Haryana

Karnal

CC/26/2022

Sandeep - Complainant(s)

Versus

Universal Sompo General Insurance Company Limited - Opp.Party(s)

K.K. Lodhi

07 May 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No. 26 of 2022

                                                        Date of instt.17.01.2022

                                                        Date of Decision:07.05.2024

 

Sandeep age 30 years, son of Shri Mamy Ram, resident of house no.6, Ravidasspura New Char Chaman, Karnal.

                                                                        …….Complainant.

                                              Versus

 

Universal Sompo General Insurance Company Ltd., Joy Tower 5^th floor, C-20/14, C-Block Sector-62, Noida (UP), through its Manager.

 

                                                                        …..Opposite Party.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Dr.  Suman Singh…..Member

 

 Argued by: Shri K.K. Lodhi, counsel for the complainant.

                    Shri Mohit Goyal, counsel for the OP.

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant is a labour person and works on daily wages, on the shop as a labour in Karnal. All the family members of complainant i.e. two children and wife come under the Complete Health Care Insurance Policy of OP. Complainant was duly insured, vide policy no.2825/IMD/01/0010560100 for the period 29.05.2021 to 28.05.2021 with the OP for the basic sum insured Rs.2,00,000/-. The complainant was very seriously suffered from viral fever (Thrombocytopenia). The complainant got treatment from Shri Hari Hospital from 07.11.2021 to 12.11.2021. The complainant has spent Rs.53074/- on his treatment. After discharge from the hospital, complainant lodged a claim with the OP for reimbursement of the said amount and also submitted all the required documents. It is further alleged that OP has sent many letters to Shri Hari Hospital, Karnal for the detail of regularly medical treatment of complainant and other documents. OP sent acknowledgement letter dated 18.11.2021. On 30.11.2021, OP sent another letter, vide which the claim of complainant has been repudiated. On receipt of said letter, complainant again requested the OP through email dated 01.12.2021 for reimbursement of the claim amount but OP again rejected the claim of complainant, vide letter dated 02.12.2021 on the ground of gross discrepancies in material facts. It is wrong to suggest that complainant was negligent regarding his health and according to the terms and conditions, the negligence of the third party cannot be effected to the claim of complainant. Then complainant sent a legal notice 14.12.2021 but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence complainant filed the present complaint.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the complainant was admitted to the hospital on 07.11.2021 for c/o fever, generalized weakness, Nausea with cough with Expectoration. Complainant underwent CBC, Left Urine R/E, Degue, RBS and other related investigations during hospitalization. As per ICP, patient admitted to the hospital for main c/o cough with spatum, vomiting and fever but complainant is afebrile throughout whole hospitalization, even though he has been administered with Antipyretic injection 8 and 6 hourly, no complaints related to vomiting or cough are being recorded in progress notes since admission. As per OPD papers, patient had advised for Sputum Investigation for KOH/AFB, Blood Culture examination but no related investigation conducted during whole hospitalization. As per LAB Report, complainant had PLT count 57000 with slightly high SGOT/SGPT value on 07.11.2021 and kept getting low PLT count 18000 but no blood Grouping was conducted throughout whole hospitalization and no Blood transfusion preparation was advised as per ICP. As per complainant Cannuula had been inserted since admission but it was seem to be inserted was fresh one. The Whole Vital Chart of complainant was in single stretched. No chest x-ray was conducted even though complainant had cough with Expectoration. And from above the gross discrepancies were noted alongwith misrepresentation of material facts. Therefore, claim is not admissible as per Following Policy Clause:

1. Disclosure of Information, the policy shall be void and all premium paid thereon shall be forfeited to the company in the event of misrepresentation, mis description or non-disclosure of any material fact by the policy holder.

The competent authority has repudiated the claim of complainant and conveyed to complainant, vide letter dated 30.11.2021. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             The parties then led their respective evidence.

4.             Complainant has tendered in evidence his affidavit Ex.CW1/A, copy of insurance policy Ex.C1, copy of indoor patient file Ex.C2, copy of indoor patient receipt Ex.C3, copy of summary of bill Ex.C4, copy of claim form Ex.C5, copy of acknowledgment letter dated 18.11.2021 Ex.C6, copy of repudiation letter dated 30.11.2021 Ex.C7, copy of email dated 01.12.2021 Ex.C8 and closed the evidence on 12.01.2023 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Prashant Shukla, Senior Manager Ex.OPW1/A, copy of claim form Ex.OP1, copy of discharge summary Ex.OP2, copy of indoor receipt Ex.OP3, copy of lab report Ex.OP4, copy of repudiation letter dated 30.11.2021 Ex.OP5 and closed the evidence on 02.11.2023 by suffering separate statement.

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

7.             Learned counsel for the complainant, while reiterating the contents of complaint, has vehemently argued that complainant purchased a Complete Health Care Insurance Policy of OP, for the sum insured of Rs.2,00,000/-. The complainant was suffering from viral fever (Thrombocytopenia) and he got treatment from Shri Hari Hospital from 07.11.2021 to 12.11.2021 and has spent Rs.53074/- on his treatment. After discharge from the hospital, complainant lodged a claim with the OP for reimbursement of the said amount alongwith required documents. Complainant requested the OP several times to release his claim but OP did not pay the same and lastly repudiated the claim of complainant on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that the claim of the complainant was duly processed and the same was not found payable on the ground that there were gross discrepancies in the treatment record. Thus, the claim of complainant has rightly been repudiated by the OP and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, complainant and his family members are cover under the Complete Health Care Insurance Policy of OP. It is also admitted that during the subsistence of the insurance policy, omplainant admitted in Shri Hari Hospital, Karnal.

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.C7 dated 18.11.2021 and Ex.OP5 dated 30.11.2021 on the ground, which is reproduced as under:-

“On scrutiny of the claim documents, it is observed that insured admitted with diagnosis of Dengue Fever with TCP. Certain gross discrepancies were noted alongwith mis-representation of material facts. Hence the claim stands repudiated.

 

12.           The claim of the insured has been repudiated by the OP on the aforesaid ground. The onus to prove its version was relied upon the OP but OP has miserably failed to prove the same by leading any cogent and convincing evidence. The claim of the insured has been repudiated by the OP on the ground that there were certain gross discrepancies in the medical record. If there are any discrepancies in the medical record, it was on the hand of the treated doctor and complainant cannot blame for that. Moreover, on perusal of the medical record, there are no such discrepancies in the medical record for which the claim of the complainant was required to be repudiated. Further, it is the treated doctor who has to decide whether the hospitalization of the patient is required or not. Thus, the repudiation of the claim of insured is only on the basis of presumption and assumption, which is not admissible in the eyes of law.

13. Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

14.           Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, the act of the OP while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

15.           The complainant spent Rs.53074/- on his treatment and in this regard he has placed on record bill Ex.C4.
The said bill has not been rebutted and denied by the OP. The sum insured is Rs.2,00,000/-. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

16.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.53074/- (Rs. fifty three thousand seventy four only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of claim i.e. 30.11.2021 till its realization. We further direct the OP to pay Rs.15,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:07.05.2024

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Suman Singh)

                          Member                          Member