Haryana

Karnal

CC/671/2021

Sanjiv Kumar - Complainant(s)

Versus

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

Vinod Sharma

10 Aug 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                          Complaint No. 671 of 2021

                                                          Date of instt.01.12.2021

                                                          Date of Decision 10.08.2023

 

Sanjiv Kumar son of Shri Hari Singh, resident of village Badarpur, Tehsil Indri, District Karnal.

                                                 …….Complainant.

                                              Versus

 

Star Health and Allied Insurance Co. no.15, Sri Balaji Complex, 1^st floor, Whites Lane, Royapettah, Chennai-600014 through its Managing 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 Mohit Goyal, counsel for the 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 mediclaim policy namely ‘Corona Rakshak policy’ bearing no.P/211114/01/2021/012987, which was valid from 26.02.2021 to 10.06.2021 by paying premium of Rs.4538/-. Complainant started suffering from fever, chest pain, difficulty in breathing and the condition of the complainant started deteriorating and on examination, complainant has tested positive for covid-19 on 18.05.2021 and therefore, the complainant went to Amritdhara Hospital, Chaura Bazar, Karnal for treatment and was admitted in the said hospital on 19.05.2021. The complainant got treatment from the abovesaid hospital and ultimately, he recovered from his illness and was discharged from the hospital on 23.05.2021. After getting discharge from the hospital, complainant lodged his claim on 18.06.2021 alongwith all the relevant documents i.e. covid-19 report and treatment record with the OP for reimbursement of Rs.2,50,000/- but OP, vide letter dated 15.10.2021 repudiated the claim of the complainant 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 OP is highly illegal because there was no discrepancies in any document moreover, OP has not disclosed about the alleged discrepancies. Then complainant sent a legal notice dated 09.11.2021 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 and concealment of true and material facts. On merit, it is pleaded that OP issued a Family Health Optima Insurance Plan, vide policy no.P/211114/01/2021/012987 for the period 26.02.2021 to 16.06.2021, covering risk of Sanjeev Kumar the basic floater sum assured was 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. The insured patient was admitted at Amritdhara Hospital Private Limited Karnal on 19.05.2021 for the treatment of Covid-19. The insured submitted the claim for lumpsum benefit, on perusal of claim documents, it is observed that:-

.       “As per the discharge summary that the insured patient has Spo2 is mentioned as 84% temperature is 102F on 19.05.2021 at 1.06 p.m.

.       But as per initial assessment sheet Spo2 is 89% temperature mentioned as 101F.

.       Moreover, there are 2 copies of discharge summary (one at the time of reimbursement and 2^nd one at the time of query) for the same hospital and same hospitalization, in which one shows the vitals as temp 102 F and BP 110/80 and another discharge summary with admission shows vitals of temp 102 F and BP 90/60.

.       Further, the CT report dated 19.05.2021, taken at the time of admission shows 0 severity score and coards-1, (which clearly shows his vital are normal and the hospitalization is only for claim purpose). However, HRCT findings in the discharge summary shows 12/25”.

Based on these available records, there are multiple discrepancies in the records which amount to misrepresentation of facts. As per terms and conditions 3.5, 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. Therefore, OP was unable to settle the claim of complainant under the above policy and hereby repudiated his claim. The above decision has been taken as per the terms and conditions of the policy and based on the claim details/documents submitted. Hence, the claim was repudiated and communicated to the insured, vide letter dated 15.10.2021. 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.

3.             Parties then led their respective evidence.

4.             Complainant has tendered into evidence his affidavit Ex.CW1/A, copy of aadhar card Ex.C1, copy of legal notice Ex.C2, postal receipt Ex.C3, copy of Corona Rakshak policy Ex.C4, copy of repudiation letter Ex.C5, copy of claim receiving receipt Ex.C6, copy of RTPCR report Ex.C7, copy of terms and condition of the policy Ex.C8, copy of discharge summary Ex.C9, copy of final bill Ex.C10, copy of test report Ex.C11, copy of CT-HRCT THORAX report Ex.C12, copy of Reliance General Insurance Policy Ex.C13, copy of OPD slip of Civil Hospital, Indri Ex.C14 and Ex.C15, copy of RTCPR report Ex.C16 and Ex.C17, copy of discharge summary Ex.C18 and Ex.C19 and closed the evidence on 04.08.2022 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 proposal form Ex.OP2, copy of terms and conditions of the policy 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 indoor progress Notes Ex.OP8, copy of covid-19 report Ex.OP9, copy of liver report Ex.OP10, copy of CT-HRCT THORAX report Ex.OP11, copy of final bill Ex.OP12, copy of repudiation letter dated 15.10.2021 Ex.OP13 and closed the evidence on 11.05.2023 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 OP. The complainant suffered from Covid-19 and due to that on 19.05.2021, he was admitted in Amritdhara Hospital, Karnal and discharged on 23.05.2021. Intimation in this regard was given to the OP. After getting discharge from the hospital, complainant submitted the necessary documents for getting the benefit of abovesaid policy, but vide letter dated 15.10.2021 the claim of the complainant was rejected/repudiated by the OP on the false and frivolous ground 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 complainant was admitted at Amritdhara Hospital Private Limited-Karnal on 19.05.2021 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 OP, vide letter dated 15.10.2021 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 OP. 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.C5/Ex.OP13 dated 15.10.2021 on the ground, which is reproduced as under:-

“It is observed from the discharge summary that the insured patient has Spo2 is mentioned as 84% temperature is 102 F on 19.05.2021 at 1.06 p.m. but as per initial assessment sheet Spo2 is 89% temperature mentioned as 101F. Moreover, 2 copies of discharge summary with one copy admission vitals as temp 102 F and BP 110/80 and another discharge summary with admission vitals of temp 103F and BP 90/60.        

Based on these available records there are multiple discrepancies in the records which amounts 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.

12.           The claim of the complainant has been denied by the OP on the ground of multiple discrepancies in the records. Complainant was suffering from covid-19. In such type of disease, it is a normal thing that body temperature keeps on decreasing and increasing. 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 judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OP 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.C4/Ex.OP1 dated 26.02.2021 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 OP 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 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:10.08.2023

                                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)

                          Member                      Member