Haryana

Karnal

CC/330/2022

Harsh Lata - Complainant(s)

Versus

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

Kanav Deep Singh

13 Mar 2024

ORDER

BEFORE THE PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION KARNAL.

 

                                                Complaint No.330 of 2022

                                                Date of Inst: 10.06.2022

                                                Date of Decision: 13.03.2024

 

Harsh Lata aged about 74 years wife of Shri Pawan Kumar Gupta, resident of H.No.831, Near Tagore School, Sector-6, Urban Estate, Karnal.

…….  Complainant

Versus

 

Star Health and Allied Insurance Company Limited, SCO No.137 2^nd Floor, Sector-13, U.E., Karnal, through its authorized signatory/person.

                                                                 …… Opposite party.

 

Complaint Under Section 35 of Consumer Protection Act, 2019 as amdned upto date.

 

Before:    Shri Jaswant Singh…………President

                Sh.Vineet Kaushik……….Member

                Dr.Suman Singth…………Member

 

Argued by: Shri Kanavdeep Singh, counsel for complainant.

                 Shri Mohit Goyal, counsel for OP.

 

                (Jaswant Singh President)

 

ORDER:

                The complainant has filed the present complaint under Section 35 of Consumer Protection Act, 2019 against the Opposite party (hereinafter referred as the ‘OP’) on the averments that complainant’s husband has purchased a health insurance policy cover for himself and his family member vide policy No.P/900000/ 01/2022/00000039, valid from 07.07.2021 to 06.07.2022, after paying premium amount to the OP. During subsistence of the said policy, complainant got admitted in Virk Hospital, Karnal on 15.01.2022 suffering from deficiency in breathing and nasal obstruction due to which she was treated in hospital by Dr.Abhinav Bansal and was discharged on 18.01.2022. A total sum of Rs.52,469/- was spent on her treatment including hospital charges and Medical charges. Treatment of Septal Abscess was duly informed but instead of clearing the claim of complainant, the OP has repudiated the aforesaid claim on the ground of some tempering noted. The repudiation of claim of complainant by the OP is totally illegal and unjustified. Hence, the present complaint.

2.             On notice, OP appeared and filed its written version and raised preliminary objections regarding maintainability, etc. On merits, it is pleaded that OP issued Star Group Health Insurance Policy for the period from 08.07.2021 to 06.07.2022 covering Pawan Kumar Gupta and Harsh Lata for sum of Rs.5,00,000/-. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant alongwith the policy schedule. It is submitted that the policy is contractual in nature and claims arising therein are subject to terms and conditions forming part of the policy. The complainant has accepted the policy and is fully aware of the terms and conditions and executed the proposal form. The claim was reported on the above said policy. On scrutiny of claim documents, it was observed that submitted indoor case records have multiple tampering, thus discrepancy is noted which amounts to misrepresentation of facts. Thus, the claim was rightly repudiated vide letter dated 24.03.2022. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for complainant has tendered into evidence her affidavit Ex.CW1/A, copy of insurance policy Ex.C1, copy of receipt Ex.C2, copy of policy Ex.C3, copy of claim form Ex.C4, copy of guidance for filing claim Ex.C5, copy of Aadhar Card Ex.C6 and Ex.C7, copies of Identity Cards Ex.C8 and Ex.C9, copies of receipt of Virk Hospital Ex.C10 to Ex.C12, copies of GST invoice Ex.C13 to Ex.C20, copies of booking slip Ex.C21 to Ex.C24, copy of OPD procedure Ex.C25, copy of insurance Ex.C26, copy of discharge summary Ex.C27, copies of prescription slip Ex.C28 and Ex.C29, copies of test  prescription Ex.C30 to Ex.C31, copy of prescription slip Ex.C32, copies of test report Ex.C33 and Ex.C34, copies of medicine requisition slip Ex.C35 to Ex.C43, copy of mail Ex.C44, copy of application for claim Ex.C45, copy of sub total of all bills Ex.C46 and copy of certificate Ex.C47 and closed the evidence on 17.11.2022 by suffering separate statement.

5.             Learned counsel for OP tendered into evidence affidavit of Shri P.C.Tripathy, Zonal Manager as Ex.OPW1/A, copy of policy Ex.OP1, copy of terms and conditions Ex.OP2, copy of proposal form Ex.OP3, copy of portability form Ex.OP4, copy of claim form Ex.OP5, copy of discharge summary Ex.OP6, copy of bill Ex.OP7, copy of patient history Ex.OP8, copy of repudiation letter Ex.OP9, copy of bill assessment Ex.OP10 and closed the evidence on 20.07.2023 by suffering separate statement.

6.             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.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that husband of complainant purchased a health insurance policy for himself and his family member. During subsistence of the said policy, the complainant became ill and was admitted in Virk Hospital, Karnal on 15.01.2022 and was discharged on 18.01.2022 and spent a sum of Rs.52,469/- towards treatment etc. Thereafter, complainant lodged her claim with the OP for payment of said amount but the OP has repudiated the genuine claim of the complainant without any reason. The act of OP amounts to deficiency in service and unfair trade practice 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 claim of the complainant has been rightly repudiated because there were multiple tampering in the indoor case records and lastly prayed for dismissal of complaint.

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

10.           Admittedly, husband of complainant purchased Health insurance policy from the OP. It is also admitted that during the subsistence of the insurance policy, complainant remained admitted in Virk Hospital, Karnal and after getting discharged from the hospital, she submitted her claim for reimbursement to the OP.

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.OP9 dated 24.03.2022 on the ground, which is reproduced as under:-

“We have processed the claim records relating to the above insured patient seeking reimbursement of hospitalization expenses for treatment of septal abscess.

It is observed from the submitted indoor case records that there is multiple tampering noted. Thus there is discrepancy noted which amounts to misrepresentation of facts

As per terms and conditions of the policy issued to you, if there is any discrepancy of records amounting to misrepresentation of facts, whether by insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim.

We are therefore, unable to settle your cliam under the above policy and we hereby repudiate your claim.

12.           The claim of the complainant has been repudiated by the OP on the abovementioned ground.

13.           The onus to prove its version was relied upon the OP but OP has miserably failed to prove its version by leading any cogent and convincing evidence. The OP has failed to explain that what tampering was found in the indoor case record. Furthermore, if there is any discrepancy in the case record, it is on the part of the hospital and not on the part of the complainant. Regarding the discrepancy if any, in the hospital record, the OP can verify from the hospital by appointing its investigator but OP did not do so. How, can the complainant suffer due to the fault of the hospital. The grounds taken in the repudiation letter by the OP are based upon the presumption and assumption and are not justified in the eyes of law. It seems that only in order to deprive the complainant from her genuine claim, the OP has repudiated the claim of the complainant on the basis of unreasonable ground.  

14. 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.

 

 15.          Keeping in view the ratio of the law laid down in the abovesaid judgment, facts and circumstances of the complaint, we are of the considered view that act of the OP amounts to deficiency in service and unfair trade practice. 

16.           The complainant has alleged that she has spent Rs.52,469/- on her treatment and this fact is proved from the medical bills Ex.C10 to Ex.C25. On the other hand, as per policy terms and conditions, vide document Ex.OP10, the OP after applying the deductions, has assessed the net amount payable to the complainant is Rs.46,503/-. Hence the complainant is entitled for Rs.46,503/- only alongwith interest, compensation and litigation expenses etc.

17            Thus, as a sequel to abovesaid discussion, we partly allow the present complaint and direct the OP to pay Rs.46,503/-  (Rs. Fourty six thousand five hundred and three only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of claim (i.e. 24.03.2022) till its realization. We further direct the OP to pay Rs.20,000/- 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.

Dated:13.03.2024                                                             

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Suman Singh)

                           Member                          Member