Haryana

Yamunanagar

CC/402/2022

Manoj Kumar S/o Shanti Lal - Complainant(s)

Versus

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

Vikram Punia

28 Jul 2023

ORDER

  BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, YAMUNA NAGAR AT JAGADHRI.

 

                                                                                     Complaint No.      402 of 2022.

Date of institution:28.09.2022.

 Date of decision:   28.07.2023.

 

  Manoj Kumar aged 45 years son of Shri Shanti Lal resident of H. No.2507, Rajesh Colony, Jagadhri, District Yamuna Nagar, UID             No.7025 2329 9237, Mobile No.9812112999.

                                                                                              …Complainant.

                                       Versus.

 

1. Star Health and Allied Insurance Co. Ltd., SCO 184-185, 2^nd Floor, Sector-17, Commercial Belt, HUDA, Jagadhri, SECOND ADDRESS Star Health and Allied Insurance Company Limited, Registered and Corporate Office: 1, New Tank Street Valluvar Kottam High Road Naugam Bakkam Chennai-600034.
2. Vikarm Hospital, #07, Ram Nagar, Kanhaiya Sahib Chowk, Yamuna Nagar.
3. The Oriental Insurance Company Ltd. Divisional Office, Opposite Madhu Hotel, Yamuna Nagar for sum insured Rs.20,00,000/- w.e.f. 21.12.2021 to 20.12.2022 vide Policy No.261700/48/2022/838.

    

…Respondents.

 

CORAM:    GULAB SINGH, PRESIDENT.       

                   GEETA PARKASH, LADY MEMBER.

                   JASVINDER SINGH, MEMBER.

 

Present:       Sh. Vikram Punia, Adv. for the complainant.

                    Sh. Naveen Kaushal, Adv. for the opponent No.1.

                    Sh. SC Jindal, Adv. for the respondent No.2.

                    Respondent No.3 ex-parte.

                  

ORDER:

 

1.                This is complaint under section 35 of the Consumer Protection Act, 2019 (for short “Act”).

2.           Going through the contents of the complaint, supportive documents Ex.C.1 to Ex.C.22 and written statement filed by the opponents, supportive documents Ex.R.1 to Ex.R.13, briefly admitted facts of the complaint are, the complainant availed a health insurance policy known as Family Health Optima Insurance Plan Ex.C.3 bearing No. P/211120/01/2022/013938 (for short insurance policy) from the opponents covering self, spouse and dependent children on payment of premium in the sum of Rs.16,462/-. The date of commencement of insurance policy is 12.01.2022 to 11.01.2023 and the sum assured is Rs.5,00,000/.  On 04.07.2023, the son of complainant suffered from Enteric Fever and Gastritis disease and hospitalized in Vikram Hospital,Yamuna Nagar (for short Hospital) and remained admitted w.e.f. 04.07.2022 to 09.07.2022, fact is reflected from document Ex.C.7 issued by the Hospital.  During the treatment, the complainant incurred medical expenditure i.e. Rs.24,910/- as per bills approx, besides Rs.15,000/- as other charges, fact is reflected from bills Ex.C.5 and Ex.C.6, Ex.C11 and Ex.C12, Ex.C16 to Ex.C22 and thereafter, the complainant lodged his claim for reimbursement of medical bills, but his claim was repudiated by the opponents vide letter dated 16.08.2022 Ex.C.2 and the complainant again approached for reconsideration of the claim, but the same was also repudiated vide letter dated 29.08.2022, on the ground, the submitted medical records that the indoor case records were in stereotyped manner and was written in same handwriting, the date of discharge was tampered in the indoor case records. Thus there was discrepancy in the records which amount to mis-representation of facts, resulting to repudiation of claim.

3.                The complainant alleged, repudiation of medical insurance claim by the opponents No.1 vide letter dated 16.08.2022 Ex.C2 and letter dated 29.08.2022 is an act of negligence, deficiency in service, causing mental agony, harassment as well as financial loss, constraining him to file this complaint.

4.                The opponent No.1 in its written statement, pleading interalia non maintainability of the complaint, it has not locus standi to file and maintain the present complaint, it stopped by his own act and conduct from filing the present complaint, this Commission having no jurisdiction to try and enter the complaint, the complainant has not come to the Commission with clean hands and concealed the material facts from this Commission, and had not disputed issuance of insurance policy Ex.C.3, repudiation of claim vide letter dated 16.08.2022 Ex.C.2 and on 29.08.2022 and alleged the complainant had submitted papers for reimbursement of medical expenses for treatment of Entric Fever with Gastritis in Vikram Hospital and submitted claim.  Later on, on scrutiny of documents submitted by the complainant i.e. IPD Register, Plan of care and treatment chart, on scrutiny of the indoor case report, it was found, all the writings in the records are in stereotyped manner and the same has been written by same handwriting. It was also observed treatment record provided by the complainant that in the discharge record, the date of discharge is tampered in indoor case record, hence as per the record submitted by the complainant, there was discrepancy in the record which clearly amounts to misrepresentation of the facts. Therefore, while invoking the condition No.1 of the insurance policy, the opponent No.1 had, rightly, repudiated the claim of the complainant vide letter dated 16.08.2022 Ex.C2 and the complainant approached for reconsideration of the claim and the same was repudiated vide letter dated 29.08.2022 and committed no act of negligence, deficiency in service.

5.                The opponent No.2 in its written statement, admitted, providing of treatment to the son of complainant and remained admitted in the hospital from 04.07.2022 to 09.07.2022 for which the hospital had charged Rs.14,300/- to the complainant and the complainant had also paid for investigation charges and for medicines separately. The complainant has not leveled any allegations of medical negligence in the entire complaint against the opponent No.2. The complainant had purchased medi-claim policy from the opponent No.1 and this is a contract between the complainant and the opponent No.1 only and the opponent No.1 is liable to indemnify the expenses etc. of the complainant. Whether opponent No.1 wishes that their employees should be called or consulted to prepare the treatment files of a hospital? Does their repudiation letter goes to prove that the patient never suffered from the disease and was never treated or charged by the opponent No.2 and claim of the complainant is false? The opponent No.1 sought clarification from the opponent No.2 about the over writing on date of discharge which was replied and cleared to them by the opponent No.2 vide rejection consultation Ex.R1 according to which, Patient Krishna was admitted from 04.07.2022 to 09.07.2022 in the hospital. A diagnosis of enteric fever with gastritis was made. Patient was admitted in private room. TPR charge, nursing notes and treatment notes are filled by nursing staff and doctor as per condition of the patient. The hospital are NABH entry level hospital. The documents are filled as per the guidelines, that’s why charts might have looked stereotyped. The chart was filled in day time by day staff and in the night by night staff shift duty staff. The handwriting is different. The date of discharge is clearly mentioned in discharge paper, IPD register and inside the file. There is no tampering with date of discharge. Also date of discharge can be confirmed from IPD register. The opponent No.2 is duly insured with the Oriental Insurance Company Ltd. with professional indemnity Insurance police for a sum insured of Rs.20,00,000/- and committed no act of negligence, deficiency in service.

6.                The opponent No.3 proceeded against ex-parte vide order dated 29.03.2023 passed by this Commission, but prior to it, it had already filed written statement on 20.12.2022, stating the complaint is not maintainable because the Oriental Insurance Company is not liable to indemnify the complainant, rather to the opponent No.2, if any liability is proved against the opponent No.2. The opponent No.2 gave a good treatment to the patient and he recovered very well. The medical policy was purchased from the Star Health an Allied Insurance Co. Ltd. and same is liable to pay the medical claim of the complainant as per the terms and conditions of the policy of Star Health and Allied Insurance Co. Ltd.  

7.               Shri Vikram Punia, Adv. for the complainant in the course of arguments, reiterated to the version made into the complaint.  He also apprised this Commission about the evidence adduced on record by the complainant as well as by the opponents. 

8.               On the another hand, Sh. Naveen Kaushal, Adv. for opponent No.1 in the course of arguments, reiterated to the version made into the written statement filed by the opponents and also apprised this Commission about the evidence adduced on record by the complainant as well as opponents and in material respect, endeavoured to justify the repudiation of the claim of the complainant vide letter dated 16.08.2022 Ex.C2 and 29.08.2022.

9.              Sh. SC Jindal, Adv. for opponent No.2 in the course of arguments, reiterated to the version made into the written statement filed by the opponents and also apprised this Commission about the evidence adduced on record by the complainant as well as opponents and in material respect, endeavoured to justify the act and conduct of the opponent No.2.

10.              The moot question before the Commission is whether the opponents committed any act of negligence, deficiency in service, unfair trade practice, while repudiating the claim of the complainant vide repudiation letter dated 16.08.2022 Ex.C.2 and 29.08.2022, making the complainant entitled to the relief, as prayed or to what extent?

11.           The hospitalization of son of the complainant in Vikram Hospital, Yamuna Nagar w.e.f. 04.07.2022 to 09.07.2022 is not disputed by the opponent No.1-insurance company. The complainant raised insurance claim with the opponent No.1, fact is not disputed and he submitted necessary documents, but the opponent No.1 repudiated the claim of the complainant vide repudiation letter dated 16.08.2022 Ex.C.2 and 29.08.2022, on the ground, of misrepresentation of facts and regarding this, the opponent No.1 sought clarification from the opponent No.2 hospital and the opponent No.2 hospital vide its note Ex.R1 clarified the opponent No.1, but the opponent No.1 gave wrong interpretation and treated it mis-representation, whereas as per the complainant, it is not justified and opponent No. 1 became hyper technical and denied the claim of the complainant, qua which it had accepted the premium before issue the insurance policy. The non-payment of medical claim to the complainant is an act of negligence, deficiency in service.  Furthermore, in the repudiation letter dated 16.08.2022 Ex.C2, the opponent No.1 have not specifically mentioned, what were the discrepancies in the medical documents of the complainant. It also shows the opponent No.1 was bent on to decline the insurance claim to the complainant on one or another ground, which is not expected from company like the opponent No.1. For tiny claim, neither the complainant nor the opponent was supposed to tell lie and manipulate the record. The complainant in para No.3 of the complaint, pleaded, repudiating the claim amounting to Rs.24,910/- as per bills. However, taking into account medical bills submitted by the complainant, the opponent No.1 is liable to pay claim in the sum of Rs.24,910/-. Apart from making payment in the sum of Rs.24,910/- (Rupees Twenty Four Thousand Nine Hundred Ten only) billed amount, the opponent No.1 is also liable to be burdened with punitive damages and this Commission is of the view, in case, Rs.10,000/- only as punitive damages is awarded against the opponent No.1 to compensate the complainant in all heads, such as mental agony, harassment as well as financial loss, it will suffice the purpose and ends of justice will meet. There is no specific allegation and there is no cogent and convincing evidence on the record to condemn the act and conduct of the opponents No.2 and 3 and to fasten liability to any extent upon them. The complaint qua opponents No.2 and 3 is liable to be dismissed.  

12.              Hence, due to reasons stated here-in-before, the complaint is accepted against the opponent No.1, holding the opponent No.1 liable to make payment of medical expenses incurred by the complainant on treatment of his son in the sum of Rs.24,910/- (Rupees Twenty Four Thousand Nine Hundred Ten only) billed amount and to pay punitive damages in the sum of Rs.10,000/- (Rupees Ten Thousand) only to compensate the complainant in all heads, total Rs.34,910/- (Rupees Thirty Four Thousand Nine Hundred Ten only) within the period of 40 days from the date of order, in default of it, the opponent No.1 shall be liable to pay interest @8% p.a. simple from the date of order till actual realization. However, complaint qua opponents No.2 and 3 is dismissed.

13.          Before parting with this order, it is pertinent to mention the complaint has not been decided within prescribed period of limitation. History of proceeding shows, there is little bit delay in the disposal of the complaint, the impleading of insurance company as opponent consumed considerable time and due to post effect of covid-19 pandemic, there is heavy pendency of the case in the Commission and long date of hearing have been given and whatever the delay has been caused in the disposal of the complaint, the same was beyond the control of the Commission.

14.              File be consigned to the records. 

Dated: 28.07.2023.

Dictated by: Jasvinder Singh, Member

     

                                                                           (Gulab Singh)

                                                                          District & Sessions Judge (VRS)

(Geeta Parkash)     (Jasvinder Singh)                   President,

Lady Member.      Member.                               DCDRC, YNR.               
 

 

Typed by:  Jitender Sharma, Steno-typist.