BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.      

 

Arun Kumar son of Sh. Krishan Chand, resident of House No. 292, Seth Gauri Shankar Wali Gali, Ward no.8, Ellenabad, District Sirsa. 

 

                      ……Complainant.

1. The Manager/ Authorized Officer, Star Health & Allied Insurance Company Limited Office at upstairs Samsung Showroom near RC Hotel, Surkhab Chowk, Sirsa. 

 

2. Star Health & Allied Insurance Company Limited Office at New Tank Street, Valluvar Kottam High Road, Nungabakam, Chennai- 600034. 

 

…….Opposite Parties.

 

            Complaint under Section 35 of the Consumer Protection Act, 2019.

Before: SH. PADAM SINGH THAKUR……. PRESIDENT

   SH. OM PARKASH TUTEJA……….MEMBER

Present: Sh. Sandeep Kamboj,  Advocate for the complainant.

ORDER:-

 

2. In brief, the case of complainant is that complainant purchased Family Health Insurance policy namely Young Star Insurance policy from the ops vide policy/ cover note No. P/211121/01/2022/003984 for the period 10.07.2021 to 09.07.2022 for sum assured amount of Rs.5,00,000/- for himself, wife Pooja Mehta, daughter Urmila and son Ojus and paid an amount of Rs.17,5050/- as premium to the ops. That during the period of insurance policy, Smt. Pooja Mehta wife of complainant suffered incidental injuries i.e. ACL tear on her left knee joint front as she had slipped and fallen from the stairs in the house. It is further averred that thereafter she was initially taken to a nearby located Desi Hakim at Ellenabad and x-ray of left knee joint was got done on 18.10.2021 and she took treatment from there for 15/20 days but as there was no recovery to her problem/ pain, so she further underwent checkup and treatment from Mahatama Gandhi, Govt. Hospital, Hanumangarh Town on 12.11.2021. After thorough examination, the concerned Doctor advised MRI of left knee and medicine was prescribed by him and as such she took medicine and thereafter MRI was got done from Shah Satnam Ji Specialty Hospital, Sirsa on 22.111.2021. It is further averred that thereafter she took treatment from Dr. Kulbinder Singh Gill of Gill Hospital, Sirsa on 24.11.2021 and the doctor advised for ACL reconstruction. That thereafter complainant for better opinion also approached initially to Navjivan Multi Specialty Hospital, Hisar and thereafter to Max Health Care at Bathinda and whole of the medical records were shown there and doctors at Navjivan hospital, Hisar also advised for ACL surgery and thereafter the doctors at Max Health Care also advised for reconstruction of ACL of left knee. Then complainant had also got checked and treated his wife from Shah Satnam Ji Specialty Hospital at Sirsa on 18.12.2021 and doctors of that hospital also advised for reconstruction of the ACL. That ultimately complainant got the surgery of ACL of his wife from Navjivan Multispeciality Hospital, Hisar on 21.12.2021 and she remained there admitted till 23.12.2021. The surgery of arthroscopy ACL reconstruction with fixation was done there. It is further averred that at the time of admission of wife of complainant, due information to this effect was given to the agent of the ops’ company who assured them for payment of whole claim of complainant. That after discharge from said hospital, the complainant lodged his claim for reimbursement of amount of Rs.1,50,000/- approximately and provided all the requisite documents to the ops and requested for expedition of his claim but ops after giving assurances about payment ultimately with oblique motive and malafide intention have repudiated the claim of complainant taking totally false and vague ground that as per doctor letter dated 01.12.2021 insured fallen 8 days back whereas in record dated 26.11.2021 insured fallen 3 days back while in the present discharge summary dated 21.12.2021 it is mentioned that insured fallen two months back because in the doctor letter and declaration injury on 18.10.2021 and as such there is discrepancy, hence claim is rejected. It is further averred that alleged ground of repudiation of claim that in the OPD slip dated 24.11.2021 wherein the attending doctor only on checking of the MRI report dated 21.11.2021 due to omission made the endorsement as history for three days back but that alleged mistake/ accidental slip of mentioning three days on the part of Doctor of Navjivan Hospital, Hisar does not amount or is a proof that wife of complainant has suffered the injury of ACL etc. three days back from 24.11.2021 because the medical reports including x-ray film dated 18.10.2021 as well as subsequent medical reports itself proves the period of injury to the wife of complainant. That act and conduct of ops clearly amounts to deficiency in service and unfair trade practice due to which complainant has suffered unnecessary harassment and mental agony. Hence, this complaint. 

3. On notice, ops appeared and filed written statement raising certain preliminary objections. While admitting about issuance of policy in question, it is submitted that insured was hospitalized on 21.12.2021 at Navjeevan Multispecialty Hospital, Hisar for the treatment of ACL Tear and was discharged on 23.12.2021. The complainant submitted medical documents in support of his claim for reimbursement of medical expenses. On scrutiny of the cashless claim documents received to the company, the Medical Team observed that there are multiple gross discrepancies which amounts to misrepresentation of facts and same are reproduced as under:-

4. It is further submitted that as per terms and conditions of the policy, the claim was rejected and communicated to the insured vide letter dated 26.02.2022 on the ground of misrepresentation of facts as policy is contractual in nature and claim arising therein are subject to the terms and conditions forming part of the policy. It is further submitted that claim of complainant has been repudiated by the ops in a legal and lawful manner as fully detailed above. It is wrong that there was any accidental slip/ mistake in mentioning the history of the injury suffered by the wife of complainant. The Medical Officer describes the history of the ailment of patient as told by the patient or by the attendant. So, there was/is no question of any alleged mistake/ accidental slip on the part of the doctor who checked the wife of complainant. It is further submitted that in case it is found that company is liable to pay the claim in terms of the contract of insurance issued to the complainant, then the maximum quantum of liability under the terms of the policy shall be Rs.66,780/- in claim no. CIR/20232/211121/3677678 and liability will be ascertained for the second claim on receipt of the reimbursement documents, which is CIR/2022/211121/3537455. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.

5.         The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C28. 

6. On the other hand, ops have tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex.RW1/A and documents Ex.R1 to Ex.R21. 

7. We have heard learned counsel for the parties and have gone through the case file.

8. From the policy schedule annexed with letter dated 10.07.2021 Ex.C1, it is evident that complainant had purchased health insurance policy in question from ops for himself, wife Pooja Mehta and children Urmila and Ojus for the sum insured amount of Rs. five lacs for the period 10.07.2021 to 09.07.2022 which fact is also not in dispute. Further from the medical/ treatment record of insured Smt. Pooja Mehta, it is evident that she got checked up herself and took treatment from above said various hospitals as according to complainant on 18.10.2021 i.e. during the period of policy in question she had suffered incidental injuries i.e. ACL tear on her left knee joint front as she had slipped and fallen from the stairs in the house and ultimately Smt. Pooja Mehta got surgery of ACL from Navjivan Multispecialty Hospital, Hisar on 21.12.2021 and she remained there admitted till 23.12.2021. All the treatment record of insured Pooja Mehta including discharge summary has been placed on record by complainant as Ex.C2 to Ex.C14.  However, the claim lodged by complainant for reimbursement of expenses spent by them on the treatment of his wife has been repudiated by the ops on the above said ground of misrepresentation of facts i.e. due to discrepancy of dates of injury to Smt. Pooja Mehta. In this regard we are of the considered opinion that ops have wrongly and illegally repudiated the claim of complainant just on mere technicality and on false, baseless and vague ground because all the record reveal that she suffered injury on 18.10.2021 and the discrepancy pointed out by learned counsel for ops in the prescription slip of Navjeevan Multispecialty Hospital, Hisar dated 26.11.2021 Annexure/ Ex.C6 and in the prescription slip dated 01.12.2021 is only result of omission and mistake on the part of doctors who wrote history of fall 3 days back/ 7-8 days back and the ops cannot take benefit of this clerical mistake which is apparent on record because from all other medical record of the insured it is proved on record that she sustained injury on 18.10.2021. Moreover, the concerned doctor of Navjeevan Multispecialty Hospital, Hisar in the prescription slip dated 21.12.2021 Annexure C12 has written that history of fall at home two months back meaning thereby that patient suffered injury in the month of October, 2021 and not three days back from 26.11.2021 and not 7-8 days back as mentioned in Annexure/ Ex.C6 and Ex.R13 which is only result of mistake on the part of concerned doctors.  Moreover, the concerned doctor of Navjeevan Multispecialty Hospital, Hisar vide his certificate dated 30.12.2021 Annexure/ Ex.C14 has clarified that that patient had history of fall on 18.10.2021 and she was operated by him for ligament surgery. So, it is proved on record that ops have wrongly and illegally repudiated the claim of complainant on just false, wrong and baseless ground. Although complainant has averred that they lodged reimbursement claim of Rs.1,50,000/- approximately with the ops but however from the bills/ receipts it is evident that complainant has spent an amount of Rs.66,671/- on the treatment of his wife and according to vide bill assessment sheet Ex.R11 of ops, the final admissible amount is Rs.66,780/-. So, in our considered view the complainant is entitled to the said amount of Rs.66,780/- being admissible amount as per ops themselves and non payment of the same clearly amounts to deficiency in service on the part of ops. 

9. In view of our above discussion, we allow the present complaint and direct the ops to pay above said claim amount of Rs.66,780/- to the complainant alongwith interest @6% per annum from the date of filing of present complaint i.e. 07.06.2022 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.10,000/- as composite compensation for harassment and litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.   

 

 

Announced. Member Member President,

Dated: 10.12.2024.                                  District Consumer Disputes