014 through its MD/CEO/Authorized Signatory.

 

3. Amritdhara My Hospital, ITI Crossing, ITI Chowk, Karnal, through its Director/Authorized Signatory.

 

                                                                ……Opposite parties.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

              Dr. Rekha Chaudhary…..Member

          

 Argued by: Shri Bhaskar Bhalla, counsel for complainants.

Shri Mohit Goyal, counsel for the OPs no.1 and 2.

Shri Rajan Gupta, counsel for the OP no.3.

 

                    (Jaswant Singh President)

 

ORDER:   

                  The complainant (since deceased) has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant had purchased Family Health Optima Insurance Policy since the year 2017 and the same has been renewed, vide policy no.P/211135/011/2021/000237, valid from 06.01.2021 to 05.01.2022 by premium amount of Rs.26,781/- including GST. In the said policy complainant insured himself, his wife Bhawna and his daughter Ashmita Malik. The basic sum insured in the said policy is Rs.5,00,000/-. In the said policy pre-existing disease of the complainant were also covered namely Diabetes, Hypertension, Neurological diseases and their complications. In the month of September 2021 the complainant suffered from chest pain radiating to left arm, sweating, restlessness and the complaint was brought at the hospital of OP no.3 for treatment, where the concerned doctors after physical inspection/test found the symptoms of Acute Kidney Injury and got admitted the complainant in the hospital of the OP no.3 on 09.09.2021. During treatment of the complainant, the concerned doctor Suraj Singh MBBS. MD. DM/cardiologist of the hospital of the OP no.3 had treated the complainant in proper manner and as per the treatment done by the OP no.3, the complainant got admitted with above mention complaints. All relevant investigations were done and treatment instituted accordingly. Loading dose of DAPT was given. 2D ECHO done s/o LVEF 35%. In view of diabetes endocrinologist consultation was done and advised followed. CAG done after consent. CAG s/o TVD. PTCA to LAD done on 11.09.2021. Patient managed with antiplatelets, stain, IV Antibiotic, PPI, Antiemetic, IV Fluids and other supportive treatment. Now patient is gradually improving and patient is discharge with following medical advice from the hospital of the OP no.3 on 16.09.2021. At the time of discharge from the hospital of OP no.3, the concerned officials of the hospital of the OP no.3 has demanded an amount of Rs.2,30,000/- from the complainant, vide bill no.31569 dated 16.09.2021, however, the complainant was having cashless Health Insurance Policy and the hospital of the OP no.3 was on the panel of the Health Insurance Policy. On this the complainant intimated the hospital Authority of OP no.3 regarding health insurance, even then the Hospital Authority of OP no.3 demanded bill amount from the complainant and not cooperate to the complainant and they further advised to lodge Insurance Claim under the aforesaid Health Insurance Policy. It is pertinent to mention that the complainant come to know that OPs no.1 and 2 vide letter dated 17.09.2021 denied their earlier approval of cashless treatment of the complainant vide letter dated 11.09.2021. The complainant deposited the abovesaid bill amount on dated 17.09.2021 vide receipt no.7016 amount of Rs.50,000/-, vide receipt no.7017 amount of Rs.30,000/- and vide receipt no.7019 amount of Rs.1,50,000/- total Rs.2,30,000/-. The complainant had taken aforesaid health insurance policy from the OPs no.1 and 2 so the complainant applied for claim amount of Rs.2,30,000/- in the company of OPs, vide claim intimation no.CIR/2022/211135/3129991 by completing all formalities and it has been assured to the complainant that the claim amount will be disbursed in favour of the complainant within short span of time. After awaiting sufficient time, complainant received a letter dated 26.10.2021, vide which OPs repudiated the claim of the complainant on the false and frivolous ground. 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 and concealment of true and material facts. On merits, it is pleaded that OP issued star comprehensive insurance policy, vide policy no.P/211135/01/2021/000237 for the period 06.01.2021 to 05.01.2022, policy is in continuation since 25.12.2019 covering risk of Girish Malik-self, Bhawna-Spouse, Ashmita Malik-Dependant child for the sum insured Rs.5,00,000/-. The claim was reported under the said policy was registered as Claim no.CIR/2022/211135/3129991. The insured requested for a cashless authorization for the treatment of Cad at Amritdhara Hospital Pvt.Ltd.-Karnal. The complainant was admitted in the hospital from 09.09.2021 to 16.09.2021. As per document, OP initially approved an amount of Rs.1,00,000/- on 11.09.2021. On further scrutiny of the claim documents, it is noted that a further evaluation is required to ascertain the admission and management, hence the OPs rejected the pre-authorization and advised the insured to come for reimbursement with all necessary documents wherein the claim might be considered on merits basis, vide letter dated 16.09.2021. Subsequently, the insured submitted the claim documents for reimbursement of treatment taken for treatment of Coronary Artery Disease for Rs.2,30,000/-. It is observed from the documents that

.       The ICP’s are completely in stereotyped manner and multiple tampering is noted.

.       As per physical examination sheet there is certain overwriting and cutting in the treatment plan, pulse rate has been tampered.

.       The date of discharge is left blank in the discharge summary.

.       The payment receipt for Rs.1,50,000/- shows the insured paid the amount through Debit card and the card number is 126014047943 which has only 12 digit (which again creates a discrepancy). Thus, there is discrepancy in the records which amount to misrepresentation of facts. As per terms and conditions of the policy issued to complainant, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the complainant is not liable to make any payment in respect of any claim, hence the claim was repudiated and the same was conveyed to the insured vide letter dated 26.10.2021.

        The insured had sent email, in response to letter dated 26.10.2021, seeking reconsideration of claim. The medical team has perused the representation and has noted the contents. The team which re-examined the claim records has observed that the indoor case records were in completely stereotype manner and also lot of tempering and overwriting is noted; as per physical examination sheet, there are certain overwriting and cuttings in treatment plan, pulse rate is tampered; date of discharge is left blank in discharge summary and is written as manual type and written in single handwriting. Thus, there is discrepancy in the records which amount to mis-representation of facts. Hence, the claim is not admissible as per the terms and conditions of the policy. We are, therefore, unable to consider the insured representation and OPs informed the complainant that repudiation of claim is in order. Hence, the rejection of the reimbursement claim was conveyed to the insured, vide letter dated 18.11.2021 and 30.12.2021. It is further pleaded that as per the contract of insurance, it is the duty of the proposer to disclose all the material facts to the insurer, so that the insurer evaluates the material facts and decides, whether to accept the proposal or not as the insurance contract is based on utmost good faith. As per contract of insurance, the insured is expected to declare in the proposal form about the details of his ailments/ sickness-past medial history and the reply for the same helps the insurer to evaluates the material facts and decides, whether to accept the proposal or not. In this case, the insured has not declared past health history/complications while requesting incorporation of insured patient’s name Girish Malik in the policy schedule, which is non-disclosure of material facts, hence repudiation of claim by the company is fully justified, as the same was not payable/admissible, as per abovesaid policy condition. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             OP no.3 appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; locus standi. On merits, it is pleaded that OP no.3 has no concern with the mediclaim dispute having arisen between the complainant and the OPs no.1 and 2. The complainant after treatment was discharged in good normal health condition and there is no lapse on the part of the OP no.3. OP no.3 has wrongly arrayed in the array of the parties. It is further pleaded that complainant was admittedly reported to the hospital of OP no.3 for chief complaints of chest pain radiating to left arm, sweating and restlessness and after examination it was found that patient is suffering from symptoms of acute kidney injury and was advised accordingly to be admitted on 09.09.2021 and since the patient informed thereafter that he is having entitlement of availing a cashless mediclaim policy of OPs no.1 and 2, OP no.3 sought approval for treatment which was given on 11.09.2021, but OPs no.1 and 2 denied the cashless facility, vide letter dated 17.09.2021.  So, the patient/complainant expressed his satisfaction with treatment and deposited Rs.2,30,000/- and was discharge on 16.09.2021 in good recovering health conditions. It is further pleaded that OP no.3 submitted/placed the entire original file of the treatment record of complainant and it was pleaded that if there is some clerical error or OPs no.1 and 2 allege some stereotype record it can well peruse the original record and can investigate the treatment of complainant which by no means is imaginary and is real and if at all there are some columns noticed bank or some alleged overwriting is noticed, that can be issued afresh by way of supplementary/duplicate record subject to rectification of any inadvertent clerical error of the staff which by no means is intentional or deliberate. OP no.3 has correctly charged the patient/complainant. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint qua OP no.3.

4.             Parties then led their respective evidence.

5.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy Ex.C1, copy of discharge summary Ex.C2, copy of part II and III of discharge summary Ex.C3, copy of certificate issued by Amritdhara Hospital, Karnal Ex.C4, copy of letter dated 17.09.2021 regarding rejection and withdrawal of approval given earlier Ex.C5, copy of final bill Ex.C6, copy of cash receipts of Rs.50,000/-, Rs.30,000/- and Rs.1,50,000/- Ex.C7 to Ex.C9,  copy of letter dated 06.10.2021 regarding requirement of additional documents/ information Ex.C10, copy of repudiation of claim dated 26.10.2021 Ex.C11, copy of treatment given by Dr. Suraj Singh of Amritdhara Hospital, Karnal Ex.C12, copy of aadhar card of complainant Ex.C13 and closed the evidence on 17.08.2022 by suffering separate statement.

6.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.RW1/A, affidavit of Parmit Singh, Investigator Ex.RW2/A, copy of insurance policy Ex.R1 and Ex.R2, copy of proposal form Ex. R3, copy of pre-authorization request Ex.R4, copy of rejection letter dated 16.09.2021 Ex.R5, copy of claim form Ex.R6, copy of discharge summary Ex.R7, copy of ICU progress sheet Ex.R8, copy of urine report Ex.R9, copy of letter dated 17.09.2021 regarding rejection and withdrawal of approval given earlier Ex.R10, copy of final bill Ex.R11, cop of repudiation letters dated 18.11.2021 and 30.12.2021 Ex.R12 and Ex.R13, copy of billing sheet Ex.R14, copy of investigation report Ex.R15 and closed the evidence on 08.06.2023 by suffering separate statement.

7.             Learned counsel for the OP no.3 has tendered into evidence affidavit of Dhruv Gupta Ex.OP3/A, copy of treatment record Ex.OP3/1 and closed the evidence on 04.05.2023 by suffering separate statement.

 8.            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.

9.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that complainant had purchased a Family Health Optima Insurance policy from the OPs, which continued year by year from 2017 to 2022. On 09.09.2021, complainant suffered from chest pain and he was taken to hospital of OP no.3 where doctor examined the complainant and found the symptoms of Acute Kidney Injury. Complainant has taken the treatment for the said disease and spent Rs.3,03,952/- on his treatment. Thereafter, complainant lodged his claim with the OPs for reimbursement of the abovesaid amounts but OPs did not pay the claim and denied the same on the false and frivolous ground and prayed for allowing the complaint.

10.           Per contra, learned counsel for OPs, while reiterating the contents of the written version, has vehemently argued that on receipt of claim, OPs scrutinize the claim and found that treatment records of complainant were in completely stereotype manner and also lot of tempering and overwriting is noted; as per physical examination sheet, there are certain overwriting and cuttings in treatment plan, pulse rate is tampered; date of discharge is left blank in discharge summary and is written as manual type and written in single handwriting. There is discrepancy in the records which amount to mis-representation of facts. Thus, the claim is not admissible as per the terms and conditions of the policy and prayed for dismissal of the complaint.

 11.          Learned counsel for OP no.3 argued that if the OPs no.1 and 2 had noticed some columns blanks or overwriting in the treatment record submitted by the complainant with the OPs no.1 and 2 for reimbursement of his claim then they could investigate/ peruse the original treatment record of the complainant from the hospital or could demand the original treatment record subject to rectification of inadvertent or clerical error on the part of the OP no.3. He further argued that there are no allegations in the complaint regarding the treatment given by the doctor nor there is any complaint regarding the amount charged by the doctor and lastly prayed for dismissal of the complaint qua OP no.3.

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

13.           Admittedly, complainant purchased a Family Health Optima insurance policy from the OPs no.1 and 2. It is also admitted that during the subsistence of the insurance policy, complainant was hospitalized in Amritdhara Hospital, Karnal and spent Rs.2,30,000/- on his treatment.

15.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.R12 and Ex.R13 dated 18.11.2021 and 30.12.2021 on the grounds, which is reproduced as under:-

“Our Medical team has perused the representation and has noted the contents. The team which re-examined the claim records has observed that the indoor case records are in completely stereotype manner and also lot of tampering and overwriting is noted; as per physical examination sheet, there are certain overwriting and cuttings in treatment plan, pulse rate is tampered; date of discharge is left blank in discharge summary and is written as manual type and written in single handwriting. There is discrepancy in the records which amount to mis-representation of facts. Hence, the claim is not admissible as per the terms and conditions of the policy”.    

16.           The claim of the complainant has been repudiated by the OPs No.1 & 2 on the abovementioned ground. On perusal of the medical record, it appears that there are some overwriting in the said record. If there were any overwriting in the medical record issued by the OP no.3, for that, as to why the complainant would suffer    heavy loss. Furthermore, if there were any clerical error or overwriting in the treatment record, it could be got verified from the hospital of           OP No.3 by the OPs No.1 & 2 but they without verifying the facts    from the hospital of OP No.3 with regard to overwriting etc.               in the medical record, had straightway repudiated the claim of the complainant. The claim cannot be rejected only on the technical ground. Rejection of the claims on purely technical grounds in a mechanical manner will result in loss of confidence of policy holder in the insurance industry.

17.           Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“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”.

18.           Keeping in view the ratio of the law laid down in the abovesaid authorities and the facts and circumstances of the present complaint, we are of the considered view that the act of the OPs no.1 and 2 amounts to deficiency in service and unfair trade practice while repudiating the claim of the complainant, which is otherwise proved a genuine one.

19.           During the pendency of the complaint, complainant has been expired on 22.01.2023. The legal heirs of the complainant moved an application for impleading them, the legal heirs of Girish Malik and said application has been allowed, vide order dated 08.06.2022 by this Commission. Now, as per amended title, the legal heirs of Girish Malik are entitled for the awarded amount

20.           The complainant has spent Rs.2,30,000/- on his treatment and in this regard he has placed on file payment receipts regarding medical bills Ex.C7 to Ex.C9.  The said bills/receipts have not been denied by the OPs. Hence the LRs of the complainant are entitled for the said amount alongwith interest, compensation and litigation expenses etc.

21.           In view of the above discussion, we allow the present complaint and direct the OPs no.1 and 2 to pay Rs.2,30,000/- (Rs. two lakhs thirty thousand only) to the complainants alongwith interest @ 9% per annum from the date repudiation of claim till its realization. We further direct the OPs no.1 and 2 to pay Rs.25,000/- to the complainants on account of mental agony and harassment and Rs.11,000/- for the litigation expenses. This order shall be complied within 45 days from the receipt of copy of this order. Complaint qua OP no.3 stands dismissed. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 25.08.2023                                                                    

                                                                      President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

                (Vineet Kaushik)                (Dr. Rekha Chaudhary)

                        Member                             Member