Complaint No: 176 of 2023.
Date of Institution: 10.10.2023.
Date of order: 19.03.2024.
Ajay Kumar Sharma Son of Sh. Kewal Krishan Sharma, resident of House No. 506, Ward No. 11, Prem Nagar, Hardochhania Road, Gurdaspur. .....Complainant.
VERSUS
1. STAR HEALTH AND ALLIED INSURANCE CO. LTD., Branch Office at SCO-7-D, Block 2nd Floor, Ranjit Avenue, Amritsar, through its Branch Manager / Authorized Signatory.
2. STAR HEALTH AND ALLIED INSURANCE CO. Office at No. 15, Sri Balaji Complex, 1st Floor, WHITES LANE ROY APETTAH, CHENNAI – 600014, through its Managing Director.
….Opposite parties.
Complaint Under Section 35 of Consumer Protection Act.
Present: Complainant: In person.
For the Opposite Parties: Sh.Sandeep Ohri, Advocate.
Quorum: Sh.Lalit Mohan Dogra, President, Sh.Bhagwan Singh Matharu, Member.
ORDER
Lalit Mohan Dogra, President.
Ajay Kumar Sharma, Complainant (here-in-after referred to as complainant) has filed this complaint under section 35 of the Consumer Protection Act (here-in-after referred to as 'Act') against Star Health & Allied Ins. Co. Ltd. Etc. (here-in-after referred to as 'opposite parties).
2. Briefly stated, the case of the complainant is that the complainant took the Young Star Insurance Policy (FLOATER PLAN) from the opposite parties bearing No.P/211214/01/2022/000306 starting w.e.f 17.06.2021 to midnight of 16.06.2022. The complainant alongwith his wife Saruchi Sharma, and son Shivam Sharma were also covered under this policy as per the scheme of the opposite parties. The limit cover of the policy is Rs.5,00,000/- and yearly total premium of the policy is Rs.13,912/- including SGST and UGST. The complainant has always paid the insurance claim on time. The above said policy was renewed and the complainant was given policy No. P/211214/01/2023/000213 started w.e.f 17.06.2022 till midnight of 16.06.2023. However, the premium of the policy remained same i.e. of Rs.13,912/- Per Year. It is pleaded that on December 31st 2022, the complainant i.e. Ajay Kumar started feeling pain in his private part and he got his tests conducted from G.B. Scan Centre, Kahnuwan Road, Gurdaspur, and it was transpired that the complainant is facing Hydrocil problem. In February 2023, the complainant went to Fortis Escort, Hospital for operation to cure his Hydrocil problem. There also some tests of the complainant were got conducted and it was found that the complainant is suffering from ASD medical problem. The doctors at Fortis Escort Hospital suggested the complainant to get himself operated for ASD medical problem. Thereafter, the complainant went to Indus International Hospital, Dera Bassi Mohali for operation of ASD medical problem. It is further pleaded that in April 2023, the complainant got admitted in above said Indus International Hospital and operated there for his ASD medical problem. The complainant who has already taken Ayushman Bharat Scheme (Government of India Health Insurance Cover) and all the expenses with regard to the operation of the complainant is covered in above said Ayushman Bharat Scheme. The complainant have not taken any benefit or claim from the opposite parties with regard to his operation conducted at Indus International Hospital for his ASD medical problem. The complainant was got discharged on dated 08.05.2023 from Indus International Hospital. It is further pleaded that after discharge, the complainant again within two days, started suffering from high fever and he has been taken to Indus International Hospital again where his tests were conducted and test reports were not good. It is further pleaded that the treatment was started there, but there was no improvement in the condition of the complainant, as such he was referred to IVY Hospital, Airport Road, Amritsar for proper treatment on dated 23.05.2023. It is further pleaded that the complainant remained under treatment upto 05.06.2023 and huge amount was spent on his treatment and other related expenses. It is further pleaded that after that the complainant approached the opposite parties for reimbursement of his medical claim with regard to his operation and treatment at Indus International Hospital as well as IVY Hospital. Initially the officials of the opposite parties asked the complainant to submit all the relevant documents for the reimbursement of his medical claim, which the complainant immediately submitted, but the officials of the opposite parties continued to delay the medical claim of the complainant by giving lame excuses to the complainant. It is further pleaded that the complainant has already submitted his documents four times which is unwanted harassment to the complainant and his family and totally mal practice on the part of the opposite parties. It is further pleaded that ultimately the opposite parties issued a letter dated 06.07.2023 to the complainant vide which his medical claim was repudiated on the baseless grounds that “details regarding the investigation and treatment of the insured patient are not transparently evident. The full facts of the case may not have been presented to us. Therefore, we regret we are not in a position to admit your claim, as per Specific Condition No. 18 of the above policy issued to you”. It is further pleaded that the complainant has already submitted all the required documents four times as per its demand at the office of the OP No. 1 and the complainant was given medical Claim Number as CIR/2024/211214/0242677 and at that time, no official of the opposite parties ever raised objection that there is any doubt or objection in it. As such, the opposite parties have no right to raise any such objection afterward, without any legal ground. Moreover, it has already been reported by the Doctors of Indus International Hospital and IVY Hospital that there is no previous illness or medical problem to the complainant with regard to disease for which the claim of complainant for reimbursement was submitted. Hence, the opposite parties have no right to repudiate the medical claim of the complainant on the false grounds. It is further pleaded that the complainant served upon the opposite parties with a Legal Notice dated 31.08.2023 vide which the opposite parties were called upon to pay Rs.7,00,000/- (approx.) to the complainant alongwith interest from the date of due till its realization plus costs for causing mental and physical harassment to the complainant, within 15 days of from the date of receipt of this legal notice, but the opposite parties did not give any reply to the said legal notice despite due acknowledgement. It is further pleaded that due to this illegal act and conduct of the opposite parties the complainant has suffered great loss and also suffered mental agony, Physical harassment and inconvenience. It is further pleaded that there is a clear cut deficiency in service on the part of the opposite parties.
On this backdrop of facts, the complainant has alleged deficiency and unfair trade practice on the part of the opposite parties and prayed that necessary directions may kindly be issued to the opposite parties to pay Rs.7,00,000/- (approx.) to the complainant alongwith interest @ 24% P.A from the date of due till its realization. The opposite parties may be further burdened to pay Rs.50,000/- to the complainant for causing him mental and physical harassment alongwith Rs.50,000/- as litigation expenses to the complainant, in the interest of justice and fair play.
3. Upon notice, the opposite parties appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the complainant has no cause of action to file the present complaint against the answering opposite parties and the complainant has no locus standi to file the present complaint against the answering opposite parties. It is pleaded that the insurance is a contract between the two parties and both the parties bind with the policy and its terms and conditions. No exception or relaxation can be made on ground of equity. It is further pleaded that upon issuance of the policy the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered under the policy subject to the terms and conditions of the policy and the complainant has filed this complaint falsely and for harassing the answering opposite parties with intention to get unlawful enrichment from the answering opposite parties who are dealing with public money and are functioning under the guidelines of IRDA controlled by the Govt. of India. It is further pleaded that the matter of the fact is that the Young Star Insurance Policy having sum assured of Rs.5.00 Lacs has been taken. The policy inception date is 17.06.2021 and the policy period is from dated 17.06.2022 to 16.06.2023 covering Mr. Ajay Kumar Sharma, spouse Saruchi Sharma and child Shivam Sharma. The terms and conditions of the policy were duly explained to the complainant at the time of receipt of proposal and the same was served to the complainant alongwith policy schedule. The insured preferred claims in the 1st year and 11 months of the policy and the amount of Rs.7.00 Lacs has been claimed for both the claims. The first claim has been filed for hospitalization for a period from 10.05.2023 to 20.05.2023 in Indus International Hospital. The cashless request has been made, but it has been rejected. It is further pleaded that the insurer previously approved an amount of Rs.1,50,000/- on dated 10.05.2023 for the treatment of diagnose disease i.e. LRTI and the said approval has been given on the preauthorization request and other documents submitted by the insured. The patient has a long standing disease and there is no clarity on the duration. The past treatment record are also not provided. The answering opposite parties unable to ascertain the pay ability of this claim with the available documents and further evaluation is needed for the same. Therefore, the authorization given for cashless has been withdrawn and the cashless got rejected vide letter dated 19.05.2023 and same got communicated to the insured. It is further pleaded that the second claim has been filed for treatment in IVY Hospital for a period from 23.05.2023 to 05.06.2023 for diagnosis for ASD with AKI. The amount of Rs.4,10,601/- has been claimed. The cashless has been denied vide letter dated 25.05.2023 as the required documents are not submitted to the insurer inspite of the several requests. The documents demanded were:-
- Exact duration since diagnosed with ASD?
- Provide all previous treatment / consultation record prior to 03/2022.
- Final, composite diagnosis and further investigation has been done.
- Detailed line of management.
- Symptomatic since 2022 provide all the previous consultation and treatment record.
It is further pleaded that afterwards the claim for reimbursement already filed and it has also been rejected vide letter dated 06.07.2023 as on the scrutiny of the medical documents it was observed that the insured has ASD (hole in heart) closure done on dated 01.05.2023. History of hydrocele of which insured has not submitted the documents. Further, there were various discrepancies in the submitted documents and therefore the insurance company is not in a condition to admit the claim as per condition No. 18 of the policy which clearly provides that it is the duty of the insured to obtain and furnish all the relevant documents and additional documents and assistance required by the company while dealing with the claim. So, the claim has rightly been rejected and there is no liability of the answering opposite parties / insurance company. It is further pleaded that there is no deficiency in service on the part of the answering opposite parties / insurance company, as such the present complaint is liable to be dismissed.
On merits, the opposite parties have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in service on the part of the opposite parties. In the end, the opposite parties prayed for dismissal of complaint with costs.
4. Learned counsel for the complainant has placed on file affidavits of Ajay Kumar Sharma, (Complainant) as Ex.CW-1/A and Ex.CW-1/B alongwith other documents as Ex.C-1 to Ex.C-10 alongwith complaint.
5. Learned counsel for the opposite parties has placed on file Self-Declaration of Sh. Sumit Kumar Sharma, (Star Health & Allied Ins. Co. Ltd., Chandigarh) as Ex.OPW-1,2/A alongwith other documents as Ex.OP-1 to Ex.OP-25 alongwith reply.
6. Rejoinder not filed by the complainant.
7. Written arguments not filed by both the parties.
8. Complainant in person has argued that he took health insurance from the opposite parties which was further renewed and during the continuation of policy complainant started feeling pain in his private part and on investigation was found to be suffering from hydrocil problem. In February, 2023 complainant went to Fortis Escort, Hospital for surgery and after some tests it was found that complainant suffering from ASD medical problem and surgery was suggested. It is further argued that thereafter complainant went to Indus International Hospital, Desa Bassi, Mohali for surgery regarding ASD and was operated upon and all the expenses of the said surgery were covered under Ayushman Bharat Scheme and complainant has not taken any benefit of scheme from the opposite parties in respect of surgery for ASD at Indus International Hospital. It is further argued that after discharge, again within two days, complainant started suffering from high fever and was evacuated to Indus International Hospital but since there is no improvement as such complainant was referred to IVY Hospital, Airport Road, Amritsar on 23.05.2023 where the complainant remained admitted upto 05.06.2023 and had to spent amount on his treatment. It is further argued that complainant approached the opposite parties for reimbursement of his medical claim with regard to his operation and treatment at Indus International Hospital as well as IVY Hospital and opposite parties received all the documents but ultimately on 06.07.2023 claim was repudiated on false and flimsy grounds by relying upon some condition No.18. It is further argued that complainant was not suffered from any previous ailment when complainant purchased the policy of insurance. As such repudiation of the claim amounts to deficiency in service on the part of the opposite parties.
9. On the other hand counsel for the opposite parties has argued that policy of insurance is admitted with sum assured of Rs.5.00 Lakhs. It is further argued that the insured had preferred claim in the first year and 11 months of the policy and amount of Rs.7.00 Lakhs has been claimed for both the claims. First claim is regarding hospitalization from 10.05.2023 to 20.05.2023 at Indus International Hospital and cashless request was rejected and previous approval for Rs.1,50,000/- on 10.05.2023 was given as such it is found that patient has long standing disease and there is no clarity on the duration and past treatment record was not provided and opposite parties are unable to pay the claim with available documents and accordingly authorization given for cashless was withdrawn and rejected on 19.05.2023. It is further argued that second claim has been filed for treatment in IVY Hospital for the period 23.05.2023 to 05.06.2023 for ASD with AKI and amount of Rs.4,10,601/- was claimed and cashless was denied as following documents were not provided which are as under:-
- Exact duration since diagnosed with ASD?
- Provide all previous treatment / consultation record prior March, 2022.
- Final, composite diagnosis and further investigation.
- Detailed line of management.
- Symptomatic since 2022 but failed to provide all the previous consultation and treatment record.
As such claim lodged by the complainant was rightly repudiated by the opposite parties.
10. We have heard the Ld. counsels for the parties and gone through the record.
11. It is admitted fact complainant had purchased Young Star Insurance Policy (FLOATER PLAN) from the opposite w.e.f 17.06.2021 to 16.06.2022 which was further renewed from 17.06.2022 to 16.06.2023. It is further admitted fact that complainant remained admitted at Indus International Hospital, Dera Bassi, Mohali from 10.05.2023 to 20.05.2023 and thereafter from 23.05.2023 to 05.06.2023 and cashless request for both the treatments was declined by the opposite parties. The only issue for adjudication before this Commission is whether the claim for reimbursement of medical expenses for treatment can be repudiated by the opposite parties for want of documents.
12. Perusal of Ex.OP-16 and Ex.OP-17 shows that the opposite parties have mainly declined the reimbursement of medical expenses on the ground that as per the record there is past history of ASD and hydrocele but complainant as failed to supply the documents and have concealed the previous illness. Perusal of file shows that the policy of insurance initially started w.e.f. 17.06.2021 and if we are agree with the plea of opposite parties that the health issue started in the year 2022 even then the same was very much covered under the policy of insurance. But there is no evidence on record to prove this plea. Perusal of certificate Ex.C7 which has been issued by Dr.Ashwani Bansal of Indus International Hospital clearly shows that complainant was diagnosed with ASD (Hole in the Heart) in March, 2023 with no previous history which clearly shows that the complainant came to know about the said disease only in the year 2023 and there is no record of previous consultation and treatment undertaken by the complainant in respect of disease for which the complainant undertook treatment. We are further of the view that many diseases remain silent for number of years and come out and erupt within no time requiring emergency treatment. As such demand of documents regarding previous ailment in such like cases itself amounts to deficiency in service. Moreover, perusal of discharge summary of IVY Hospital and Indus International Hospital Ex.C4 and Ex.C5 shows that complainant has already attached the entire treatment record with the complaint also and same has been supplied to the opposite parties. As such we are of the view that denial of claim regarding hospitalization of the complainant from 10.05.2023 to 20.05.2023 at Indus International Hospital and second claim regarding treatment at IVY Hospital w.e.f. 23.05.2023 to 05.06.2023 amounts to deficiency in service on the part of the opposite parties.
13. Further, reliance is be placed on another judgment of Hon'ble Supreme Court of India reported in 2018(1) Law Herald (SC) 832 wherein it was held by Hon'ble Supreme Court of India as under:-
"Insurance-Life Insurance-Premium accepted without conducting of medical examination-Amounts to waiving off condition precedent in proposal form-Insurer held liable to pay".
We are of the view that the opposite parties cannot refuse to settle the claim of the complainant by demanding record of previous ailments. Moreover, the opposite parties have renewed the policy of insurance from time to time receiving premium. As such having renewed the policy of insurance from time to time without having availed medical examination of the complainant prior to renewal of the policy amounts to waiver and as such opposite parties cannot refuse to settle the claim by referring to and repeatedly demanding the documents regarding previous ailment with which the present case has no concern.
14. We also placed reliance upon judgment of Hon'ble Punjab State Consumer Dispute Redressal Commission, Chandigarh reported in 2014(3) C.P.J. 13 : 2014(87) R.C.R.(Civil) 264 wherein it was held as under:-
"Insurance Company failed to produce any evidence to show that appellant was suffering from said disease at the time of taking policy - No affidavit of any doctor or person who recorded history of patient".
This Commission is of the view that it was obligatory on the part of the opposite parties before renewal of the policy of insurance must had insisted for medical examination of the complainant and since the opposite parties have failed to get the complainant medically examined before renewal, as such opposite parties have no right to take any such ground later on. Even, in the present case opposite parties have failed to place on record any evidence or affidavit of any doctor regarding previous ailment in respect of which documents are being demanded.
15. We also placed reliance upon judgment of Hon'ble Supreme Court of India reported in 2022 LiveLaw (SC) 506 wherein it was held by the Hon'ble Supreme Court of India as under:-
"Insurance - Insurance companies refusing claim on flimsy grounds and/or technical grounds - While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control. (Para 4.1)".
We are of the view that the opposite parties cannot refuse to settle the claim of the complainant by referring to the record of previous ailments. Moreover, the opposite parties have issued the policy of insurance after having received premium, as such opposite parties cannot refuse to settle the clam by referring to previous ailment and repeatedly demanding documents. We are of the view that insurance companies are only interested in procuring business this way or the other but at the time of the settlement they find one excuse or the other some of which are totally ignorable.
16. From the above discussion and evidence on record complainant has fully proved that during the continuation of policy of insurance complainant remained admitted in hospital and had submitted the necessary documents with the opposite parties for settlement of the claim but the opposite party has repudiated the claim without any justification which amounts to deficiency in service.
17. Accordingly, present complaint is partly allowed and opposite parties are directed to pay claim lodged for the treatment undertaken w.e.f. 10.05.2023 to 20.05.2023 at Indus International Hospital, Dera Bassi, Mohali and in respect of treatment at IVY Hospital, Airport Road, Amritsar from 23.05.2023 to 05.06.2023 within 30 days of receipt of copy of this order. However, it is made clear that if claim is not settled and paid within 30 days of the receipt of copy of this order the entire payable amount shall carry interest @ 9% P.A. w.e.f. 10.10.2023 till realization. Since complainant has suffered mental tension, agony and harassment as such complainant is also entitled for Rs.15,000/- and Rs.5,000/- as costs of litigation which will be paid by the opposite parties to the complainant within above referred time of 30 days of the receipt of copy of this order.
18. Copy of the order be communicated to the parties free of charges. File be consigned.
(Lalit Mohan Dogra)
President.
Announced: (B.S.Matharu)
March 19, 2024 Member.
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