Haryana

Karnal

CC/557/2021

Sagar Kamboj - Complainant(s)

Versus

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

Pardeep Kamboj

08 Sep 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                      Complaint No. 557 of 2021

                                                      Date of instt.05.10.2021

                                                      Date of Decision:08.09.2023

 

Sagar Kamboj son of Shri Surinder Singh, resident of house no.668, sector-16, Urban Estate, Karnal.

                                               …….Complainant.

                                              Versus

 

1. Star Health and Allied insurance Company Limited, Branch office Karnal II, SCF-137, Second floor, above, ICICI Bank Sector-13, Karnal through its Branch Manager.

 

2. Star Health and Allied insurance Company Limited, registered and Corporate 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.

 

Before   Shri Jaswant Singh……President.

              Shri Vineet Kaushik…….Member

              Dr. Rekha Chaudhary……Member

          

Argued by:  Shri Pardeep Kamboj, counsel for the complainant.

                    Shri Mohit Goyal, counsel for the OPs.

 

                    (Jaswant Singh, President)

ORDER:                     

          

                 The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant purchased a Corona Rakshak Policy from the OPs, for the sum assured of Rs.2,50,000/-, vide policy certificate no.P/211130/01/2021/005069. The said policy was commencing from 31.03.2021 to 14.07.2021. The complainant has paid the premium of Rs.4538/-. On 18.06.2021, complainant fell ill and thereafter  complainant got conducted the Covid-19 test from through RTPCR Kalpaa Chawla Government Medical College, Hospital, Karnal and doctors of Kalpana Chawla Government Medical College, Hospital Karnal issued the covid-19 test report dated 19.06.2021 as positive. After receiving the Covid-19 report he family member of the complainant got him admitted in Amritdhara Hospital, Chaura Bazar, Karnal on 20.06.2021 where the complainant was treated by Dr. A.K. Kohli and he remained under his observation from 20.06.2021 to 23.06.2021. The complainant has paid Rs.42,350/- to the said hospital. After discharge from the hospital, complainant approached the OPs and submitted all the relevant documents including original insurance policy, medical bills, test etc. After submitting the relevant documents, complainant contacted 3-4 times with the OPs and requested to pay the claim amount under the abovesaid policy but OPs did not pay the same  and lingered the matter on one pretext or the other and lastly repudiated the claim of the complainant, vide its letter dated 21.09.2021 on the ground that as per available record, there are multiple discrepancies in the record which amounts to misrepresentation of facts. The repudiation of the claim of complainant by the OPs is totally illegal and unlawful because there were no discrepancies. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence this complaint.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability and concealment of true and material facts. On merit, it is pleaded that OPs issued a Corona Rakshak Insurance Plan, vide policy no.P/211130/01/2021/005069 for the period from 31.03.2021 to 14.07.2021 covering Mr. Sagar Kamboj for the sum insured of Rs.2,50,000/-. 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 further pleaded that t he claim was reported on the abovesaid policy was registered as claim no.CIR/2022/211130/2856070 in regard to hospitalization of insured patient Sagar Kamboj at Amirdhara Hospital Private Limited-Karnal on 20.06.2021 for treatment of Covid-19. The insured submitted claim documents for reimbursement. On perusal of claim documents, it is observed that:- As per the investigation report dated 19.06.2021, the insured is covid-19 positive. It is observed from the submitted medical records that the indoor case records are in stereotyped. Also SPO2 level dropped as per the ICP, but there is no details of O2 supply in indoor case record and in final bill. Thus, there is discrepancy in the records which amounts to misrepresentation of facts. As per terms and conditions, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim. Hence, the claim was repudiated and communicated to the insured, vide letter dated 21.09.2021. The insured sent us a representation on 28.09.2021, in response to our letter dated 21.09.2021 seeking re-consideration of your claim. The medical team has perused representation and has noted the contents therein. The team which re-examined the claim records has observed that the indoor case records are in stereotyped. Also SPO2 level dropped as per the ICP, but there is no details of O2 supply in indoor case record and in final bill. Thus, there is discrepancy in the records which amounts to misrepresentation of facts. The OPs are unable to consider the representation of complainant and informed the inured/complainant, vide letter dated 09.10.2021 that repudiation of claim is in order. There is no deficiency in service on the part of the OPs. 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.             Complainant has tendered into evidence his affidavit Ex.CW1/A, copy of collection receipt Ex.C1, copy of certificate of insurance Ex.C2, copy of diagnosis of treatment Ex.C3, copy of covid-19 test report Ex.C4, copy of RTCPR report Ex.C5, copy of admission and discharge record Ex.C6, copy of sheet I Ex.C7 to Ex.C9, copy of TPR chart Ex.C10 and Ex.C11, copy of summary sheet Ex.C12, copy o test report Ex.C13, copy of final fill Ex.C14, copy of test name Ex.C15, copy of covid-19 test report Ex.C16, copy of discharge summary Ex.C17, copy of claim receiving receipt Ex.C18, copy of emails Ex.C19 to Ex.C24, copy of repudiation letter Ex.C25, copy of aadhar card of complainant Ex.C26 and closed the evidence on 16.06.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Sumit Kumar Sharma Ex.OPW1/A, copy of Corona Rakshak policy Ex.OP1, copy of terms and conditions of the policy Ex.OP2, copy of proposal form Ex.OP3, copy of Field Visit Report Ex.OP4, copy of claim form Ex.OP5, copy of discharge summary Ex.OP6 and Ex.OP7, copy of final bill dated 23.06.2021 Ex.OP8, copy of repudiation letter dated 21.09.2021 Ex.OP9, copy of repudiation letter dated 09.10.2020 Ex.OP10 and closed the evidence on 13.07.2023 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 the complainant, while reiterating the contents of the complaint, has vehemently argued that complainant had purchased a Corona Rakshak Policy from the OPs. The complainant suffered from Covid-19 and due to that on 20.06.2021, he was admitted in Amritdhara Hospital, Karnal and discharged on 23.06.2021. Intimation was given to the OPs. After getting discharge from the hospital, complainant submitted the necessary documents for getting the benefit of abovesaid policy, but vide letter dated 21.09.2021, the claim of the complainant has  been rejected/repudiated by the OPs on the false and frivolous ground and lastly prayed for allowing the complaint. Complainant relied upon the case law titled as Future Generali Insurance Co. Ltd. Versus Ashishbhai Satishchandra Dave in first appeal no.139 of 2022, decided on 03.03.2022 of Hon’ble State Commission, Ahmedabad.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that the complainant was admitted at Amritdhara Hospital Private Limited-Karnal on 20.06.2021 for the treatment of covid-19 positive. On scrutiny of the documents, it is observed that there was discrepancy in the records which amounts to misrepresentation of facts. As per terms and conditions of the policy, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make the payment in respect of any claim. Thus, the claim of complainant was rightly repudiated by the OPs, vide letter dated 21.09.2021 and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, complainant purchased a Corona Rakshak Policy from the OPs. It is also admitted that during the subsistence of the insurance policy complainant was hospitalized in Amritdhara Hospital due to covid-19. It is also admitted that the sum insured under the policy is Rs.2,50,000/-.

11.           The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.C25/Ex.OP9 dated 21.09.2021 on the ground, which is reproduced as under:-

“It is observed from the submitted medical records that the indoor case records are in stereotyped. Also, SPO2 level dropped, but there is no detail of O2 supply in indoor case record. Thus, there is discrepancy in the records which amount to misrepresentation of facts.

As per terms and conditions of the policy issued to you, if there is any misrepresentation whether by the 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 claim under the abovesaid policy and we hereby repudiate your claim”.

12.           The claim of the complainant has been denied by the OPs on the ground of multiple discrepancies in the records. The onus to prove its version was relied upon the OPs but OPs have miserably failed to prove the same by leading any cogent and convincing evidence. Rather as per discharge summary Ex.C17/Ex.OP6 complainant was hospitalized on 20.06.2021 and discharged on 23.06.2021 for the treatment of Covid-19 positive, fever, cough, dyspnoea, sore throat and weakness. Further, if there are any discrepancies in the record on the hands of the treating doctor for that complainant cannot be blamed. Thus, it is well proved on record complainant had suffered from Covid-19. Hence, the repudiation of the claim of complainant is unjustified and not tenable in the eyes of law. Moreover, nowadays, it has become the routine practice of the insurance companies to reject the genuine claim on minor technicality.  Hence, the repudiation of the claim of complainant is unjustified, arbitrary and not tenable 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 judgment, facts and circumstances of the present complaint, we are of the considered view that act of the OPs amounts to deficiency in service and unfair trade practice while repudiating the claim of the complainant, which is otherwise proved genuine.

15.           As per Corona Rakshak Policy Ex.C2/Ex.OP1 dated 31.03.2021, the insured amount is of Rs.2,50,000/-. 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 OPs to pay Rs.2,50,000/- (Rs.two lakhs fifty thousand) as sum insured to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.5500/- 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:08.09.2023      

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)

                          Member                      Member