Haryana

Karnal

CC/190/2020

Sewa Singh - Complainant(s)

Versus

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

Kunal Chopra

03 Jul 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                          Complaint No.190 of 2020

                                                          Date of instt.28.05.2020

                                                          Date of Decision 03.07.2023

 

Sewa Singh son of Ajit Singh, resident of village and post office Sounkra opposite Ratan Giri Mandir, tehsil Nilokheri, District Karnal and shop no.155, New Grain Market, Taraori, District Karnal (Aadhar card no.647014172557). Phone no.999608000.

 

                                                 …….Complainant.

 

                                              Versus

 

Star Health and Allied Insurance Co. Ltd. Branch office at SCF-137, Sector 13, Urban Estate, near ICICI Bank, Karnal.

 

                                                                     …..Opposite Party.

 

Complaint under Section 12 of the Consumer Protection Act, 1986 as amended under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

   

 

 Argued by: Shri Balwan Singh, counsel for complainant.

                    Shri A.K. Vohra counsel for the opposite party.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant purchased a star health insurance policy bearing no.P/21114/01/2016/001695 from OP on 31.08.2015 having insurable interest of Rs.5 lakhs. Said policy also covers the wife and child of complainant namely Paramjeet Kaur and Gurjant Singh respectively. The complainant has been regularly getting it renewed by paying the premium of same and that policy is now valid upto 31.08.2020. The said policy covers all the risk factor of his and his family members. The wife of complainant has suffered Osteoarthritis B/L knees and was facing huge problem in walking and sitting etc. The complainant took her to Healing Touch Super Specialty Hospital, Ambala, for her treatment and doctor after examination advised for total knee replacement and as such she was admitted in the hospital on 09.10.2018 and discharged on 15.10.2018. During this period her both knees were replaced. The complainant spent an amount of Rs.96856/- on treatment of his wife and thereafter the complainant lodged a claim with OP for the reimbursement of the abovesaid amount. OP got completed certain formalities from complainant and also took original bills and other documents and assured that the aforesaid amount would be reimbursed to the complainant very soon. Vide letter dated 23.12.2018, OP instructed the complainant to provide some more documents and details of Paramjit Kaur which were duly given to OP and after that OP again assured to the complainant that OP will reimburse the said amount within a period of one month but now more than 15 months have been passed but OP has not paid the said amount. Complainant approached the OP so many times and requested to reimburse the abovesaid amount but OP did not pay any heed to the request of complainant and lingered the matter on one pretext or the other. Then complainant sent a legal notice dated 07.03.2020 to the OP but it also did not yield any result. 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; premature; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the insured availed Family Health Optima Insurance Plan covering Mr. Sewa Singh-self, Mrs. Paramjeet Kaur-spouse for the sum insured of Rs.5,00,000/-. The insured approached for cashless treatment and subsequently submitted claim documents for reimbursement of medical expense. On scrutiny of the claim documents, it is observed that as per the discharge summary the insured patient is diagnosed as rheumatoid arthritis and has a past history of HTN/RA/Post Hysterectomy and as per the consultation report dated 25.09.2017 the insured patient has complaints of pain in bilateral knees and hands for the past one year. It is further pleaded that OP made requests to the complainant, vide letter dated 23.11.2018, 08.12.2018, 23.12.2018 and 07.01.2019 to furnish the previous hospitalization documents, all previous consultation reports, investigation reports and treatment details/follow up details of rheumatoid arthritis and pain bilateral knees and hands. As per condition no.3 of the policy, the complainant has to submit all the required documents and details called for by the OP. The complainant is bound to supply the said information as the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. On non-supply the required documents the claim of the complainant was repudiated, vide speaking letter dated 14.08.2019 and further complainant was suggested that if he wish to pursue the matter further, he may represent to the office of the Insurance Ombudsman, Chandigarh. It is further pleaded that the insured preferred claims in the 4^th year of the policy and it is necessary to mention here that previously cashless claim no.CLI/2019/211114/0125807 settled on the basis of 2018 policy for incision Hernia to Paramjeet Kaur and had paid a sum of Rs.3,98,002/- as per terms and conditions of the policy. It is denied for want of knowledge regarding wife of complainant suffered from Osteoarthritis B/L knees and was facing huge problem in walking and sitting etc. It is wrong to allege that the complainant took her to Healing Touch Super Specialty Hospital, Ambala for her treatment. There is no deficiency in service and unfair trade practice on the part of the OP. 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 the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of Aadhar card Ex.C1, copy of legal notice Ex.C2, AD Ex.C2/A, postal receipt Ex.C3, bill Ex.C4, insurance policies Ex.C5/1, Ex.C5, copy of authorization letter Ex.C6, copy of bill invoice Ex.C7, copy of bill Ex.C8, copy of discharge summary Ex.C9, copy of letter dated 23.12.2018 regarding requirements of additional documents Ex.C10, copy of payment receipt Ex.C11, copy of bills Ex.C12 and Ex.C13 and closed the evidence on 24.11.2021 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit Sumit Kumar Sharma, Senior Manager Ex.OP1/A, copy of family health optima policy Ex.O1, copy of policy schedule Ex.O2, copy of proposal form Ex.O3, copy of request letter for cashless Ex.O4, copy of query for pre-authorization Ex.O5, copy of letter for denial of pre-authorization Ex.O6, copy of letter dated 05.11.2018 Ex.O7, copy of discharge summary Ex.O8, copy of prescription slip Ex.O9, copy of bill invoice Ex.O10, copy of letter dated 23.11.2018 Ex.O11, copy of certificate of Healing Touch Hospital, Ambala Ex.O12, copy of repudiation letter dated 14.08.2019 Ex.O13 and closed the evidence on 18.11.2022 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 the complainant purchased a star health insurance policy from the OP on 31.08.2015.  Said policy also covers the wife and children of complainant. The complainant has been regularly renewing the said policy upto 31.08.2020. The wife of complainant has suffered knees problem and she got admitted in Healing Touch Super Specialty Hospital, Ambala, where both knees were replaced and complainant spent an amount of Rs.96856/- on the treatment of his wife. Complainant lodged a claim with OP but OP has repudiated the claim of the complainant, vide letter dated 23.12.2018 on the false and frivolous grounds 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 the insured availed Family Health Optima Insurance Plan. The insured approached for cashless treatment and subsequently submitted claim documents for reimbursement of medical expenses. On scrutiny of the claim documents, it was observed that the insured patient is diagnosed as rheumatoid arthritis and has a past history of HTN/RA/Post Hysterectomy. The insured patient has complaints of pain in bilateral knees and hands for the past one year. OP made requests to the complainant through various letters to furnish the previous hospitalization documents but complainant did not supply the same and due to non-supply of the documents, the claim of the complainant was repudiated, vide letter dated 14.08.2019 and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, complainant has availed Family Health Optima Insurance Plan from the OP. It is also admitted that during the subsistence of the insurance policy, the wife of complainant has taken a treatment in Healing Touch Super Specialty Hospital, Ambala.

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.O13 dated 14.08.2019 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 advanced osteoarthritis bilateral knee, hypertension, rheumatoid arthritis.

It is observed from the submitted discharge summary of the above hospital that the insured patient is diagnosed as rheumatoid arthritis and as per the consultation report dated 25.09.2017 the insured patient has complaints of pain bilateral knees and hands for the past 1 year. Hence, we requested the insured to furnish the previous hospitalization documents, all previous consultation reports, investigation reports and treatment details/follow up details of rheumatoid arthritis and pain bilateral knees and hands and the same has not been provided which amounts to non-submission of required documents.”

We note that the documents required by us are not submitted despite repeated requests. In the absence of the above documents, we are not able to process your claim further.

As per condition no.3 of the policy, the insured person has to submit all the required documents and details called for by us.

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

 

12.           In letter dated 23.11.2018 Ex.O11, OP has sought the following documents, which is reproduced as under:-

1.     As per submitted consultation dated 25.09.2017, patient complaint of pain bilateral knees and hands since one year, kindly provide all previous investigation, consultation and treatment done in one year prior to 25.09.2017.

2.     A letter from treating doctor stating duration of osteoarthritis and rheumatoid arthritis.

3.     First consultation paper when prheumatoid arthritis diagnosed with first positive investigation report for rheumatoid arthritis.

4.     x-ray, MRI report done.

5.     Pre anesthetic check record.

6.     Implant invoice.

7.     Discharge summary for hysterectomy done.

 For non submission of the abovesaid documents, OP has rejected the claim of the complainant.

13.           OP had asked the complainant to complete the abovesaid formalities. The most of the documents sought by the OPs are irrelevant and there is no legal hitch to decide the  claim without the submission of the pending documents, when the complainant had already submitted the required documents for settlement of the claim. Hence, the demand of abovementioned documents is unnecessary and irrelevant and just to harassing the complainant and denying the claim of the complainant. Moreover, it is also unbelievable that an insured whose personal interest is involved for such amount why he will not supply the documents to the insurance company for getting his claim amount and will indulge himself in unwanted litigation. Hence, in view of the above, we found no substance in this contention of the OP.

14.           The onus to prove its case was relied upon the OP, but OP has miserably failed to prove the same by leading any cogent and convincing evidence. The case of the OP is based upon the discharge summary Ex.O8, wherein in the column of past illness it is mentioned HTN/RA/Post hysterectomy (3 years back) posts Hernioplasty (June 2018).  The document Ex.O8 placed on record by the OP is a photocopy and the has failed to prove the said document either by examining concerned doctor or by tendering his affidavit in evidence. Thus, the said document has no weightage.

15.           In the present case, the insured patient has taken the treatment for knees replacement on 09.10.2018. The policy in question has been purchased in the year 2015. At the time of purchasing the policy, the wife of complainant was not suffering from any disease. Furthermore, if for the sake of arguments, it is presumed that complainant had taken the treatment of HTN/RA/Post hysterectomy, however, there is no nexus between the treatment taken by the insured patient and past treatment as alleged by the OP.

16.           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”.

 17.          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 OP while repudiating the claim of the complainant amounts to deficiency and unfair trade practice.

18.           The complainant has spent Rs.96856/-on the treatment of his wife and in this regard he has placed on file invoice/bill Ex.C7 and Ex.C8. The said bills have not been rebutted by the OP. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

19.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.96856/- (Rs. ninety six thousand eight hundred fifty six 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 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:03.07.2023         

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)       

                                Member