Order by:

Aparana Kundi, Member

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that Sanjeev Kumar i.e. father of the complainant has availed ‘Family Health Optima Insurance-2017’, vide policy no.P/211222/01/2022/000152 for the period of 12.04.2021 to 12.04.2022 from the Opposite Parties. Prior to this policy, the father of the complainant has been purchasing the policies from the Opposite Parties for the last three years. On 19.02.2022, the complainant was plying Cricket and while playing cricket, he got injury on his knee. For treatment complainant booked appointment with doctor H.S. Ghuman at Jalandhar and he called him on 21.02.2022. The doctor examined complainant and he advised reconstruction of AVL (R) and also advised MRI to complainant. He also advised operation of knee to the complainant. Thereafter the complainant got MRI on 01.04.2022 from the Mann Health Care Pvt. Ltd. Hospital at Jalandhar and after that complainant was admitted in Spine & Ortho Care, Jalandhar for operation/surgery. The complainant undergone Upper Spinal Anaesthesia on 04.04.2022 and spent Rs.96,313/- for treatment. The complainant lodged claim with Opposite Parties No.1 & 2, through Opposite Party No.3. On 03.09.2022, Opposite Party No.2 demanded MRI report, OT note, self declaration and opinion of doctor from the complainant. The complainant submitted all the required documents, through Opposite Party No.3, but despite that on 18.10.2022, the Opposite Parties declined the claim for want of required documents. Alleged that the complainant somehow arranged the amount of Rs.96,313/- and got deposited the said amount in the hospital. Thereafter the complainant handed over all the documents to the office of Opposite Parties as per their requirement, but the Opposite Parties have not paid the said amount to the complainant. On 26.12.2023, the complainant issued a registered AD notice to the Opposite Parties, but to no effect. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay Rs.96,313/- as hospital charges.

b)      To pay an amount of Rs.1,00,000/- as compensation for mental tension and harassment.

c)       To pay an amount of Rs.50,000/- as litigation expenses.

d)      And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite Parties No.1 & 2 appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complaint is time barred; the present pre mature complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Parties as per policy terms and conditions. Averred that the present complaint pertains to insurance claim under ‘Family Health Optima Insurance Plan’ bearing No.P/211222/01/2022/000152 valid from 12.04.2021 to 11.04.2022 covering Sanjeev Kumar, Monika Rani, Neha and complainant himself for a sum of Rs 10,00,000/-. However it is submitted that the aforesaid insurance policy was issued to the insured by the answering Opposite Party subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of the contract. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Averred further that the insured submitted claim documents for reimbursement for the treatment of Right ACL Injury at Spine and Orthocare, Jalandhar on dated 04.04.2022 to 06.04.2022. On scrutiny of submitted documents, certain documents were necessary to process the claim, hence Opposite Parties asked the insured vide letters dated 03.09.2022, 18.09.2022 and 03.10.2022 to furnish the following documents:-

i.        Letter from the treating doctor stating the exact duration of symptoms and first consultation papers taken for the same.

ii.       The MRI report, OT notes for the procedure done.

iii.      Self declaration letter stating detailed circumstances of injury with date, time and place.

          The required documents were not provided despite queried. In the absence of above documents/details, Opposite Parties were not able to process the claim. As per Condition No.2 of the above policy, the insured person had to submit all the required documents and details called for by Opposite Parties. Hence, the claim was repudiated vide letter dated 18.10.2022. Averred further that the instant complaint is neither maintainable in law nor on facts; no deficient services have been rendered by the answering Opposite Parties as alleged by the complainant; the complaint being pre-mature and false is not maintainable; the complainant has not come with clean hands and has not disclosed the entire true facts; The complainant has suppressed the material facts from this Commission as well as from the Opposite Parties. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       Opposite Party No.3 appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complaint is not maintainable in this Commission; the complainant has got no locus-standi to file the present complaint against answering Opposite Party; the complaint is false, frivolous, baseless, vague and malicious. Averred that answering Opposite Party is the agent of Opposite Parties No.1 & 2, through answering Opposite Party, father of the complainant purchased the policy from Opposite Parties No.1 & 2. The complainant never handed over any document to Opposite Party No.3 for submission of hospital documents in the office of Opposite Parties No.1 & 2 and the story claimed by the complainant is false and frivolous one and answering Opposite Party has no role in any claim lodged by the policy holder. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

4.       In order to prove the case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C24.

5.       On the other hand, Opposite Parties No.1 & 2 have placed on record affidavit of Sh.Sumit Kumar, Authorized Signatory, Star Health & Allied Insurance Co. Ltd. Ex.OP1 & +2/A alongwith copies of documents Ex.OP1, 2/1 to Ex.OP1, 2/11. Whereas, Opposite Party No.3 has placed on record his affidavit as Ex.OP3/1.

6.         We have heard the ld. counsel for both the parties and also gone through the record.

7.       It is well proved on record that the complainant is the holder of Insurance policy namely “Family Health Optima Insurance Plan” having no.P/211222/01/2022/000152 for the period 12.04.2021 to 11.04.2022 covering himself and his family members. It is also proved on record that during the policy coverage, the complainant suffered knee injury (Sports Injury) on 19.02.2022, while playing cricket and thereafter consulted Dr.H.S.Ghuman on 21.02.2022, who suggested surgery to the complainant, the consultation slip is already placed on file as Ex.C4. On 04.04.2022, complainant got admitted in Spine and Ortho Care, Hospital, Jalandhar for the treatment/operation of ‘Right ACL Injury’ and after treatment got discharged on 06.04.2022. After getting discharged from the hospital the complainant lodged the claim with the Opposite Parties for the reimbursement of expenses incurred on the treatment, which was rejected by the Opposite Parties vide letter dated 18.10.2022 placed on record as Ex.OP1,2/11.

8.       The main objection raised by the Opposite Parties No.1 & 2 in the written reply is that the complaint is time barred, but the objection raised by the Opposite Parties No.1 & 2 is not genuine, as the complaint was filed before this Commission on 03.04.2024 and the treatment in question was taken by the complainant on 04.04.2024. Moreover, the Opposite Parties rejected the claim of the complainant vide letter dated 18.10.2022, so the actual cause of action accrued to the complainant on 18.10.2022. Hence, the present complaint is not time barred.  

9.       The Opposite Parties rejected the claim of the complainant vide letter dated 18.10.2022, the contents of letter are reproduced as follows:-

“Please refer to our letter dated 03-Sep-2022, 18-Sep-2022 and 03-Oct-2022, advising you to send us the following documents to further process your claim:-

10.     The perusal of the abovesaid rejection letter reveals that the Opposite Parties rejected the claim of the complainant for want of some documents. On scrutiny of documents placed on record, we found that all the documents demanded by the Opposite Parties from the complainant are placed on file and were sent to the Opposite Parties at the time of issuing notice also. It means that they already got all the documents during the pendency of this complaint, but still never tried to settle the claim.  Further, in case, if the complainant has failed to submit aforesaid documents, the Opposite Parties can procure the said documents from the hospital concerned at their own, but the Opposite Parties failed to do so and have not placed on record any documents showing that they ever approached the hospital concerned for getting the aforesaid documents.

11.     Vide instant complaint, the complainant claimed the amount of Rs.96,313/- i.e. expenses incurred upon the treatment and said amount has duly been proved on record vide Ex.C11 to C21.

12.     In view of the discussion above, we allow the complaint of the complainant in part and direct the Opposite Parties to pay an amount of Rs.96,313/-(Rupees Ninety Six Thousand Three Hundred Thirteen only) to complainant. Opposite Parties are further directed to pay Rs.3000/-(Rupees Three Thousand only) to be paid to the complainant on account of litigation expenses. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 30 days from the date of receipt of copy of this order, failing which, the Opposite Parties are burdened with additional amount of Rs.5000/-(Rupees Five Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission