On 6.9.2012 complainant Vinod Kumar purchased hospitalization policy from Star Health and Allied Insurance Company  i.e. from the opposite parties,  for  sum insured of Rs.Ten lakhs.  On the same day, his brothers viz  Shyam Sunder and Parmod Kumar, had  also purchased same policies, for same insured amounts of Rs. Ten Lakh each. On 7.9.2012, all of a sudden, complainant suffered from some heart problem, for which he was immediately admitted in Maharaja Agarsen Hospital, Punjabi Bag, New Delhi. There he was medically treated by

Dr.B. B. Chanana  and Dr. Subhash Gupta,  for Coronary angioplasty for which, PTCA +ICS-LAD was successfully done. He was discharged from the hospital on the next day, in stable condition. The hospital bill was for Rs.1,60,439/-.  Discount of Rs.17,558/- was given and so complainant was charged for remaining sum of Rs.1,42,881/-. According to the complainant in this complaint, his said admission in the hospital, was immediately informed to the opposite parties by his brother Shyam Sunder on telephone, as well as, vide his written application dated 7.9.2012 (Ex.C-1). That thereafter registered letter dated 17.9.2012 (Ex.C-2) was also sent in this regard to the opposite parties. The complainant duly lodged  his medi claim of  Rs.1,42,881/- with the opposite parties, but it was not settled, despite his repeated visits to the office of the opposite parties and  despite his legal notice dated 5.11.2012 (Ex.C-5); hence this complaint, for a direction to the opposite parties, for payment of  said medi claim of Rs.1,42,881/-, with up to date interest, besides damages for his harassment, mental agony etc. and litigation expenses.

2.       Simple case of the opposite parties, in their joint reply is that as per terms and conditions of the insurance Policy, the opposite party was to be ”immediately” informed, regarding hospitalization of the insured  within a period of 24 hours, from the  time of his admission in the hospital. But here in the case in hand, said information was given only on 17.9.2012 i.e. after delay of 10 days which is violation of terms and conditions of the insurance policy.  It is further pleaded that on receipt of this letter of the complainant, the opposite parties had requested the complainant, for providing hospitalization documents, but the same were not provided and therefore opposite parties were not in a position to evaluable his claim. It is also pleaded that the opposite parties have not denied the claim of the complainant, but the complainant himself has not followed the procedure, for taking the claim.

3.       In order to make out his case, the complainant has placed on record Ex.C-1 copy of letter of Sham Sunder, brother of the complainant, dated 7.9.2012 written to the opposite parties, for giving information regarding hospitalization of the complainant on that very  day; Ex.C-2 copy of another letter dated 17.9.2012 of  complainant Vinod Kumar, written to the opposite party mentioning for his own hospitalization on 7.9.2012 and also mentioning earlier letter of dated 7.9.2012 of his brother Sham Sunder in this regard; Ex.C-3 and Ex.C-4 original postal receipts of this letter; Ex.C-5 copy of legal notice dated 5.11.2012; Ex.C-6 and Ex.C-7 its postal receipts; Ex.C-8 copy of insurance policy of the complainant; Ex.C-9 copy of hospital bill of the complainant dated 9.9.2012, for total expenses of Rs.1,60,439/- showing that after giving discount of Rs.17,558/-, payable amount was Rs.1,42,881/-.  It also shows that earlier payment of Rs.5000/- was adjusted and so net bill was of Rs.1,37,881/-; Ex.C-10 copies of receipts for payment of Rs.1,37,881/- and Rs.5,000/-; Ex.C-11 copy of check  list of Discharge summery, Diet chart, All blood investigation  report, X-ray, stent cover , old reports  and copies of  test reports etc; given at the time of discharge of the complainant from the hospital including discharge summary; coronary angiography report, Ex.C-12; Ex.C-13 and Ex.C-14 copies of insurance policies of Parmod Kumar and Sham Sunder, brothers of the complainant respectively.

4.       In reply thereto, opposite parties have placed on record Ex.R-1 details of three insurance policies of the complainant and of his two borthers; and Ex.R-2 copy of terms and conditions of the insurance policies.

5.       We have gone through the record of the case carefully and have heard ld. Counsel for the parties.  We are of the considered opinion that there is every merits in this case and so it deserves acceptance.   

6.       Claim of the complainant is being denied by the opposite parties  simply on the ground that immediate information was not given to the opposite parties  for admission of the complainant in the hospital, within 24 hours from the time of his admission.  But there is absolutely no merit in this case of the opposite parties. On the other hand it is proved that said information was given on the very day of his admission in the hospital. Ex.C-1 is the copy of letter of Sham Sunder dt.7.8.2012 itself  written to the opposite parties  informing the admission of the complainant in the hospital on that very day.  Since the complainant was admitted in the hospital due to heart problem, so at that time he himself was not in a position to inform the opposite parties for his own admission in the hospital.  It is also not expected that patient himself, should give information to the insurance company for his own admission.  Sham Sunder and Parmod Kumar are two real  brothers of the complainant. Sham Sunder by way of this letter Ex.C-1, had informed the opposite parties regarding admission of the complainant in the hospital on that very day of admission. The complainant, subsequently sent his letter dated 17.9.2012 (Ex.C-2) to the opposite parties.  Even in this letter Ex.C-2 dated 17.9.2012 the complainant specifically mentioned for said earlier letter Ex.C-1  dated 7.9.2012  written by his brother Vinod  Kumar.  This subsequent letter, was sent under postal receipts  Ex.C-3 and Ex.C-4.  Receipts of this letter is even admitted by the opposite parties. Reference of these two letters, also find mention in subsequent legal notice dated 5.11.2012(Ex.C-5).  But both these letters, as well as, said legal notice, remained unreplied. Had said immediate information, regarding admission of the complainant in the hospital on that very day, not received by the opposite parties, then in all probabilities at least these could have been replied. Therefore now at this belated stage, opposite parties  cannot be allowed to say that it did not receive said letter dated 7.9.2012  (Ex.C-1) or there was no immediate information to it regarding admission of the complainant in the hospital.

7.       Even otherwise word “immediate” has to be construe, as per the facts and circumstances of each case.  If patient is very serious, then naturally first priority of the patient and his attendants, would be to immediate get  medical relief instead of rushing to inform the insurance company. Further this condition  also, cannot be said as mandatory in nature.  To our mind it is only obligatory in nature, as word ‘should’ has been used in it.  In this regard, there is no dispute that efforts would be made to “immediately” inform the Insurance  company,  for the hospitalization of the insured.  But in violation thereof, genuine claim can be declined. But here in the case in hand,  as  above discussed and found, there was prompt information, given to the opposite parties, for the admission of the complainant in the hospital, what to say for any unreasonable delay.

8.       Claim of the complainant also been denied on the ground that hospital documents, were not supplied to the opposite parties.  We also do not find any merit in this contention. Receipt of the claim of the complainant  is admitted. The complainant was discharged from the hospital on the very next day of angioplasty. Ex.C-9 is the hospital bill.  It mentions the details of the expenses. It was a package medical treatment.  Rs.5,000/- was deposited in advance on 7.9.2012 and remaining amount of Rs.1,37,881/- was deposited at the time of discharge from the hospital i.e. on 9.9.2012. The complainant had submitted his claim for said medical expenses of Rs.1,42,881/-. Case of the complainant, in this regard, is supported by his unrebutted affidavit.  Therefore in the circumstances it cannot be said that necessary medical documents, were not available  to the opposite parties,  to evaluate his claim.  It is nothing but a lame excuse on the part of the opposite parties to delay the due. 

9.       Claim of the complainant was also not formally accepted or repudiated, by any specific communication for a long continuous delay.  It was despite his repeated visits, repeated requests and despite his legal notice dated 5.11.2012  which also  remained  unreplied.  For  this,  complainant has to file this complaint.  This  act and conduct on the part of the opposite parties is  also deficiency of service.

10.      Resultantly, this complaint is hereby allowed, with a direction to the opposite parties, to pay Rs.1,42,881/-, to the complainant with interest @ 9% per annum, from the  date of hospitalization of the complaint i.e.  7.9.2012, till payment. Complainant is also hereby awarded compensation of Rs.10,000/- for his   harassment and mental agony etc. and litigation expenses of Rs.2200/- against the opposite parties.