Haryana

Karnal

CC/488/2021

Ansul Gusain - Complainant(s)

Versus

Stars Health And Allied Insurance Company Limited - Opp.Party(s)

Manish Kashyap

06 Nov 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                      Complaint No. 488 of 2021

                                                      Date of instt.14.09.2021

                                                      Date of Decision:06.11.2023

 

Ansul Gusain son of Shri Darshan Lal aged about 45 years resident of house no.345 ward no.1, Civil Hospital Road, near Darbar Colony, Ladwa Kurukshetra 136132.

                                               …….Complainant.

                                              Versus

1. Star Health and Allied Insurance Company Limited, registered and corporate office at 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai 600034 through its authorized signatory/Zonal Manager.

 

2. Stars Health and Allied Insurance Company Limited, registered and corporate office at 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai 600034 through its Director.

 

3. Stars Health and Allied Insurance Company Limited, SCF-137, 2^nd floor sector 13 Urban Estate, near ICICI Bank Karnal 132001 through Branch Manager.

 

4. Directors, Stars Health and Allied Insurance Company Limited, registered and corporate office at 1, new tank street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034.

 

5. The Branch Manager, Stars Health and Allied Insurance Company Limited, SCF-137, 2^nd floor Sector-13, Urban Estate, near ICICI Bank Karnal-132001.

 

6. Sarah Najeebullah, Manager, Claim relation Cell, Stars Health and Allied Insurance Company Limited, office at SCO 15, Sri Balaji Complex, whites Lanes Royapettah, Chennai-600014.

 

7. Mrs. Vijaya Lakshmi Pandit, Senior General Manager, Stars Health and Allied Insurance Company Limited office at SCO 15 Sri Balaji Complex, whites Lanes Royapettah Chennai 600014.

 

 

…..Opposite Parties.

       

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.

              Shri Vineet Kaushik…….Member

              Dr. Suman Singh……Member

          

Argued by:  Shri Manish Kashyap, counsel for the complainant.

                    Shri Gaurav Gupta, counsel for the OPs.

 

                    (Jaswant Singh, President)

ORDER:                     

          

                The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant has purchased a Health Insurance Policy from ICICI Lombard in the year 2014 with sum insured to the tune of Rs.3,00,000/- and accumulated bonus Rs.75000/- total Rs.3,75,000/- which was continued upto 2018 without any interruption. In the year 2018, the official of the OPs approached the complainant and explained the benefits of scheme of Star Health and Allied Insurance Company. Agent of the OPs told the complainant that if he will port/take over the policy from ICICI Lombard to their company then they will raise the sum insured to Rs.10,00,000/- with approximate same premium which the complainant paid to ICICI Lombard. Further, agent of the OPs told the complainant that it will be cashless policy. Under the assurance of representative of OPs, complainant purchased Family Health Optima Insurance Plan for his family, vide policy no.P/211114/01/2019/003513 dated 07.08.2018 with sum insured to the tune of Rs.10,00,000/- from the OPs and paid premium of Rs.19,872/- on 03.08.2018. The policy was valid from 07.08.2018 to 06.08.2019 and the complainant alongwith his wife Geeitak, his daughter Anshita and son Manit Gusain were insured under the said scheme. In the year 2019, complainant renewed the said policy and OPs further enhanced the amount of sum insured to Rs.15,00,000/- and Rs.2,50,000/- bonus total Rs.17,50,000/-, vide renewal endorsement policy No.P/211114/01/2020/004172 dated 07.08.2019 and complainant paid the premium of Rs.23441/- on 29.07.2019. The policy was valid from 07.08.2019 to 06.08.2020.

2.             It is further averred that on 18.08.2019, the wife of complainant has suffered Cortical Venous Thrombosis (CVT) i.e. Brain Hemorrhage and therefore, she immediately taken to Medanta-The Medicity Hospital Sector 38 Gurugram, where she was admitted and operated by the doctors. The said hospital comes under the policy of the OPs. During the treatment of his wife on dated 22.08.20219 sent a correspondence to the company on mail id which was replied by the OP no.6 on 23.08.2019 in which OP no.6 has replied that the complainant has not disclosed the medical history of his wife and therefore, the company will not admit the claim of the complainant. On 24.08.2020, complainant sent a correspondence to OPs alongwith opinion of the doctors of the Medanta Hospital in which it was clearly mentioned that current CVT attack is not related to any previous illness. Thereafter, complainant contacted the OPs no.5 to 7 so many times and requested to approve the claim of complainant, as such OPs have approved an amount of Rs.3,75,000/-, which was directly credited in the account of Medanta-The Medicity Hospital, Gurugram. The wife of complainant remained admitted upto 06.09.2019 and the total amount of bill of hospital which was raised upto 06.09.2019 was Rs.11,87,738/- and OPs have approved the claim of Rs.3.75,000/- only and remaining amount of medical expenditure was paid by the complainant to the hospital. The complainant was not in capacity to carry forward the treatment of his wife in the abovesaid hospital as OPs have refused to reimbursed the medical bills on the false and baseless ground. As such, wife of complainant was discharged from the hospital on 06.09.2019 in a serious condition. Under the compelling circumstances, complainant shifted his wife under serious condition to Shri Hari Hospital, Karnal on 06.09.2021 where she remained admitted upto 29.10.2019 and complainant has incurred Rs.5,71,562/- on here treatment which is still remain continuing one. The complainant sent correspondence even to Grievances Department on 16.10.2019 but the Grievance Department of OPs also denied the claim of the complainant, vide mail dated 25.10.2019.

3.             It is further averred that, there was lockdown in the country due to Covid-19 since March, 220 and on dated 15.06.2020, wife of complainant was again admitted to Shri Hari Hospital, Karnal and she has undergo second surgery and complainant again incurred an amount of Rs.2,14,585/- on surgery of his wife and she discharged on 27.06.2020 from the hospital and presently wife of complainant is totally bedridden and totally depends on others. Then complainant sent a legal notice dated 13.07.2020 to the OPs, vide which demanded Rs.15,99,158/-. On receipt of the said notice, in the month of September, 2020 OPs approved to refund of Rs.7,48,634/- only but refuse to refund the remaining amount. The complainant again requested the OPs to refund the remaining amount but OPs did not pay any heed to the request of complainant. Then complainant again sent a legal notice dated 15.02.2021 to OPs, vide which he demanded the remaining amount of Rs.8,50,524/- but OPs did not pay the same and refused to pay the said amount. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

4.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction and concealment of true and material facts. On merits, it is pleaded that the insured availed the Family Health Optima Insurance Policy covering Mr. Ansul Gusain self and Geetika-spouse, Anshita  and Manit Gusain-dependent children for the sum insured of Rs.15,00,000/- and the bonus of Rs.2,50,000/- for the period from 07.08.2019 to 06.08.2020.  The complainant had insurance policy earlier with the ICICI Lombard Gen. Insurance Company, since 07.08.2014 for the sum insured of Rs.3,00,000/- and ported his policy to OPs’ company. It is further pleaded that insured Mrs. Geetika has requested for cashless authorization for hospitalization expenses at Medanta The Medicity Gurugram from 18.08.2019 to 06.09.2019 for the treatment of CVT. Documents based upon the details provided by the hospital, OPs have approved an amount of Rs.3,75,000/- towards the expenses for the treatment of the insured-patient, which is maximum payable as already explained policy will be reinstated to portable policy sum insured (3 lakhs). Subsequently, insured issued a legal notice to OPs and on receipt of said notice, the claim was again reviewed and considered an amount of Rs.7,48,634/- for settlement on 02.09.2020.  The OPs have paid an amount of Rs.11,23,634/- towards the claim, deducting only an amount of Rs.64,014/-. It is further pleaded that as per allegations of the complainant, the insured was hospitalized at Shri Hari Hospital, Karnal from 06.09.2019 to 29.10.2019 and insured the expenses of Rs.5,71,562/-. Further for second surgery, patient was again admitted in the said hospital from 15.06.2020 to 26.06.2020 and incurred an amount of Rs.2,14,858/-. All the said allegations were vehemently denied by the OPs. Complainant has not approached with the OP for medical expenses of hospitalization at Shri Hari Hospital. OP has not received the medical bills of the amount claimed in the complaint. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

5.             Parties then led their respective evidence.

6.             Complainant has tendered into evidence his affidavit Ex.CW1/A, copy of policy certificate of ICICI Lombard Ex.C1, copy of tax certificate Ex.C2, copy of health care card Ex.C3, copy of star health policy for the period 07.08.2018 to 06.08.2019 Ex.C4, copy of star health policy for the period 07.08.2019 to 06.08.2020 Ex.C5, copy of premium receipt Ex.C6, copies of emails Ex.C7 to Ex.C11, copy of denial letter dated 23.08.2019 of cashless treatment Ex.C12, copy of opinion of Dr. Seema of Medanta hospital Ex.C13, copy of rejection letter Ex.C14, copy of mail 16.10.2019 to 19.10.2019 Ex.C16, copy of mail dated 25.10.2019 Ex.C17, copy of legal notice dated 13.07.2020 Ex.C18, postal receipts Ex.C19 to Ex.C25, legal notice dated 15.02.2021 Ex.C26, postal receipt Ex.C27 to Ex.C33, acknowledgement Ex.C34 and Ex.C35, copy of CT scan reports dated 30.09.2019 and 09.10.2019 Ex.C36 and Ex.C37, copy of medical bills Ex.C38 to Ex.C42, copy of lab bills Ex.C43 to Ex.C65, copy of x-rays report and their bills Ex.C66 to Ex.70, copy of medical bills Ex.C71 to Ex.C127, copy of discharge summary Ex.C128, copy of bill dated 27.06.2020 Ex.C129, copy of IPD receipts Ex.C130 to Ex.C132, copy of CT scan reports dated 18.06.2020 Ex.C133 and Ex.C134, copy of lab reports dated 21.06.2020 Ex.C135 and Ex.C136, copy of indoor patient file Ex.C137, copy of patient and physical record Ex.C138 and closed the evidence on 31.05.2022 by suffering separate statement.

7.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma Senior Manager Ex.RW1/A, copy of terms and conditions of the policy Ex.R1, copy of policy schedule Ex.R2, copy of portability form Ex.R3, copy of proposal form Ex.R4, copy of pre-authorization request Ex.R5, copy of field visit report Ex.R6, copy of pre-authorization query letter dated 21.08.2019 Ex.R7, copy of denial letter dated 21.08.2019 Ex.R8, copy of cashless request letter dated 29.08.2019 Ex.R9, copy of discharge summary Ex.R10, copy of final bill Ex.R11, copy of bill assessment sheet Ex.R12, copy of legal notice Ex.R13, copy of bill assessment sheet Ex.R14 and closed the evidence on 13.04.2023 by suffering separate statement.

8.              We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

9.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that initially complainant had purchased a Health Insurance policy from ICICI Lombard, which was continued upto the year 2018 and thereafter complainant ported the said policy to the OPs. On 18.08.2019, the wife of complainant namely Geeitaka has suffered from Cortical Venous Thrombosis (CVT) i.e. Brain Hemorrhage and she was taken to Medanta-The Medicity Hospital, Sector 38, Gurugram, where she admitted and got operated. The policy was a cashless policy, despite repeated requests, OPs approved an amount of Rs.3,75,000/- and the same was credited to the account of abovesaid hospital whereas the complainant spent Rs.11,87,738/- on the treatment of his wife. Complainant requested the OPs so many times to pay the remaining amount but OPs did not pay any heed to the request of complainant. He further argued that on 06.09.2019, complainant shifted his wife to Shri Hari Hospital, Karnal for further treatment and in the said hospital complainant has spent Rs.5,71,562/-on the treatment of his wife. On 15.06.2020, wife of complainant again admitted in the said hospital and complainant spent Rs.2,14,585/- on surgery of his wife. Complainant spent total amount of Rs.15,99,158/- on the treatment of his wife. Complainant requested the OPs to pay the said amount but OPs did not pay the same. Complainant sent the legal notices to the OPs and on receipt of legal notices, complainant approved Rs.7,48,634/- to the complainant and remaining amount of Rs.8,50,524/- has not paid by the OPs. Complainant lodged the claim with the OPs for reimbursement of the said amount but OPs did not pay the same and repudiated the claim of the complainant on false and frivolous grounds and prayed for allowing the complaint.

10.           Per contra, learned counsel for OPs, while reiterating the contents of the written version, has vehemently argued that the complainant purchased the policy in question for a period of 07.08.2018 to 06.08.2019 and thereafter from 07.08.2019 to 06.08.2020 by way of portability from ICICI Lombard. Insured Mrs. Geetika has requested for cashless authorization for hospitalization expenses at Medanta -The Medicity Gurugram from 18.08.2019 to 06.09.2019 for the treatment of CVT. OPs have approved an amount of Rs.3,75,000/- towards the expenses for the treatment of the insured-patient. Insured issued a legal notice to OPs and on receipt of said notice, the claim was again reviewed and considered an amount of Rs.7,48,634/- for settlement on 02.09.2020.  The OPs have paid total an amount of Rs.11,23,634/- towards the claim, deducting only an amount of Rs.64,014/-. OPs have denied the fact that the insured was hospitalized at Shri Hari Hospital, Karnal from 06.09.2019 to 29.10.2019 and insured the expenses of Rs.5,71,562/-. Further for second surgery, patient was again admitted in the said hospital from 15.06.2020 to 26.06.2020 and incurred an amount of Rs.2,14,858/-. Complainant has not approached with the OPs for medical expenses of hospitalization at Shri Hari Hospital and lastly prayed for dismissal of the complaint.

11.           We have duly considered the rival contentions of the parties.

12.           Admittedly, insured availed family health Optima insurance policy covering the complainant, Geetika-spouse, Anshikta and Manit Gusain dependent child for the sum insured of Rs.15,00,000/- and bonus of Rs.2,50,000/- for the period from 07.08.2019 to 06.08.2020. It is also admitted that during the subsistence of the insurance policy, the wife of the complainant had taken the treatment and admitted in Medanta-The Medicity Hospital, Gurugram. It is also admitted that the OPs had paid an amount of Rs.11,23,634/- to the complainant on account of reimbursement of medical expenses.

13.           The OPs have made deductions of Rs.64014/- on various grounds i.e. towards the dietician, blood grouping, bed bath, wet wipes, thermometer digital, underpad disposable, cannula, mask, mineral water bottle, pressure montoring kit, gloves, cotton roll, liquid gel, drape, HMEF filter adult, glucometer strip accucheck, uro meter, trolley cover blue, power, mak swab, hexidine, mouth wash, CHG Hrub, Blanket Adult Arizant, AMBU Fibre optic Ascope, blood glucose by Glucometer and nursing charges, etc. The above said deductions had been made as per the terms and conditions of the policy, which is justified. Hence, the OPs had rightly deducted the said amount. i.e. Rs.64014/- and paid an amount of Rs.11,23,634/-.

14.           The complainant has alleged that the his wife had taken treatment from Shri Hari Hospital, Karnal, and remained admitted there from 06.09.2019 to 29.10.2019 and from 15.06.2020 to 26.06.2020 and incurred an amount of Rs.5,17,562/- and Rs.2,14,858/- respectively. The complainant has further alleged that the OPs have not paid the said amount. Per-contra, OPs have alleged that the complainant had approached for availing cashless treatment towards the above said admissions at Shri Hari Hospital, Karnal and same was denied and complainant was advised to submit claim form alongwith medical record for reimbursement vide letters dated 29.08.2019 Ex.C11, 13.09.2019, 28.09.2019 and 13.10.2019. But the complainant has failed to apply for reimbursement of the said amount.

15.           The onus to prove that the complainant has applied for reimbursement of his claim was relied upon the complainant but the complainant has miserably failed to prove his version by leading cogent and convincing evidence. The complainant has not placed on file a single documents/receipt vide which he had applied for reimbursement of his claim with the OPs and the OPs had received the claim form alongwith other documents. Rather OPs had sent a letter dated 15.10.2019 Ex.C15, to the complainant, whereby, the complainant was advised to apply his claim for reimbursement, which is reproduced as under:-

“We refer to intimation of claim dated 13.10.2019, we have advised you vide our letters dated 13.09.2019 and 28.09.2019 to send to us the duly completed claim form alongwith discharge summary, investigation reports, hospital bills, payment receipt, prescription, medical bills etc” .

16.           It is pertinent to mentioned here that on 31.05.2022, the complainant tendered into evidence his affidavit and documents/medical records Ex.C1 to Ex.C35 but in all the thirty five documents/medical records, there is no documents pertaining to Shri Hari Hospital, Karnal. Thereafter, the complainant had seek an adjournment for leading remaining evidence. On 14.09.2022, the complainant has tendered in his evidence Ex.C36 to Ex.C138, and all these documents/medical record pertaining to Shri Hari Hospital, Karnal. If the complainant was in his possession the medical records of Shri Hari Hospital, Karnal then the complainant should have tendered these documents alongwith Ex.C1 to Ex.C35 but he has tendered the documents pertaining to Shri Hari Hospital, Karnal, on 14.09.2022. It appears that the above said documents/medical records pertaining to Shri Hari Hospital, Karnal, was not in his possession till 31.05.2022. Hence, it has been proved on file that the complainant has applied only for cashless facility and has never approached to the OPs for reimbursement of his claim. Hence, the OPs cannot be blamed for the fault of the complainant.

 17.          Thus, as a sequel to abovesaid discussion, the present complaint is devoid of any merits and same deserves to be dismissed and same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance

 

Dated: 06.11.2023.   

     

                                                                  President,

                                                       District Consumer Disputes

                                                       Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Suman Singh)

                     Member                        Member