Haryana

Karnal

CC/28/2021

Sandeep Sethi - Complainant(s)

Versus

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

Vinod Dogra

21 Oct 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 28 of 2021

                                                        Date of instt.13.01.2021

                                                        Date of Decision:21.10.2022

 

1.     Sandeep Sethi (aged 34 years), son of late Shri Shyam Sunder Sethi.

2.     Roma Sethi (aged 34 years) wife of Shri Sandeep Sethi, both residents of house no.CHD KCB-S-019, CHD City, Karnal.

 

                                               …….Complainant.

                                              Versus

 

1.     Star Health and Allied Insurance Company Limited, having its registered and Corporate office Sri Balaji Complex, 15, Whites Road, Chennai-600014 through its Authorized Signatory.

2.     Star Health and Allied Insurance Company Limited, having its Branch office at 2^nd floor, SCF 137, Sector 13, Urban Estate near ICICI Bank, Karnal, 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 Vinod Dogra, counsel for the complainants.

                    Shri Naveen Khetarpal, counsel for the OPs.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainants have filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant no.1 obtained Family Health Optima Insurance plan under cashless policy from the OP no.2 bearing no.P-211114/01/2019/000459, valid from 24.04.2018 to 23.04.2019. The sum insured under the policy was Rs.5,00,000/-. After the expiry of policy, the policy was got renewed by the OP no.2 for further period of one year w.e.f. 24.04.2019 to 23.04.2020 after paying the premium amount of Rs.11,506/-. Initially, complainant no.2 got some problem of severe pain in her abdomen and vomiting with high grade fever with chills and she was taken to Mool Chand Kidney & Urological Institute, Karnal on 14.02.2020 and she remained admitted there upto 16.02.2020. During this period, she was hospitalized for conservative treatment with I/V, Fluids. However, the entire hospital charges amounting to Rs.40,000/- paid by the OPs to the hospital. Thereafter, due to abdominal pain, complainant no.2 was referred to Sir Gangaram Hospital, Rajender Nagar, New Delhi and as per advise of Dr. Sandeep Chaudhary, Medical Officer, Mool Chand Kidney & Urological Institute, Karnal, she remained admitted there from 16.02.2020 to 02.03.2020 and was diagnosed for the disease. On being discharge from Sir Gangaram Hospital, New Delhi, complainant no.1 has submitted the relevant receipts for medicines, Doctor charges bill/receipts, pathological tests etc. in original respect of complainant no.1 to the OPs with a request to release an pay the claim amounting to Rs.6,48,166/-. The claim application submitted by the complainant no.1 was duly entertained by the OPs but when OPs did not intimate the complainant no.1 about the progress of claim, then complainant contacted the OPs and requested to reimburse the claim but OPs did not pay any heed to the request of complainant and delay the matter on one pretext or the other and lastly repudiated the claim of complainants on the false and frivolous ground. In this way there is deficiency in service 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 insured availed Family Health Optima Insurance Plan covering Mr. Sandeep Sethi-self, Mrs. Roma sethi-spouse and Suhana sethi-dependent child for the sum insured of Rs.5,00,000/-, vide policy no. 211114/01/2019/000459, valid from 24.04.2018 to 23.04.2019, which was subsequently renewed, vide policy no. 211114/01/2020/000525, valid from 24.04.2019 to 23.04.2020. 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 complainants alongwith insurance policy. The policy in 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 insured preferred claims in the second year of the policy previous claim CLI/2020/211114/0906070, DOA 15.02.2020 for Acute Pancreatitis, Roma Sethi, claim settled for Rs.33,700/-. The insured, Mrs. Roma Sethi raised a request for pre-authorization for cashless treatment at Sir Ganga Ram City hospital-Delhi on 16.02.2020 for the treatment Acute Pancratitis/Cholecithiasis with CBD Stone.

.      It is observed from the documents submitted that the hospitalization for Acute Pancratitis, cholelithiasis and Choledocolithsis has arisen within two years from the date of commencement of the first policy.

.      As per the waiting period/exclusion no.3 (ii) (b) of the policy, the claim is not admissible for a period of 2 years from the date of inception of the first policy.

A waiting period of 24 consecutive months of continuous coverage from the inception of this policy will apply to the following ailments/illness/diseases:-

b)     All treatments (conservative, interventional, laparoscopic and open) related to Hepato- pancreato-billary diseases including Gallbladder and Pancreatic calculi. All types of management for kidney and Genitourinary tract calculi.

The rejection of the reimbursement claim is conveyed to the insured, vide letter dated 18.02.2020. The insured has not approached for reimbursement of medical expenses towards the above mentioned hospitalization. Hence, the OPs are not aware of the expenses incurred towards the treatment. 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 the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, letter dated 17.02.2020 Ex.C1, copies of bills and receipts Ex.C2 to Ex.C5, copies of receipts of payment Ex.C6 to Ex.C15, copy of final bill dated 02.03.2020  of Rs.4,13,912/- Ex.C16, copy of final bill of Rs.1,90,231/- Ex.C17, copy of summary of bill Ex.C18, copy of receipts of payment dated 20.03.2020 Ex.C19 to Ex.C21, copy of provisional bill Ex.C22, copy of receipt dated 12.03.2020 and provisional bill Ex.C23 and Ex.C24, receipts dated 11.03.2020 Ex.C25 and Ex.C26, copy of admission slip Ex.C27, copies of receipt dated 19.03.2020 Ex.C28 and Ex.C29, copy of bill Ex.C30, copy of advance receipt dated 11.03.2020 Ex.C31, copy of bills of Rs.6590/- Ex.C32 and Ex.C33, copy of receipt of Rs.3800/- dated 31.03.2020 Ex.C34, copy of Doctor’s slip dated 31.03.2020 Ex.C35, copy of receipt dated 19.03.2020 Ex.C36 and closed the evidence on 07.01.2022 by suffering separate statement.

5.             On the other hand, learned counsel for OPs has tendered into evidence affidavit of P.C.Tripathy Zonal Manager Ex.RW1/A, copy of terms and conditions of the insurance policy Ex.R1, insurance policies Ex.R2 and Ex.R3, copy of proposal form Ex.R4, copy of request for cashless facility Ex.R5, copy of field visit report Ex.R6, copies of letter query for cashless Ex.R7 and Ex.R8, copy of rejection of cashless Ex.R9 and Ex.R10, copy of treatment record Ex.R11, copy of endoscopic ultra sound report Ex.R12, copy of ERCP report Ex.R13, copy of discharge summary Ex.R14, copy of causality assessment sheet Ex.R15, copy of pathology report Ex.R16 and closed the evidence on 14.02.2022 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 complainant, while reiterating the contents of the complaint, has vehemently argued that complainant no.1 had obtained a Family Health Optima Insurance plan under cashless policy from the OP no.2. The sum insured under the policy was Rs.5,00,000/-. Initially, complainant no.2 got some problem of severe pain in her abdomen and vomiting with high grade fever with chills and she was taken to Mool Chand Kidney & Urological Institute, Karnal on 14.02.2020 and she remained admitted there upto 16.02.2020. During this period, she was hospitalized for conservative treatment with I/V, Fluids. However, the entire hospital charges amounting to Rs.40,000/- paid by the OPs to the hospital. Thereafter, due to abdominal pain, complainant no.2 was referred to Sir Gangaram Hospital, Rajender Nagar, New Delhi and as per advise of Dr. Sandeep Chaudhary, Medical Officer, Mool Chand Kidney & Urological Institute, Karnal, she remained admitted there from 16.02.2020 to 02.03.2020. In the said hospital complainant no.2 spent Rs.Rs.6,48,166/- on her treatment. After getting discharge from the hospital complainant no.1 has submitted the claim application alongwith relevant documents with the OPs for reimbursement of the claim but OPs did not pay the same and repudiated the claim of complainants on the false and frivolous ground. He further argued that the alleged terms and conditions of the policy on the basis of which the claim of the complainant was repudiated never explained nor supplied by the OPs at any time 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 insured availed Family Health Optima Insurance Plan for the sum insured of Rs.5,00,000/-. The insured preferred claims in the second year of the policy for Acute Pancreatitis, Roma Sethi, claim settled for Rs.33,700/-. The insured, Mrs. Roma Sethi raised a request for pre-authorization for cashless treatment at Sir Ganga Ram City hospital-Delhi on 16.02.2020 for the treatment Acute Pancratitis/ Cholecithiasis with CBD Stone, which has arisen within two years from the date of commencement of the first policy and s per the waiting period/exclusion no.3 (ii) (b) of the policy, the claim is not admissible for a period of 2 years from the date of inception of the first policy. Thus, the claim of the complainant has been rightly repudiated and duly conveyed to the insured, vide letter dated 18.02.2020. The insured has not approached for reimbursement of medical expenses towards the above mentioned hospitalization. Thus, the OPs are not aware of the expenses incurred towards the treatment and prayed for dismissal of the complaint.

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

10.           Admittedly, complainant has taken Family Health Optima Insurance Policy from the OPs, valid from 24.04.2018 to 23.04.2019 and the same was renewed for the period of 24.04.2019 to 23.04.2020. It is also admitted that complainant no.2 namely Roma Sethi had taken treatment from Mool Chand Kidney and Urological Institute, Sector 13, U.E. Karnal from 14.02.2020 to 16.02.2020 during the subsistence of the insurance policy and OPs had paid the treatment charges to the said hospital to the tune of Rs.33,700/. It is also admitted that complainant no.2 again remained admitted in Sir Ganga Ram Hospital, Rejender Nagar, New Delhi for her further treatment from 16.02.2020 to 02.03.2020.

11.           The claim of the complainant has been denied by the OPs, vide letter Ex.R9 dated 18.02.2020 on the ground reproduced as under:-

“it is observed from the documents submitted that the hospitalization for treatment of acute pancreatitis, cholelithiasis and choledocolithiasis has arisen within two years from the date of commencement of the first policy.

As per the waiting period/ exclusion no.3 (ii) b of the policy, the claim is not admissible for a period of 2 years from the date of inception of the first policy.

We are therefore, unable to consider the approval for cashless treatment of the above diagnosed disease..”

 

12.           Admittedly, complainant no.2 got admitted in Mool Chand Kidney & Urological Institute, Karnal on 14.02.2020 for the problem of severe pain in her abdomen and vomiting with high grade fever and OPs paid Rs.33,700/- to the said hospital directly. Thereafter, complainant no.2 admitted in Sir Ganga Ram Hospital, Rejender Nagar, New Delhi for treatment of same disease and OPs have refused to reimbursement the claim amount which has been spent by the complainant no.2 on her treatment. When OPs have already paid the claim to complainants for the same disease spent by them in Mool Chand Kidney & Urological Institute, Karnal, the denial of the OPs for second claim of the same disease is totally arbitrary and unjustified. It is not a case of the OPs that the abovesaid claim amount was paid to the complainants inadvertently. Moreover, complainant has taken a plea that OPs neither disclosed alleged terms and conditions at the time of commencement of the policy nor same were supplied to the complainant any point of time. On the other hand, as per version of the OPs, the terms and conditions were sent to the complainant alongwith policy. But the OPs have failed to produce on record any evidence that they have sent/communicated the same to the complainant at any stage. They further failed to produce any receipt/acknowledgement that the terms and conditions were sent/received by the complainants. Hence, the plea taken by the OPs has no force. In this regard, we relied upon New India Assurance Co. Ltd Versus Anil Manglunia 2016 (1) CPR 150 (NC),wherein Hon’ble National Commission held that OP failed to provide policy clause to the complainant and rejected genuine claim of the complainant. Hence, they do not find any merit in the revision petition and the same is hereby dismissed.

 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 the abovesaid judgments, facts and circumstances of the complaint, we are of the considered view that act of the OPs amounts to deficiency in service and unfair trade practice. 

15.           The complainant has claimed Rs.6,48,166/-  and in this regard he has placed on file copies of bills and receipts Ex.C2 to Ex.C17, Ex.C19 to Ex.C21, Ex.C25 and Ex.C26, Ex.C28 and Ex.C29 but the insured amount covered under the policy in question is Rs.5,00,000/-. OPs have already paid Rs.33,700/- to the complainants. Hence the complainant is entitled for Rs.4,66,300/-(5,00,000-33,700) alongwith interest, compensation for mental agony and harassment and litigation expenses etc.

16.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.4,66,300/-(Rs.four lakhs sixty six thousand three hundred only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of 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.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.

Dated:21.10.2022                                                                   

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)

                           Member                          Member