Haryana

Karnal

CC/272/2021

Jitender Wadhwa - Complainant(s)

Versus

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

Dheeraj Sachdeva

01 May 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 272 of 2021

                                                        Date of instt.09.06.2021

                                                        Date of Decision:01.05.2024

 

Jitender Wadhwa son of Shri Ved Parkash Wadhwa, resident of house no.1474, Sector-9, Urban Estate, Karnal.

 

                                               …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Company Ltd. having its office at –SCO 242, 1^st floor, Sector-12, opposite Mini Secretariat Karnal. 132001.through its Manager/authorized person. Also at SCF 137, Sector-13, near ICICI Bank, Urban Estate, Karnal.

 

2. Star Health and Allied Insurance Company Ltd. having its registered and corporate office at-1, New Tank street, Valluver, Kottam High Road, Nungambakkam, Chennai-600034. Phone no.044-28302700/28288800.

                                                                         …..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Dr.  Suman Singh…..Member

 

 Argued by: Shri Dheeraj Sachdeva, Adv. for the complainant.

                    Shri Naveen Khetarpal, Adv. for the OPs.

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant purchased a medical insurance policy bearing no.P/211114/01/2020/014553 since 08.02.2017 from the OPs and policy in continuation till today. The latest premium of the policy is Rs.15827/-. The period of insurance was from 12.03.2020 to 11.03.2021. In the last week of December, 2020 during the covid-19 Pandemic, the complainant fell ill with the complaints of fever, loose stool and accordingly the complainant visited the Virk Hospital, Karnal and the doctor after investigation diagnose the complainant Covid positive and the complainant admitted on 29.12.2020 and discharged on 04.01.2021 and spent an amount of Rs.2,00,000/- approximately on his treatment. At the time of admission, complainant informed to the OPs for cashless facility but the cashless facility was not provided by the OPs on the ground that Virk Hospital, Karnal is the non-network hospital. After discharge from the hospital, complainant submitted his claim with the OPs and also submitted all the required documents and claimed Rs.1,74,140/- but OPs paid only Rs.95,720/-.  OPs deducted the amount of Rs.78420/- on the flimsy ground that the injections/medicines are not payable as per the ICMR guidelines. On this complainant demanded the ICMR guidelines but till today no ICMR guidelines provided by the OPs. After repeated requests of complainant, vide letter dated 02.03.2021 OPs approved an amount of Rs.1,06,330/- out of total bill of Rs.1,74,410/- but again deducted the amount of Rs.67810/-. Complainant requested the OPs for disbursement of the said amount but OPs did not pay any heed to the request of complainant and rejected the claim of complainant, vide email dated 10.05.2021 on the ground that the drugs like Ulicrit etc. are not payable as per ICMR guidelines. 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 written version raising preliminary objections with regard to maintainability; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the insured availed Family Health Optima Insurance Policy covering Mr. Jitender Wadhwa self, Lovisha Wadhwa spouse and Harshita and Janvi as dependent child for the sum insured of Rs.5 lacs, vide policy no.P/211114/01/2020/014553 for the period from 12.03.2020 to 11.03.2021.  The insured, Mr. Jitender Wadhwa was Hospitalized at Nivaran Virk Hospital Pvt. Ltd. Karnal on 29.12.2020 to 04.01.2021 for the treatment of Covid-19 based on the submitted reimbursement documents, the claim was processed and an amount of Rs.1,00,814/- was approved and paid to insured through NEFT-no.46211407982912 on 15.02.2021. On insured request of claim reconsideration, the claim was again reviewed and considered for settlement for an amount of Rs.10,610/- was paid to insured on 06.03.2021. Therefore, an amount of Rs.1,11,424/- was paid to the complainant, after making necessary deductions of Rs.67,810/-. The details of deductions are as under:-

.   As per the other excluded expenses, the charges towards the fixer (no.56-Rs.150/-), Spirometer (no.139-Rs.640/-) Gloves (no.163-Rs.800/-) and PPE kit Rs.6000/- Mask (no.183-Rs.20/-) and Bandage (no.56-Rs.54/-) are not payable. Hence an amount of Rs.65510/- was deducted.

.   As per the other excluded expenses no.72 (Ulinastatin, known as a protease inhibitor, is found in the urine, plasma and all organs(66) and has been used to treat acute pancreatitis-which is irrelevant to the present diagnosis an further it falls under the unproven therapy as per the exclusion no.21.Thus, the charge towards Ulicrit Liquid, an amount of Rs.56,646/- was deducted.

.   As per coverage clause D, the charges towards Emergency ambulance charges into sum of Rs.750/- is payable. Hence an amount of Rs.50/- was deducted.

.   As per the exclusion no.5, the charges towards physiotherapy are not payable. Further, as per the exclusion no.27, the charges towards admission charges are not payable. Hence, an amount of Rs.2250/- was deducted.

The amount of Rs.1,11,424/- is the maximum payable as per terms and conditions of the policy and same has already paid to the insured. 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.             Parties then led their respective evidence.

4.             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 bill assessment sheet dated 10.02.2021 Ex.C3, copy of letter from Doctor Virk Hospital Ex.C4, copy of bill assessment sheet Ex.C5, copy of emails to OPs Ex.C6 and closed the evidence on 09.12.2021 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 terms and conditions of insurance policy Ex.R1, copy of insurance policy Ex.R2, copy of portability form Ex.R3, copy of guidelines on Standardization in Health Insurance Ex.R4, copy of detail of proposed charges for Covid cases Ex.R5, copy of proposal form Ex.R6, copy of claim form Ex.R7, copy of treatment record of Virk Hospital, Karnal Ex.R8, copy of IPD bill Ex.R9, copy of bill assessment sheet Ex.R10, copy of request letter dated 10.05.2021 regarding  review of claim amount settled Ex.R11 and closed the evidence on 03.07.2023 by suffering separate statement.

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

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant purchased a medical insurance policy from the OPs. In December 2020, complainant was suffering from covid-19 and remained admitted in Virk Hospital, Karnal from 29.12.2020 to 04.01.2021 and spent an amount of Rs.1,74,140/- on his treatment. The cashless request of complainant was denied by the OPs. After discharge from the hospital, complainant submitted his claim with the OPs for reimbursement of the said amount and also completed all the required formalities but OPs paid only Rs.1,06,330/- and deducted the remaining amount on the ground that the injections/medicines are not payable as per the ICMR guidelines but till today no ICMR guidelines provided by the OPs. Complainant requested the OPs for disbursement of the remaining amount but OPs did not pay the same and rejected the claim of complainant on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that complainant was hospitalized at Virk Hospital Pvt. Ltd. Karnal on 29.12.2020 to 04.01.2021 for the treatment of Covid-19. The claim was processed and an amount of Rs.1,11,424/- has been paid to the complainant. The deduction of Rs.67,810/-was rightly made by the OPs as per ICMR guidelines and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, complainant has availed the Family Health Optima Insurance Plan from the OPs. It is also admitted that in the said policy complainant (self), his wife and dependent children were covered, for the sum insured of Rs.5,00,000/-. It is also admitted that during the subsistence of the insurance policy complainant was hospitalized in Virk Hospital Karnal for the treatment of Covid-19 and spent Rs.1,74,440/- It is also admitted that the policy in question is continued since 2017. It is also admitted that an amount of Rs.1,11,424/- has already been paid to the complainant.

11.           The remaining claim amount has been denied by the OPs on the ground that Ulicrit was not payable as per ICMR guidelines and deduction of Rs.67,810/-has rightly been made by the OPs. The onus to prove its version was relied upon the OPs but they have miserably failed to prove the same by leading any cogent and convincing evidence. OPs have neither supplied the alleged ICMR guidelines to the complainant nor placed on file during the course of evidence. It appears that alleged guidelines have not been supplied by the OPs to the complainant. It further appears that the deduction made by the OPs on the basis of presumption and assumption, which is not admissible in the eyes of law.  Rather,  complainant has placed on file certificate Ex.C4 dated 17.02.2021 issued by Dr. Netarpal Rawal, MD Medicines Consultant Physician of Virk Hospital, Karnal wherein Doctor has certified that the patient Jatinder Wadhwa son of Shri Ved Parkash Wadhwa was admitted in Virk Hospital on 29.12.2020 vide IPD no.8761/20 with the diagnosis of Covid-19 and was discharged on 04.01.2021. As per ICMR guidelines, Experimental Therapy Drugs used in treatment of Covid-19 like Remedisifir etc. are excluded from the Covid Treatment Package and are payable. Ulicrit is also an experimental Therapy Drug and used in this case. Patient responded well to the treatment and was discharge in a stable condition.

12.           On perusal of the abovesaid certificate, it is clear that Experimental Therapy Drugs used in treatment of Covid-19 like Remedisifir etc. are excluded from the Covid Treatment Package and are payable. Thus, in view of the above, the deduction made by the OPs are not justified.

13.           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.”

 

14.           Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, the act of the OPs while repudiating the claim of the complainant amounts to deficiency in service. Hence, the complainant is entitled for remaining amount of Rs.67,810/- alongwith interest, compensation for harassment, mental pain and agony and towards the litigation expenses.

15.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.67,810/- (Rs.sixty seven thousand eight hundred ten only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OP to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- 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: 01.05.2024 

  President,       

District Consumer Disputes

Redressal Commission, Karnal.

 

                  (Vineet Kaushik)              (Dr. Suman Singh)        

                         Member                             Member