DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi- 110016

Case No.117/2022

Mr. Amir Mohammad

A-2/312, Madangir,

New Delhi-110062

….Complainant

Versus

Star Health and Alied Insurance Co. Ltd.

Hauz Khas, New Delhi-110016

        ….Opposite Party

 Date of Institution    :   04.04.2022    

 Date of Order            :   02.09.2024    

Coram:

Ms. Monika A Srivastava, President

Ms. Kiran Kaushal, Member

Present: Complainant in person.

               Adv. Megha Gupta for OP.

ORDER

Member: Ms. Kiran Kaushal

1.       Briefly put, complainant  took an insurance policy namely ‘Family Health Optima Insurance Plan’ from M/s Star Health and Allied Insurance Company Ltd. (hereinafter referred to as OP).

2.       It is  stated that during the subsistence of the policy, complainant’s wife felt chest pain for which she was admitted to the hospital on 29.01.2022. Complainant was suffering from Acute Viral and was admitted in the hospital from 29.01.2022 to 02.02.2022. It is stated that complainant  incurred the expense of Rs.40,000/- for the said period.

3.       It is further stated that the complainant filed a claim with OP which was repudiated. It is next stated that the complainant took loan on heavy interest to pay the bill of the hospital as OP had declined the cashless claim.

4.       Aggrieved by the circumstances above, complainant prays for direction to OP to refund the amount paid to OP company and to pay compensation to Rs.30,000/- towards deficient services, mental harassment along with cost of litigation. 

5.       OP filed the written version stating inter alia that the complainant along with his wife was covered under Star Group Health Insurance Policy for the sum insured of Rs.2,00,000/- . It is stated that complainant’s wife was admitted for treatment of Acute Viral Illness and the complainant raised a pre-authorization request for cashless treatment. Complainant was asked to submit admission c/s, complete work up, ICPS, vital sign and drugs chart vide letter dated 31.01.2022. As the complainant failed to submit any documents, the claim could not be processed.

6.       Subsequently, complainant submitted medical documents for reimbursement of the claim. On scrutiny of the medical documents including all investigations report, including blood test report, urine report, X-ray report, ultrasound report and covid test report, it was observed that hospitalization of the insured patient was not warranted for the above diagnoses.

7.       It is stated that all vitals were normal throughout the hospitalization and it was noticed that several unwarranted investigations were carried out hence, the claim was rejected vide letter dated 21.02.2022.

8.       It is next stated that as per the Exclusion no.4-

 The company shall not be liable to make any payments under this policy in respect of any expanses what so ever incurred by the insured person in connection with or in respect of Expanses related to any admission primarily for diagnostic and evaluation purpose only are excluded.

9.       In light of the above, it is stated that the claim has been rejected as per the terms and conditions of the policy which were provided to the insured at the time of giving the insurance policy. Thus, it is prayed, that the complaint be dismissed with heavy costs.

10.     Rejoinder has been filed by the complainant reiterating the averments made in the complaint. Evidence is filed on behalf of both the parties. Written arguments have been filed on behalf of OP. Submissions made are heard. Material placed on record is perused.

11.     Before we proceed with the merits of the case, it is pertinent to reproduce the repudiation letter dated 21.02.2022

 We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expanses for treatment of acute viral diagnosis.

12.     Now, we refer to the discharge summary of the wife of the complainant which states as under-

Diagnosis:- Acute Viral Illness

History and presenting complaints:

Patient presented to BHMRC with complaints of fever for 3 days along with generalized weakness and severe body ache. She was admitted in Isolation ward for further evaluation and management.

Course During Hospital Stay:

Patient  was admitted in Isolation ward with above mentioned complaints and was started on I/V antibodies (inj Monocef), antipyretics and other supportive treatment. Her COVID 19 RT PCR came negative and hence was shifted to general ward. Her routine blood investigations revealed Hemoglobin  10.9, TLC 9.39 and platlet 1,36,000/cumm, LEFT and RFT were within normal limits. Coagulation profile revealed PT 11.6, INR 1.03. HbA1C was 5.8%. Her chest X-ray was normal. In view history of self fall and trauma to legs, X-ray right ankle and X-ray left knee done which revealed no bony abnormalities/fracture. Orthopedician opinion with Dr. D Singh was taken and advice followed. Urine exam showed 2-3 pus cells and rest WNL. Her ESR was 35, TSH was 6.88, Vit D low of 30 (supplementation done), Iron 67, TIBC 224, ferritin 70, Vit B12 972 and floate 3.3. Urine and blood culture showed no growth. USG abdomen showed normal study. Patient has improved with conservative treatment and is afebrile and is  now being discharged in stable condition with the following medical advice.

13.     It is clear from the discharge summary above, that the complainant was suffering from fever for 03 days along with generalized weakness and severe body ache. It is noticed that the doctors at the hospital deemed fit to get her Covid test, chest x-ray and other blood and urine tests done. It is not complainant case that the complainant visited the hospital for any diagnoses or for evaluation purposes. She was admitted to the hospital only on the advise of the doctors present therein.

14.     Complainant’s reasoning for repudiation that the hospitalization of the patient is not warranted for Acute Viral Illness does not go well with this Commission. We have not lost sight to the fact that the complainant was admitted to the hospital only on the advise of the doctors.

15.     In light of the discussion above, we find that OP was not right in repudiating the claim of the complainant. Thus, OP is directed  to pay the bill amount i.e Rs.38,902/- with interest @6% p.a from the date of the bill i.e 02.02.2022 within 03 months from the date of order, failing which OP shall pay the above stated amount @9% till realization.

Parties be provided copy of the judgment as per rules. File be consigned to the record room. Order be uploaded on the website.