DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

Complaint Case No : CC/254/2021

Date of Institution   : 08.11.2021

Date of Decision    : 05.07.2023

Rohitash Goyal son of Sh. Partap Chand resident of H.No. B-2/543, Pharwahi Bazar, Octave Showroom, Barnala, Tehsil and District Barnala(Mobile 98146-01171).      

                          …Complainant Versus

1. Star Health and Allied Insurance Company Limited, New Tank Street, Valluvar Kottam High Road, Nungambakam, Chennai-600034 through its Manager/Authorized Signatory. 

2. Star Health and Allied Insurance Company Limited, SCO-133, 2nd floor, above TATA Motor Finance, Near Hotel Sweet Milan, Goniana Road, Bathinda-151001 through its Manager/Authorized Signatory.   

                         …Opposite Parties

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

Present: Sh. Varun Singla counsel for complainant.

Sh. Rohit Jain and Sh. Lokeshwar Sewak counsel for opposite parties.

Quorum:-

1. Sh. Jot Naranjan Singh Gill : President

2.Smt. Urmila Kumari : Member

2.(ORDER BY JOT NARANJAN SINGH GILL, PRESIDENT):

The complainant namely Rohitash Goyal has filed the present complaint 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 complainant purchased FAMILY HEALTH OPTIMA INSURANCE PLAN  by submitting proposal dated 12.7.2021 and proposal was accepted by the opposite parties and policy bearing No. P/211217/01/2020/000930 was issued to the complainant by paying the premium amount of Rs. 11,506/- and the complainant alongwith his family (wife namely Ishu Goyal and one child namely Gaurish Goyal) were medically examined and insured in this policy. It is further alleged that the complainant continued the said policy regularly without any discrimination and paid the premium amount and issued Renewal Endorsement No. P/211217/01/2021/001423 which was valid till midnight of 11.7.2021. It is alleged that the above said policy covered all the risk related to any disease, illness, bodily injury and hospitalization expenses upto limit coverage of Rs. 5,00,000/- to an extent as agreed. It is further alleged that during the subsistence of the policy the complainant's son namely Gaurish Goyal suffered some health issues. Therefore, the complainant took his son to Dr. Kanwar Mohan's Squint Centre, Chandigarh for his treatment where the complainant's son was diagnosed to have partially accommodative esotropia and was advised surgery for the right eye and the complainant's son remained admitted from 16.2.2021 at 8 AM to 16.2.2021 at 5 PM and an expenditure of Rs. 69,000/- was charged by the above said hospital. The complainant approached the opposite party No. 2 for the medical claim which is covered under the policy and the complainant submitted all the original documents as said by them and the opposite party No. 2 assured the complainant that they will incur all the expenses of treatment as per the policy bought and will give the claim amount within a week. The opposite parties repudiated the claim and sent clam denial mail dated 13.3.2021 to the complainant, where the reason for rejection was of Cosmetic Correction. Thereafter, again a request was made for giving the claim and again the claim was repudiated on 24.6.2021 and a mail received by the complainant with reason of rejection that the patient has undergone treatment which is during the second year of the policy. The opposite parties did not pay even a single penny of claim as assured to the complainant till today which is withheld by the opposite parties without any justified cause.  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 claim amount of Rs. 69,000/-.  

ii) Further, to pay the amount of Rs. 50,000/- on account of compensation for harassment and Rs. 10,000/- 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 complainant purchased FAMILY HEALTH OPTIMA INSURANCE PLAN by submitting proposal dated 12.7.2021 and proposal was accepted by the opposite parties and policy bearing No. P/211217/01/2020/000930 was issued to the complainant by paying the premium amount of Rs. 11,506/- and the complainant alongwith his family (wife namely Ishu Goyal and one child namely Gaurish Goyal) were medically examined and insured in this policy. The above said policy was valid from 12.7.2019 to midnight of 11.7.2020 and thereafter the complainant continued the said policy regularly without any discrimination and paid the premium amount and issued renewal endorsement No. P/211217/01/2021/001423 which was valid till midnight of 11.7.2021 and the policy covered all the risk of coverage related to any disease, illness, bodily injury and hospitalization expenses upto limit coverage of Rs. 5,00,000/- to an extent as agreed as per terms and conditions of the policy which was issued to the complainant alongwith policy. It is further submitted that it is matter of record that during the subsistence of the policy the complainant's son namely Gaurish Goyal suffered some health issues and due to this reason the complainant took his son to Dr. Kanwar Mohan's Squint Centre, Chandigarh, for his treatment where the complainant's son was diagnosed to have partially accommodative esotropia and was advised surgery for the right eye and thereafter the complainant's son remained admitted from 16.2.2021 at 8 AM to 16.2.2021 at 5 PM and an expenditure of Rs. 69,000/- was charged by the said hospital. It is admitted to the extent that the complainant approached the opposite party No. 2 for the medical claim and the complainant submitted all the original documents with the opposite party No. 2 and the opposite parties repudiated the claim and sent claim denial mail dated 13.3.2021 to the complainant, where the reason for rejection was of Cosmetic Correction and again a request was made for giving the claim and again the claim was repudiated on 24.6.2021 and a mail received by the complainant with reason of rejection that the patient has undergone treatment which is during the second year of the policy. It is denied that the opposite parties did not pay even a single penny of claim as assured to the complainant till today which is withheld by the opposite parties without any justified cause. 

5. It is further submitted that the true facts of the case are that the insured submitted the claim documents for reimbursement of medical expenses towards the treatment of Esotropia (Esotropia is an eye misalignment in which one eye is deviated inward, or nasally. The deviation may be constant or intermittent). It is observed from the submitted records including the discharge summary that the insured-patient has undergone treatment for the above disease which is a cosmetic correction. As per Exclusion- Cosmetic or plastic surgery- Code Excl 08 of the above policy, the company is not liable to make any payment under the policy in respect of expenses for cosmetic or plastic surgery or treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. Hence, claim was rejected and conveyed to insured vide our letter dated 13.3.2021. It is further submitted that the insured send a representation to review the claim on 1.6.2021 to the opposite parties and alongwith the medical certificate dated 13.4.2021 issued by Dr. Kanwar Mohan, in response to our letter dated 13.3.2021. It is further submitted that the medical team of the opposite parties has perused representation of the complainant and the medical certificate of the doctor and has observed that the insured patient has undergone treatment for the ESOTROPIA disease which is during second year of the policy. As per Exclusion- Specified disease/procedure waiting period- code Excl.02.F.1, Treatment of Cataract and disease of the anterior and posterior chamber of the Eye, Disease of ENT, Disease related to Thyroid, Benign disease of the breast. Thus, the expenses incurred by the insured person for treatment of the above mentioned disease shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us. As such, the opposite parties are unable to consider the representation, hence the claim is again rejected on 24.6.2021. Therefore, there is no deficiency in service on the part of opposite parties and prayed for the dismissal of complaint. 

6. The complainant has filed rejoinder to the written version filed by the opposite parties and reiterated the averments as mentioned in the complaint. 

7. To prove his case the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy Ex.C-2, copy of insurance plan Ex.C-3 (containing 2 pages), copy of ID card Ex.C-4, copy of receipt of premium paid Ex.C-5 (containing 2 pages), copy of advanced premium receipt Ex.C-6, copy of letter Ex.C-7, copy of renewed insurance plan Ex.C-8 (containing 2 pages), copy of renewed ID card Ex.C-9, copy of premium paid Ex.C-10, copy of advanced premium receipt Ex.C-11, copies of receipts Ex.C-12 to Ex.C-14, copies of bills Ex.C-15 & Ex.C-16, copy of receipt dated 16.2.2021 Ex.C-17, copy of discharge summary Ex.C-18, copy of certificate Ex.C-19, copy of repudiation of claim Ex.C-20 dated 13.3.2021 (containing 2 pages), copy of repudiation of claim Ex.C-21 dated 24.6.2021 (containing 2 pages), copy of adhaar card Ex.C-22 and closed the evidence.  

8. To rebut the case of the complainant the opposite parties tendered into evidence affidavit of Sumit Kumar Sharma Ex.O.Ps-1, copies of policies Ex.O.Ps-2 & Ex.OPs-3, copy of terms and conditions Ex.O.Ps-4 (containing 12 pages), copy of proposal form Ex.O.Ps-5 (containing 4 pages), copy of claim form Ex.O.Ps-6 (containing 4 pages), copy of discharge summary Ex.O.Ps-7, copy of bill Ex.O.Ps-8, copy of letter dated 13.4.2021 Ex.O.Ps-9, copies of repudiation letters Ex.O.Ps-10 & Ex.O.Ps-11, copy of bill assessment sheet Ex.O.Ps-12 and closed the evidence.   

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

10. It is not disputed between the parties that the complainant purchased FAMILY HEALTH OPTIMA INSURANCE PLAN by submitting proposal dated 12.7.2021 and proposal was accepted by the opposite parties and policy bearing No. P/211217/01/2020/000930 (Ex.C-3) was issued to the complainant by paying the premium amount of Rs. 11,506/- and the complainant alongwith his family (wife namely Ishu Goyal and one child namely Gaurish Goyal) were medically examined and insured in this policy. It is further not disputed between the parties that the above said policy was valid from 12.7.2019 to midnight of 11.7.2020 and thereafter the complainant continued the said policy regularly without any discrimination and paid the premium amount and issued renewal endorsement No. P/211217/01/2021/001423 which was valid till midnight of 11.7.2021 (Ex.C-8) and the policy covered all the risk of coverage related to any disease, illness, bodily injury and hospitalization expenses upto limit coverage of Rs. 5,00,000/- to an extent as agreed as per terms and conditions of the policy which was issued to the complainant alongwith policy. 

11. Ld. Counsel for the complainant argued that during the subsistence of the policy the complainant's son namely Gaurish Goyal suffered some health issues and the complainant took his son to Dr. Kanwar Mohan's Squint Centre, Chandigarh for his treatment where the complainant's son was diagnosed to have partially accommodative esotropia and was advised surgery for the right eye and the complainant's son remained admitted from 16.2.2021 at 8 AM to 16.2.2021 at 5 PM (Ex.C-18 & Ex.C-19) and an expenditure of Rs. 69,000/- was charged by the above said hospital (Ex.C-15). It is also argued that the complainant approached the opposite party No. 2 for the medical claim which is covered under the policy and the complainant submitted all the original documents as said by them and the opposite party No. 2 assured the complainant that they will incur all the expenses of treatment as per the policy bought and will give the claim amount within a week but the opposite parties repudiated the claim and sent clam denial mail dated 13.3.2021 (Ex.C-20) to the complainant, where the reason for rejection was of Cosmetic Correction. Thereafter, again a request was made for giving the claim and again the claim was repudiated on 24.6.2021 (Ex.C-21) and a mail received by the complainant with reason of rejection that the patient has undergone treatment which is during the second year of the policy. It is also argued that the opposite parties did not pay even a single penny of claim as assured to the complainant till today which is withheld by the opposite parties without any justified cause.

12. Ld. Counsel for the opposite parties argued that the insured submitted the claim documents for reimbursement of medical expenses towards the treatment of Esotropia (Esotropia is an eye misalignment in which one eye is deviated inward, or nasally, the deviation may be constant or intermittent) and it is observed from the submitted records including the discharge summary that the insured-patient has undergone treatment for the above disease which is a cosmetic correction. It is further argued that as per Exclusion- Cosmetic or plastic surgery- Code Excl 08 of the above policy, the company is not liable to make any payment under the policy in respect of expenses for cosmetic or plastic surgery or treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured and the claim was rejected and conveyed to insured vide our letter dated 13.3.2021 (Ex.O.Ps-10). It is further argued that the insured send a representation to review the claim on 1.6.2021 to the opposite parties and alongwith the medical certificate dated 13.4.2021 issued by Dr. Kanwar Mohan, in response to our letter dated 13.3.2021 and the medical team of the opposite parties perused representation of the complainant and the medical certificate of the doctor and has observed that the insured patient has undergone treatment for the ESOTROPIA disease which is during second year of the policy and as per Exclusion- Specified disease/procedure waiting period- code Excl.02.F.1, Treatment of Cataract and disease of the anterior and posterior chamber of the Eye, Disease of ENT, Disease related to Thyroid, Benign disease of the breast. Thus, the expenses incurred by the insured person for treatment of the above mentioned disease shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us, as such the opposite parties are unable to consider the representation and hence the claim is again rejected on 24.6.2021 (Ex.O.Ps-11), so there is no deficiency in service on the part of opposite parties and prayed for the dismissal of complaint. 

13. From the perusal of records it is established that the opposite parties have rejected the claim of the complainant on such flimsy grounds as we are of the view that generally the insurance companies not ensured the clauses specifically or to the notice of the person concerned, in fact like all these conditions which are generally hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy and these types of activities on the part of insurance companies must be checked and stopped.

14. In the present case the opposite parties rejected the claim second time on 24.6.2021 (Ex.C-21/Ex.O.Ps-11) as per Exclusion- Specified disease/procedure waiting period- code Excl.02.F.1, Treatment of Cataract and disease of the anterior and posterior chamber of the Eye, Disease of ENT, Disease related to Thyroid, Benign disease of the breast. Thus, the expenses incurred by the insured person for treatment of the above mentioned disease shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us, as such the opposite parties are unable to consider the representation. We are of the view after gone through the nature of the policy that this clause does not appear to be justified in any manner. Further, the policy is renewed from 12.7.2020 to 11.7.2021 for the period of one year by the opposite parties than the condition like that any claim will not be entertained until the expiry of 24 months of continuous coverage after the date of inception of the first policy is not justified and also the very purpose of purchasing the policy for one year shall become redundant. In support of his case the complainant relied the upon the Judgment of the Hon'ble Punjab and Haryana High Court, Chandigarh in case titled Religare Health Insurance Vs The Chairman Peremanent Lok Adalat CWP No. 107 of 2020, decided on 7 January 2020, vide which it is held that since the company itself is issuing policies for the tenure of 1 year then the company cannot claim that the company shall not pay any claim before the period of 2 years. 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. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The insurance company in such cases reply upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. 

15. From the above discussion, it 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. 69,000/- alongwith interest @ 7% per annum from the date of filing the present complaint till realization. The opposite parties are further directed to pay Rs. 5,500/- on the account of consolidated amount of compensation alongwith litigation expenses to the complainant. 

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

17. 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:

       5th Day of July, 2023

 

            (Jot Naranjan Singh Gill)

            President

 

(Urmila Kumari)

Member