DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

 

Complaint Case No : CC/84/2022

Date of Institution   : 07.03.2022

Date of Decision    : 08.11.2023

Chirag Bansal son of Sh. Sat Pal resident of Backside Punjab State Electricity Board, Ward No. 15, Gill Colony, Barnala, District Barnala, Punjab.       

                          …Complainant Versus

1. Star Health and Allied Insurance Company Limited, SCO No. 17, 18, 19, 2nd Floor Jhandu Tower, Miller Ganj, G.T. Road, Ludhiana-141003, through its Branch Manager.  

2. Star Health and Allied Insurance Company Limited, Regd. Office:1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034 through its Managing Director.    

                         …Opposite Parties

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

Present: Sh. R.K. Singla counsel for complainant.

Sh. Rohit Jain counsel for opposite parties.

Quorum:-

1. Sh. Jot Naranjan Singh Gill : President

2.Sh. Navdeep Kumar Garg : Member

 

(ORDER BY JOT NARANJAN SINGH GILL, PRESIDENT):

The present complaint has been filed under Section 35 of the Consumer Protection Act 2019, (amended upto date) against Star Health and Allied Insurance Company Limited and others (hereinafter referred as opposite parties).  

2. The facts leading to the present complaint are that the father of the complainant namely Sat Pal purchased one cashless Family Health Optima Insurance Plan for himself, complainant and mother of the complainant named Madhu Bansal for the period from 24.8.2021 to 23.8.2022 and paid premium of Rs. 26,781/- for sum of Rs. 5,00,000/- and at the time of insurance the said members were medically checked and found fit for insurance purpose by the authorized doctors of the opposite parties. It is further alleged that on 29.10.2021 Chirag Bansal was admitted to Partap Nursing Home, Barnala due to fever and the opposite parties were duly intimated regarding this and the complainant remained admitted in the said hospital from 29.10.2021 to 31.10.2021. The complainant incurred expenses of Rs. 8,963/- on his treatment. The complainant informed the opposite parties regarding this and asked to pay the medical bill of the complainant being a cashless policy and on this the opposite parties asked the complainant to pay the said amount at your own and the said amount will be reimbursed to him very soon. Accordingly, the complainant paid the said bill and submitted claim form alongwith original discharge summary, receipts of the payment and receipts of the bills. It is further alleged that the complainant received a letter dated 24.1.2022 from the opposite parties mentioning that the claim of the complainant has been repudiated without any reason and justification. Thus, there is deficiency in service on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.- 

i) To pay the sum of Rs. 8,963/- the treatment amount alongwith interest @ 18% per annum from the date of payment i.e. 31.10.2021 till realization.  

ii) Further, to pay the amount of Rs. 50,000/- on account of compensation for harassment and Rs. 5,000/- as litigation expenses.  

3. Upon notice of this complaint, the opposite parties appeared and filed written version taking preliminary objections interalia on the grounds that the complainant has got no locus-standi or cause of action to file the present complaint, the present complaint is not maintainable, the complainant dragged the opposite parties in false litigation, not come with clean hands etc.  

4. On merits, it is admitted that the father of the complainant purchased one cashless Family Health Optima Insurance Plan for himself, complainant and mother of the complainant named Madhu Bansal for the period from 24.8.2021 to 23.8.2022 and paid premium of Rs. 26,781/- for sum of Rs. 5,00,000/-. It is denied that at the time of insurance the said family members were medically checked and found fit for insurance purpose by the authorized doctors of the opposite parties. It is denied that on 29.10.2021 Chirag Bansal was admitted to Partap Nursing Home, Barnala due to fever and remained admitted in the said hospital from 29.10.2021 to 31.10.2021. It is further alleged that the complainant failed to submit the documents alongwith claim form and the opposite parties vide letter dated 9.12.2021 and 24.12.2021    requested the complainant to submit the following documents;-

i)Kindly submit proper original discharge summary alongwith hospital seal and sign.

ii)Submit original final bill with detailed break up alongwith hospital seal and sign. 

iii)Submit cash paid receipt/s in original alongwith hospital seal and sign towards the final bill. 

iv)Submit prescription towards submitted receipt. 

v)Complete set of indoor case papers.

It is further alleged that the complainant failed to submit the same and as per Condition No. 2 of the policy, the insured has to submit all the required documents and details called by the opposite parties. Hence, the claim was repudiated vide letter dated 24.1.2022 by the opposite parties. It is alleged that the the insured Sat Pal (self), Madhu Bansal (spouse) and Chirag Bansal, dependent child for sum insured Rs. 5,00,000/- vide policy No. P/211218/01/2021/003648 for the period from 7.7.2020 to 6.7.2021. P/211218/01/2022/006856 for the period from 24.8.2021 to 23.8.2022. It is further alleged that the terms and conditions of the policy were explained to complainant at the time of proposing policy and the same were served to the complainant alongwith policy schedule. Therefore, there is no deficiency in service on the part of opposite parties and prayed for the dismissal of complaint. 

5. Ld. Counsel for complainant on 21.6.2022 has suffered the statement that I do not want to file any rejoinder on behalf of complainant.

6. To prove his case the complainant tendered into evidence his own affidavit Ex.C-1, copy of insurance policy Ex.C-2, copy of discharge summary Ex.C-3, copy of receipts Ex.C-4, copy of receipt of bills Ex.C-5 (containing 6 pages), copy of repudiation letter Ex.C-6 and closed the evidence. 

7. To rebut the case of the complainant the opposite parties tendered into evidence affidavit of Sumit Kumar Sharma Ex.O.Ps-1, copy of terms and conditions Ex.O.Ps-2 (containing 6 pages), copy of policy Ex.O.Ps-3 (containing 5 pages), copy of proposal form Ex.O.Ps-4 (containing 4 pages), copy of field visit report Ex.O.Ps-5 (containing 3 pages), copy of claim form Ex.O.Ps-6 (containing 4 pages), copy of discharge summary Ex.O.Ps-7, copy of Lab report Ex.O.Ps-8 (containing 4 pages),  copies of receipts are Ex.O.Ps-9 to Ex.O.Ps-15, copy of letter dated 9.12.2021 Ex.O.Ps-16 (containing 2 pages), copy of letter dated 24.1.2022 Ex.O.Ps-17 (containing 2 pages), copy of letter repudiation of claim dated 24.1.2022 Ex.O.Ps-18 (containing 3 pages), copy of assessment sheet Ex.O.Ps-19 and closed the evidence.    

8. We have heard the learned counsel for the parties and have gone through the record on file. Written arguments filed by the opposite parties. 

9. It is not disputed between the parties that the father of the  complainant purchased one cashless FAMILY HEALTH OPTIMA INSURANCE PLAN for himself, complainant and mother of the complainant for the period from 24.8.2021 to 23.8.2022 and paid premium of Rs. 26,781/- for sum of Rs. 5,00,000/- vide policy bearing No. P/211218/01/2022/006856 (Ex.C-2 & Ex.O.Ps-3). 

10. In order to prove his case the complainant has placed on record his detailed affidavit Ex.C-1. He has further placed on record copy of insurance policy Ex.C-2, which shows that the same was valid from 24.8.2021 to midnight of 23.8.2022. From the policy it further shows that the basic floater sum insured is Rs. 5,00,000/- and the name of the insured Sat Pal (self), Chirag Bansal (dependent) and Madhu Bansal (spouse) is mentioned. The complainant further placed on record copy of discharge summary Ex.C-3, which shows that the patient Chirag Bansal was admitted on 29.10.2021 and was discharged on 31.10.2021. Further, copy of receipt dated 29.10.2021 Ex.C-4, which shows that the patient Chirag Bansal paid Rs. 6,300/- to the hospital for his treatment. Further, copy of receipt dated 31.10.2021 Ex.C-5, which shows that the hospital received Rs. 300/- from the patient Chirag Bansal on account of tests CBC, LFT. Another copy of receipt dated 29.10.2021 of Rs. 720/- of Life Care Computerized Laboratory which is inside Dr. Partap Nursing Home. Another copy of receipt of Rs. 550/- dated 30.10.2021 of the same laboratory on account of medical tests done. Further, copy of receipt dated 30.10.2021 of Palak Medicos of Rs. 381 on account of medicines. Further, copy of receipt dated 29.10.2021 of Rs. 386/- of Palak Medicos on account of medicines. Further, copy of receipt dated 31.10.2021 of Rs. 331/- of Palak Medicos on account of medicines and the above said medicines receipts were stamped and duly signed by the doctor. The complainant has further placed on record copy of repudiation letter  dated 24.1.2022 Ex.C-6 vide which the opposite parties has repudiated the claim of the complainant. 

11. On the other hand the opposite parties in order to rebut the case of the complainant has placed on record affidavit of Sumit Kumar Sharma O.Ps-1. Copy of terms and conditions Ex.O.Ps-2 and policy Ex.O.Ps-3 which is not disputed. The opposite parties further placed on record  Ex.O.Ps-4 copy of proposal form, which shows the name of Proposer Sat Pal and other insured person Madhu Bansal and Chirag Bansal. Further, Ex.O.Ps-6 is the copy of claim form which is duly signed by Sat Pal and in Ex.O.Ps-6 it is mentioned that the hospitalization expenses Rs. 6,300/- (medicine charges Rs. 1098 and others Rs. 1570/-). Ex.O.Ps-7 is discharge summary which is not disputed. Further, Ex.O.Ps-8 are of the copies of Laboratory reports for which the opposite parties have claimed that the same are not signed, but the perusal of above said Laboratory report shows that all the reports are related to the treatment of Patient Chirag Bansal and the Laboratory is inside Dr. Partap Nursing Home, Barnala, so we are of the view that the same are admissible documents. Ex.O.Ps-9 is the copy of receipt vide which the date of admission and date of discharge of patient Chirag Bansal is mentioned and the amount of Rs. 6,300/- is also mentioned which was charged by the hospital. Further, Ex.O.Ps-10 to Ex.O.Ps-12 are the copies of receipt bill and the same are signed by the medical technologist. Ex.O.Ps-13 to Ex.O.Ps-15 are the copies of medical bills and the same are also counter signed by doctor. The opposite parties further placed on record copy of letters dated 9.12.2021 & 24.12.2021 Ex.O.Ps-16 & Ex.O.Ps-17 vide which they demanding the documents from the complainant, but no postal receipts were placed on record by the opposite parties in this regard to prove the service of the same.  Further, Ex.O.Ps-18 is the repudiation letter and Ex.O.Ps-19 is the bill assessment sheet. 

12. So, perusal of the record shows that the opposite parties repudiated the claim of the complainant that the technician sign is not available in the reports and serial dated medicine bills are not admissible. We have gone through the copies of hospital bills Ex.C-4 and the same are stamped and signed by the treating doctor Dr. Partap Singh. Further, the receipt bills Ex.C-5 of Life Care Computerized Laboratory which is situated inside of Dr. Patap Nursing Home, Barnala are in the name of Patient Chirag Bansal and are duly signed by medical technologist Gurpreet Singh. The medicine bills of Palak Medicos are also stamped and duly counter signed by the doctor. Therefore, it is established that the opposite parties have rejected the claim of the complainant on such flimsy grounds. The complainant also relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and  others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that 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.   

13. From the above discussion, it is proved that the claim of the complainant was repudiated by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service on the part of opposite parties. Therefore, the present complaint is partly allowed against the opposite parties and the opposite parties are directed to pay Rs. 8,968/- alongwith interest @ 7% per annum from the date of filing the present complaint till realization. The opposite parties are further directed to pay Rs. 4,000/- on the account of consolidated amount of compensation alongwith litigation expenses to the complainant. 

14. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order.

15. Copy of this order be supplied to the parties free of costs as per rules. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

       8th Day of November, 2023

 

            (Jot Naranjan Singh Gill)

            President 

(Navdeep Kumar Garg) Member