Haryana

Karnal

CC/429/2020

Randhir Singh - Complainant(s)

Versus

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

Vinod Sharma

28 Feb 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                       Complaint No. 429 of 2020

                                                        Date of instt.14.10.2020

                                                        Date of Decision:28.02.2022

 

Randhir Singh son of Shri Krishan Chand resident of village and Post office Parwala, District Karnal.

 

                                               …….Complainant.

                                              Versus

 

Star Health and Allied Insurance Company Limited, SCO 104 (1st floor), Mugal canal, Sector 13 Extension, Sector 13, Karnal through its Branch Manager.

                                                                      …..Opposite Party.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

              Dr. Rekha Chaudhary…..Member

 

 Argued by: Shri Vinod Sharma, counsel for complainant.

Shri Naveen Khetarpal, 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 to as ‘OP’) on the averments that complainant purchased a Health Policy namely “Family Health Optima Insurance Plan” from the OP, vide policy no.P/211114/01/2016/001758, valid from 03.09.2015 to 02.09.2016 and said insurance plan covered the complainant himself, his wife Saroj Bala, his sons namely Akshay Lather and Anurag Lather. The complainant paid a sum of Rs.11,766/- including service Tax of Rs.1446/- to the OP  and policy was issued in the name of complainant. The said policy was got renewed by the complainant from time to time and in the year 2019, the said policy was renewed by the OP, vide Renewal Endorsement no.P/211114/01/2020/005711, valid from 05.09.2019 to 04.09.2020, for which, complainant paid the premium of Rs.20077/-During the subsistence of the said policy, the son of complainant namely Akshay Lather started suffering from respiratory/breathing problem as he started facing difficulty in breathing and at that time, the son of complainant was in U.S.A. and he told the complainant in this regard. Complainant asked his son to come to India and he came to India in the month of September, 2019. Thereafter, complainant got his son examined from a local doctor, but treatment given by said doctor did not provide any relief to the son of complainant. Thereafter, complainant took his son to Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi and got him examined there and after examining the son of the complainant, the attending doctors diagnosed the disease as “Saddle Nose Deformity with retracted columella. Ant Rhinoscopy-Right DNS with Bilateral ITH”. The doctors advised surgery for the abovesaid disease. It is further averred that before admission, complainant told the officials/doctors of the said hospital that his son is insured with OP under the abovesaid policy and thereafter, OP was informed regarding the operation because it was a cashless policy and the entire expenditure of the treatment was to be borne by the OP. However, vide letter dated 29.10.2019, the OP rejected the claim of the complainant for cashless treatment on the ground that “the insured patient has been admitted for Septorhinoplasty/Septal framework surgery/cosmetic surgery. Expenses for this are not admissible in accordance with exclusion no.4.24 of the policy”.

2.             It is further averred that since the condition of the son of complainant was deteriorating and therefore, complainant decided to get his son operated in the said hospital at his own expenses and thus his son was admitted in the abovesaid hospital on 01.11.2019 and surgery was operated upon the son of complainant and he was discharged from the hospital on 04.11.2019. The complainant paid a sum of Rs.3,00,000/- approximately towards the treatment of his son. Thereafter, complainant requested the OP so many times for reimbursement of the said amount but OP refused to pay the same and repudiated the claim of the complainant, vide letter dated 29.10.2019 on the ground that the insured patient has been admitted for cosmetic surgery. The rejection of the claim of complainant by OP is totally unjustified because the complainant had approached in the abovesaid hospital for the treatment of severe breathing problem being suffered by his son and this fact is well mentioned in the discharge summary issued by the doctors. The son of the complainant was diagnosed as “DNS with B/L ITH”. The son of complainant was suffering from Deviated Nasal Septum(DNS) and the patient suffering from this disease will face difficulty in breathing and other symptoms are sleep Apnea, Snoring, Repetitive sneezing, facial pain, nosebleeds, mouth breathing, difficulty with breathing and mild to severe loss of the ability to smell. A deviated septum is an abnormal condition in which the top of the cartilaginous ridge leans to the left or the right, causing obstruction of the affected nasal passage. The condition can result in poor drainage of the sinuses. The patient can also complain of difficulty breathing, headaches, bloody noses, or of sleeping disorders such as snoring or sleep apnea. The treatment for the said disease is only the surgery and during the said surgery, the nasal septum is straightened and the surgeon moves the septum to a normal position and in some cases, the surgeon also will reshape the external appearance of the nose and in this way, the entire procedure/surgery which was done by the doctors was for the treatment of the abovesaid severe disease being suffered by the son of complainant, however, the OP intentionally and deliberately rejected the cashless treatment of the son of complainant, compelling the complainant to bear the treatment of operation at this own expenses. Moreover, there was no exclusion clauses regarding the abovesaid surgery in the policy documents handed over to the complainant by the OP. In this way there was deficiency in service on the part of the OP. Hence complainant filed the present complaint, seeking direction to the OP/insurance company to pay Rs.3,00,000/-alongwith interest @ 18% per annum and also to pay a sum of Rs.2,00,000/- as compensation for mental agony and Rs.55,000/- as litigation costs.

3.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; limitation and concealment of true and material facts. On merits, it is pleaded that the insured availed “Family Health Optima Insurance policy” covering Mr. Ranbir Singh-self and Saroj Bala-spouse, Akshay Lather and Anurag Lather sons for the sum insured of Rs.5,00,000/-, vide policy no.P/211114/01/2020/005711 for the period from 05.09.2019 to 04.09.2020. It is further pleaded that 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 policy schedule. It is further pleaded that in the 5^th year of the policy, the complainant has submitted pre authorization claiming Rs.1,98,200/- on 29.10.2019, towards hospitalization of Mr. Akshay Lather from Sir Ganga Ram Hospital-Delhi for date of admission 01.11.2019 for the treatment of DNS RT ITH with the complaints of Nasal Obstruction and advised to undergo Septal Framework surgery. As per pre authorization form and consultation slip dated 29.10.2019, it is noted that the insured patient has been admitted for septorhinoplasty/septal framework surgery/cosmetic surgery. The abovementioned ailment, it is noted that expenses for this treatment are not admissible in accordance with exclusion no.4.24 of the policy.

As per the exclusion no.4.24, all types of cosmetic, Aesthetic treatment of any description, all treatment for erectile dysfunctions, change of sex.

Hence, the cashless claim for medical expenses was rejected and communicated to the treating hospital as well as the insured, vide letter dated 29.10.2020. The claim was rejected at the level of pre authorization and the insured has not come for reimbursement. It is further pleaded that as per the complainant, he spent an amount of Rs.3,00,000/- on the treatment of his son but he has not submitted any bills for reimbursement. There is no deficiency in service on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

4.             Parties then led their respective evidence.

5.             Complainant has tendered into evidence his affidavit Ex.CW1/A, insurance policy Ex.C1, repudiation letter dated 29.10.2019 Ex.C2, claim form Ex.C3, discharge summary Ex.C4, medical bills Ex.C5 to Ex.C7, Aadhar card of complainant Ex.C8 and closed the evidence on 04.08.2021 by suffering separate statement.

6.             On the other hand, OP has tendered into evidence affidavit of P.C.Tripathy Ex.RW1/A, terms and conditions of the insurance policy Ex.R1, insurance policy Ex.R2, proposal form Ex.R3, letter of insured regarding renewal of health policy Ex.R3/A, request for cashless Ex.R4, treatment slip Ex.R5, rejection for cashless Ex.R6 and Ex.R6/A and closed the evidence on 03.11.2021 by suffering separate statement.

7.             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.

8.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that complainant purchased a medical insurance policy from the OP, which was got renewed every year, continuously since 2015 to 2020. He further argued that son of complainant was suffering from respiratory/breathing problem and he was admitted in Sir Ganga Ram Hospital New Delhi, for which doctor’s diagnoses the disease and operation was conducted in the said said hospital. The complainant prior to admission intimated the OP regarding the operation and for the cashless claim for approval to the OP but OP rejected the claim of the complainant for cashless treatment. Complainant spent a sum of Rs.3,00,000/-on the treatment of his son. Complainant submitted the claim with the OP for reimbursement of the amount but OP did not pay the claim and lingered the matter on one pretext or the other and lastly repudiated the claim of complainant on the false and frivolous ground. Hence prayed for allowing the complaint.

9.             Per contra, learned counsel for OP, while reiterating the contents of the written version, has vehemently argued that the insured patient has been admitted for septorhinoplasty/septal framework surgery/cosmetic surgery. The said ailment is not admissible, in accordance with exclusion no.4.24 of the policy.  As per the exclusion n.24, all types of cosmetic, Aesthetic treatment of any description, all treatment for erectile dysfunctions, change of sex. Hence, the cashless claim for medical expenses was rejected and communicated to the treating hospital as well as the insured, vide letter dated 29.10.2020. Hence, prayed for dismissal of the complaint.

10.           Admittedly, the complainant has purchased a Health Policy from OPs. It is also admitted that the said policy covered the complainant himself, his wife Saroj Bala and sons Akashay Lather and Anurag Lather. It is also admitted that son of complainant namely Akshay Lather had taken treatment from Sir Ganga Ram hospital, New Delhi during the subsistence of the insurance policy.  It is also admitted that the sum insured of the policy in question of Rs.five lakhs.

11.           The claim of the complainant has been repudiated by the OP, vide letter Ex.R6/Ex.C2 dated 29.10.2019 on the following ground:-

        “the insured patient has been admitted for septorthinoplasty/septal framework surgery/cosmetic surgery. Expenses for this treatment are not admissible in according with exclusion no.4.24 of the policy”.

 

12.           The claim of the complainant has been repudiated by the OP on the ground that son of complainant had taken the treatment for septorthinoplasty/septal framework surgery/cosmetic surgery. The said disease is not admissible in accordance with exclusion no.4.24 of the policy. As per the exclusion no.24, all types of cosmetic, Aesthetic treatment of any description, all treatment for erectile dysfunctions, change of sex. Hence the claim of the complainant has been rightly repudiated.  The onus to prove its version lies upon the OP but OP has failed to prove its version by leading any cogent and convincing evidence. No treatment record has been placed on file by the OP to prove that son of complainant has taken treatment for septorthinoplasty/septal framework surgery/cosmetic surgery.

13.           On the other hand, as per version of the complainant that his son was suffering from respiratory/breathing problem. To prove his stand complainant has placed on file discharge summary Ex.C4 wherein it is clearly mentioned that “the patient complained of Nasal Blockage in both Nostril, Insidous in onset, gradually progressive, more on lying down. Associate with post Nasal Discharge. No associated fever, headache”. Hence, the plea taken by the OP with regard to that the son of complainant has taken treatment for cosmetic surgery has no force.

14. Further,Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others (2008) 151 PLR 313, 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.           The above said authorities are also fully applicable in the present complaint. In the present complaint also, the OP has not placed on record any treatment record of son of complainant regarding receiving treatment of cosmetic surgery, rather it is proved on record that the son of complainant has taken treatment for Nasal Blockage in both Nostril. So, the OP has wrongly, illegally and arbitrarily repudiated the claim of the complainant.

16.           As per version of the complainant, he has spent Rs.3,00,000/- on the treatment of his son but he has placed on record bill Ex.C6 of Rs.1,85,895/- Hence, complainant is entitled to the above said amount of Rs.185,895/- alongwith compensation and litigation expenses.

17.           In view of above discussion, we allow this complaint and direct the OP to pay claim amount of Rs.1,85,895/- (one lakh eighty five thousand eight hundred ninety five only) to the complainant alongwith interest @9% per annum from the date of repudiation of the claim till its realization. We further direct the OP to pay a sum of Rs.20,000/- as compensation for harassment and mental agony suffered by her and also to pay a sum of Rs.11,000/- as litigation expenses to the complainant. This order shall be complied with within 45 days from the date of 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:28.02.2022

                                                                       

                                                                  President,

                                                       District Consumer Disputes

                                                       Redressal Commission, Karnal.

 

 

              (Vineet Kaushik)             (Dr. Rekha Chaudhary)

                     Member                                Member