DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/42/2023
Date of Institution: 18.04.2023
Date of Decision: 19.07.2024
1. Jatinder Kumar son of Jagdish Rai Garg;
2. Jyoti Garg wife of Jatinder Kumar son of Jagdish Rai Garg residents of H.No. 152, 22 Acre, Barnala-148101.
…Complainants
Versus
1. Star Health and Allied Insurance Company Ltd., No. 15, SRI Balaji Complex, 1st Floor, Whites Lane, Roy Apettah, Chennai-600014 through its Authorized Signatory.
2. Star Health and Allied Insurance Company Ltd., 2nd Floor, Above Delhi Tractor and Combines, Opposite PNB Bank, College Road, Barnala through its Branch Manager.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Ms. Himani Bansal Adv counsel for complainant.
Sh. Rohit Jain Adv counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Star Health and allied Insurance Company Limited & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant 1 Jatinder Kumar purchased one Health insurance policy named as Young Star Insurance Policy bearing no. P/211229/01/2022/001378 from OP No. 2 and said policy was valid from 31.01.2023 to 30.01.2024 in which complainant no. 1 Jatinder Kumar, his wife Jyoti Garg complainant no. 2 and his two minor children are insured for Rs.5,00,000/- for the next one year for any type of aliment and medical need to the whole members of the family. It is alleged that prior to the said policy, complainant no, 1 had also previously purchased the same policy in the last year, which was valid from 31.1.2022 to 30.01.2023. It is further alleged that in the month of February 2022 complainant no. 2 Jyoti Garg suffered from stone problem and she remained admitted in the empanelled hospital of the opposite parties Named as RG Stone & Super Speciality Hospital, Ludhiana, where she remained admitted under the treatment of doctors from the period from 23.02.2023 to 25.02.2023 and treatment was started by doctors with the prior authorization, because the policy purchased by the complainants was cashless and an amount of Rs. 64,000/- was charged by said hospital for operating the same and Rs. 5836/- were charged for the medicines and Rs. 1000/- were also charged and thus total amount of Rs. 70,836/- was paid by the complainants in cash in-spite of cashless policy and which makes clearly that there is deficiency on the part of the opposite parties. It is alleged that the complainants immediately approached to the opposite parties for submission of the claim documents and after completion of all required documents the opposite parties accepted all the requisite documents and generated claim information No. CIR/2023/211229/1543371 of the said claim of the complainants and assured that claim will be paid very soon to the complainants by cheque or through account. The complainants approached the opposite parties many times to pay the amount of claim but the opposite parties never accede the legitimate request of the complainants. It is alleged that the opposite parties have rejected the genuine claim of the complainants without any justified reason vide rejection letter dated 28.02.2023 by mentioning that, "As per internal verification insured underwent Renal Surgery 3 to 5 Years back. The required documents are not submitted inspite of query. Hence rejected". It is alleged that the complainant no. 2 has not underwent any alleged renal surgery nor she has any documents regarding the same. The opposite parties with malafide intention, without any justified reason repudiated the claim of the complainants on flimsy ground. The complainants have also sent a legal notice dated 23.03.2023 to the opposite parties, but they have not replied the said notice. As such, the act and conduct of the opposite parties comes within the definition of the unfair trade practice as well as deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to release the claim amount of Rs. 70,836/- alongwith interest @ 18% from the date of admission till realization.
- To pay Rs. 50,000/- towards mental tension and harassment.
- Further, to pay Rs. 11,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking preliminary objections interalia on the grounds that the complainant has no locus-standi to file the present complaint. The present complaint is not legally maintainable. The complainant has no cause of action to file the present complaint. The complainant has not come with clean hands etc.
4. On merits, it is submitted that the complainant no. 1 Jatinder Kumar purchased one Health insurance policy named as Young Star Insurance Policy bearing no. P/211229/01/2022/001378 from OP No. 2 and said policy was valid from 31.01.2023 to 30.01.2024 in which complainant no. 1 Jatinder Kumar, his wife Jyoti Garg complainant no. 2 and his two minor children are insured for Rs.5,00,000/- for the next one year for any type of aliment and medical need to the whole members of the family. It is further submitted that prior to the said policy, complainant no. 1 had also previously purchased the same policy in the last year, which was valid from 31.1.2022 to 30.01.2023. It is submitted that the Policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. It is further alleged that the insured has requested for cashless and submitted the documents for Hospitalization on 23.02.2023 in RG Stone & Superspeciality Hospital towards the treatment of LEFT RENAL CALCULI and the insured preferred claim in the 2nd year of the Young Star Insurance policy. It is further alleged that initially the pre authorization request for cashless treatment was approved for Rs. 20,000/- and on further perusal of the documents submitted by the treating hospital, it was observed from the indoor case sheet (Pre Anesthesia assessment form dated 23.02.2023) of RG Stone Hospital Collected by internal verification it is clearly mentioned Kidney stone surgery five years back, the required past record renal stones 3 to 5 years is not submitted. Hence, the Pre Authorization Request for cashless Treatment was rejected and the same was informed to the insured vide letter dated 28.02.2023. It is denied that the complainants approached to the opposite parties for submission of the claim documents or that after completion of all required documents they accepted all the requisite documents or that generated claim information no. CIR/2023/211229/1543371 of the said claim of the complainants. It is also denied that the opposite parties assured that claim will be paid very soon to the complainants by cheque or through account. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
5. Ld. Counsel for complainants on 10.10.2023 suffered the statement that I do not want to file any rejoinder against the version of opposite parties.
6. The complainants tendered into evidence affidavit of Jatinder Kumar Ex.C-1, copy of policy alongwith premium receipt Ex.C-2 (containing 5 pages), copy of Discharge Summary Ex.C-3 copies of bills and receipts Ex.C-4 to Ex.C-6, copy of rejection letter Ex.C-7, copy of legal notice Ex.C-8, postal receipt Ex.C-9 & Ex.C-10 and closed the evidence.
7. To rebut the case the opposite parties tendered into evidence affidavit of Sumit Kumar Sharma Ex.O.Ps-1, copy of proposal form Ex.Ops-2 (containing 4 pages), copy of policy Ex.O.Ps-3 (containing 4 pages), copy of terms and conditions Ex.O.Ps-4 (containing 6 pages), copy of request letter Ex.O.Ps-5 (containing 6 pages), copy of preauthorization assessment Ex.O.Ps-6, copy of cashless authorization letter Ex.O.Ps-7 (containing 6 pages), copy of query on enhancement Ex.O.Ps-8, copy of rejection letters Ex.O.Ps-9 & Ex.O.Ps-10 and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file.
9. It is admitted case of the opposite parties that the complainant no. 1 Jatinder Kumar purchased one health insurance policy named as Young Star Insurance Policy bearing no. P/211229/01/2022/001378 from OP No. 2 and said policy was valid from 31.01.2023 to 30.01.2024 in which complainant no. 1 Jatinder Kumar, his wife Jyoti Garg complainant no. 2 and his two minor children are insured for Rs.5,00,000/- for the next one year for any type of aliment and medical need to the whole members of the family and prior to the said policy, complainant no. 1 had also previously purchased the same policy in the last year, which was valid from 31.1.2022 to 30.01.2023 (as per Ex.C-2 & Ex.O.Ps-3). It is also not disputed between the parties that the insured remained admitted in RG Stone & Super Speciality Hospital, Ludhiana, where she remained admitted under the treatment of doctors from the period from 23.02.2023 to 25.02.2023 (as per Ex.C-3).
10. Ld. Counsel for the complainants argued that the treatment was started by doctors with the prior authorization, because the policy purchased by the complainants was cashless and an amount of Rs. 64,000/- was charged by said hospital for operating the same and Rs. 5836/- were charged for the medicines and Rs. 1000/- were also charged and thus total amount of Rs. 70,836/- was paid by the complainants (as per Ex.C-4 to Ex.C-6). It is further argued that the complainants immediately approached to the opposite parties for submission of the claim documents and after completion of all required documents the opposite parties accepted all the requisite documents and generated claim information No. CIR/2023/211229/1543371 of the said claim of the complainants and assured that claim will be paid very soon to the complainants by cheque or through account but till today nothing has been paid. It is argued that the opposite parties have rejected the genuine claim of the complainants without any justified reason vide rejection letter dated 28.02.2023 (Ex.C-7) by mentioning that, "As per internal verification insured underwent Renal Surgery 3 to 5 Years back. The required documents are not submitted inspite of query, hence rejected". It is argued that the complainant no. 2 has not underwent any alleged renal surgery nor she has any documents regarding the same but the opposite parties with malafide intention without any justified reason repudiated the claim of the complainants on flimsy ground. It is further argued that the complainants have also sent a legal notice dated 23.03.2023 (Ex.C-8) to the opposite parties, but they have not replied the said notice.
11. On the other hand, Ld. Counsel for the opposite parties argued that on perusal of the documents submitted by the treating hospital, it was observed from the indoor case sheet (Pre Anesthesia assessment form dated 23.02.2023 Ex.O.Ps-6) of RG Stone Hospital Collected by internal verification it is clearly mentioned Kidney stone surgery five years back, the required past record renal stones 3 to 5 years is not submitted, hence the Pre Authorization Request for cashless Treatment was rejected and the same was informed to the insured vide letter dated 28.02.2023 (Ex.O.Ps-9). It is further argued that in the reply the opposite parties denied that the complainants approached to the opposite parties for submission of the claim documents and after completion of all required documents they accepted all the requisite documents or generated claim information no. CIR/2023/211229/1543371 of the said claim of the complainants.
12. From the perusal of the file it is established that on 23.2.2023 complainant No. 2 Jyoti Garg suffered from stone problem and she remained admitted in RG Stone & Super Speciality Hospital, Ludhiana, where she remained admitted under the treatment of doctors from the period from 23.02.2023 to 25.02.2023 and this fact is proved from discharge summary Ex.C-3 and complainants spent an total amount of Rs. 70,836/- (i.e. Rs. 64,000/- was charged by said hospital for operating the same and Rs. 5836/- were charged for the medicines and Rs. 1000/- were also charged as per Ex.C-4, Ex.C-5 & Ex.C-6). Ld. Counsel for the complainants further argued that in this regard the intimation was given to the opposite parties and complainant lodged his claim along with required documents with the opposite parties and they issued a Claim No. CIR/2023/211229/1543371 of the said claim of the complainants and assured that claim will be paid very soon to the complainants by cheque or through account, but till today nothing has been paid. Ld. Counsel for complainants also argued that the claim of the complainants was repudiated vide letter dated 28.2.2023 Ex.C-7 by the opposite parties on unreasonable and unjustified grounds. On the other hand, opposite parties argued that on perusal of the documents submitted by the treating hospital, it was observed from the indoor case sheet (Pre Anesthesia assessment form dated 23.02.2023 Ex.O.Ps-6) of RG Stone Hospital Collected by internal verification it is clearly mentioned Kidney stone surgery five years back, the required past record renal stones 3 to 5 years is not submitted, hence the Pre Authorization Request for cashless Treatment was rejected and the same was informed to the insured vide letter dated 28.02.2023 (Ex.O.Ps-9). We have gone through the Ex.O.Ps-6 on which the opposite parties rejected the claim of the complainants. But this document is neither stamped by the doctor nor the same is signed by any doctor. Apart from this document the opposite parties have failed to place on record any cogent evidence to prove their allegation. On the other hand, the complainants have alleged that they do not have any document in this regard. Moreover, from the file it shows that the complainants purchased the above said policy on 31.1.2022 and the same was valid till 30.1.2023 and the said policy was again renewed on 31.2023 to 30.1.2024, so at this stage how the opposite parties could have raised the objection that the complainant No. 2 has underwent renal surgery 3 to 5 years back. We are of the view that it was in the hands of insurance company to see and not to issue policy where person is not entitled to claim on account of treatment of Pre-existing disease. Moreover, there is nothing on record from the side of opposite parties that they have conducted the medical examination/investigation of the insured at the time of issuing the policy. So, we are of the view that at this stage the opposite parties cannot be escaped from their liabilities by raising these types of unreasonable and unjustified grounds. The learned counsel for the complainant also relied upon the judgment of the Hon'ble Punjab and Haryana High Court (DB) 2012 (1) RCR (Civil)-901 in which the Hon'ble High Court held that “Claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the policy. Single judge allowed the claim on the ground that it was for Insurance Company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. No interference called for in the order of Single Judge. Held the pre-existing condition existed in the year 2002 which was five years prior to acquiring Insurance Policy. Claim cannot be denied. Ld. Counsel for the complainant also relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that 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.
13. From the above discussion, it is proved that the claim of the complainants was rejected by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties.
14. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 70,836/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant No. 1. The opposite parties are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant No. 1 and Rs. 5,000/- as litigation expenses to the complainant No. 1. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
19th Day of July, 2024
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
