Haryana

Karnal

CC/361/2021

Munish Kumar - Complainant(s)

Versus

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

Suman Panwar

19 Oct 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 361 of 2021

                                                        Date of instt.28.07.2021

                                                        Date of Decision:19.10.2022

 

Munish Kumar aged about 37 years so of Shri Hukam Chand, resident of village and Post Office Khanpur, Tehsil Indri, District Karnal. Aadhar no.504970498399.

                                               …….Complainant.

                                              Versus

 

1.     Star Health and Allied Insurance company Ltd. Registered & Corporate office 1, New Tank street, Valluvat Kotlam High Road, Nungambakkar, Cheennai-600034, through its M.D.

 

2.     Star Health & Allied Insurance Company Ltd. Branch Office at SCF-137, 2^nd floor, Sector-13, Urban Estate, Karnal-132001, through its Branch Manager.

                                                                      …..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 Rajesh Bhardwaj, counsel for complainant.

                    Shri Naveen Kheterpal, counsel for the OPs.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant 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 a Corona Rakshak Policy, vide policy no.P/211114/01/2021/013303, valid from 28.02.2021 to 13.06.2021 i.e. for total 105 days from the OPs after paying the total premium amount of Rs.4538/- including of all taxes. As per the policy, it is clearly mentioned that if the insured/patient admitted in hospital for the period of 72 hours continuously due to the disease of Corona then OPs will pay Rs.2,50,000/- in lump sum benefit for treatment of Covid-19. The complainant was suffering from some breathing problem and on the instruction of doctor, the complainant got himself examined for Covid-19 from Kalpana Chawla Government Medical College Hospital, Karnal on 25.03.2021 and the report of the complainant was found positive and advised to admit in hospital. On 26.03.2021, the complainant had admitted in Amritdhara Hospital, Karnal and continuously remained admitted in the hospital till 31.03.2021 and after admission in the hospital, information was given to the OPs. After discharge from the hospital, complainant submitted the whole necessary documents for getting the benefit of abovesaid policy, but vide letter dated 17.05.2021 the claim of the complainant was repudiated by the OPs on ground that “the submitted medical records that multiple tampering is noted in the ICPs. Thus, there is discrepancy in the records which amount to misrepresentation of facts”. After receiving the said letter, complainant contacted the OPs and asked the reason for rejection of claim, but OPs did not pay any heed to the request of complainant. Then complainant sent a legal notice dated 01.07.2021 through his counsel, to the OPs but it also did not yield any result. In this way there is deficiency in service on the part of the OPs. Hence complainant filed the present complaint seeking direction to the OPs to pay Rs.2,50,000/- to the complainant alongwith interest @ 24% and to pay compensation of Rs.1,00,000/- on account of mental pain, agony and harassment and Rs.11000/- towards litigation expenses.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi; mis-joinder and non-joinder of necessary party and concealment of true and material facts. On merits, it is pleaded that the insured availed Corona Raksha Insurance Plan, vide policy no.P/211114/01/2021/013303 for the period 28.02.2021 to 13.06.2021 covering Mr. Munish Kumar for the sum insured of Rs.2,50,000/-. The insured patient Mr. Munish Kumar was admitted at Amritdhara Hospital Private Limited-Karnal on 26.03.2021 for the treatment of covid-19 positive. It is observed from the submitted medical records that multiple tampering is noted in the ICPs. Thus, there is discrepancy in the records which amounts to misrepresentation of facts. The terms and conditions of the policy were explained to the complainant at the time of proposing policy. As per terms and conditions of the policy, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make the payment in respect of any claim. Therefore, OPs are unable to settle the claim of the complainant and repudiated the same, vide letter dated 17.05.2021. There is no deficiency in service 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 complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy Ex.C1, copy of final bill of Amritdhara Hospital Ex.c2, copy of hospital discharge summary Ex.C3, copy of investigation chart Ex.C4, copy of Covid test report Ex.C5, copy of lab test report Ex.C6, copy of HRCT chest report Ex.C7, copy of admission and discharge record Ex.C8, copy of hospital TPR chart Ex.C9, copy of RTPCR test report Ex.C10, copy of legal notice Ex.C11, postal receipt Ex.C12, copy of reply of legal notice Ex.C13 and closed the evidence on 08.02.2022 by suffering separate statement.

5.             On the other hand, learned counsel for 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, copy of terms and conditions of insurance policy Ex.R2, copy of proposal form Ex.R3, copy of claim form Ex.R4, copy of discharge summary Ex.R5, copy of admission and discharge record Ex.R6, copy of Covid report Ex.R7, copy of final bill Ex.R8, copy of repudiation letter Ex.R9, copy of statement of insured Ex.R10, copy of conversation between the insured and investigator Ex.R11, CD Ex.R12, copy of claim verification report Ex.R13 and closed the evidence on 20.05.2022 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 had purchased a Corona Rakshak Policy from the OPs. The complainant suffered from Covid-19 and due to that on 26.03.2021, he was admitted in Amritdhara Hospital, Karnal and discharged on 31.03.2021. Intimation in this regard was given to the OPs. After getting discharge from the hospital, complainant submitted the necessary documents for getting the benefit of abovesaid policy, but vide letter dated 17.05.2021 the claim of the complainant was rejected/repudiated by the OPs 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 the complainant was admitted at Amritdhara Hospital Private Limited-Karnal on 26.03.2021 for the treatment of covid-19 positive. It was observed from the submitted medical records that multiple tampering was noted in the ICPs. Thus, there was discrepancy in the records which amounts to misrepresentation of facts. As per terms and conditions of the policy, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make the payment in respect of any claim. Therefore, OPs were unable to settle the claim of the complainant and repudiated the same, vide letter dated 17.05.2021 and lastly prayed for dismissal of the complaint.

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

10.           The claim of the complainant has been repudiated by the OPs, vide repudiation letter dated 17.05.2021 Ex.R9 on the ground that in the submitted medical records that multiple tampering is noted in the ICPs.

11.           The onus to prove its case lies upon the OPs but OPs have miserably failed to prove its case by leading any cogent and convincing evidence. Rather as per discharge summary Ex.R5 complainant was hospitalized on 26.03.2021 and discharged on 31.03.2021 for the treatment of Covid-19 positive, high fever with chills, cough, dyspnoea, bodyache and headache. Thus, it is well proved on record complainant had suffered from Covid-19. Hence, the repudiation of the claim of complainant is unjustified and not tenable in the eyes of law.

12.  

                “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”.

13.           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 amounts to deficiency in service and unfair trade practice while repudiating the claim of the complainant, which is otherwise proved genuine.

14.           As per Corona Rakshak Policy Ex.C1/Ex.R1 dated 28.02.2021 the insured amount is of Rs.2,50,000/-. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

15.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.2,50,000/- (Rs.two lakhs fifty thousand) as sum insured to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs to pay Rs.20,000/- 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:19.10.2022

                                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)

                          Member                      Member