BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 419 of 2022
Date of Institution : 01.07.2022
Date of Decision : 06.11.2024
Maninder Singh, aged 34 years son of Shri Dalbir Singh, resident of Dhani Khoowali, Patli Dabar, Tehsil and District Sirsa (Haryana).
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., Branch Office: Satya Sales Samsung Plaza Showroom Building, Adjoining R.C. Regency Hotel, Hisar Road, Sirsa, Tehsil and District Sirsa through its Branch Manager.
2. Star Health and Allied Insurance Company Ltd., No. 15, Sri Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai- 600 014, through its authorized signatory.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA……….MEMBER
Present: Sh. JBL Garg, Advocate for the complainant.
Sh. Ravinder Monga, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that he purchased a Family Health Optima Insurance Plan from ops vide policy No. P/211121/01/2022/005425 for the period 17.08.2021 to 16.08.2022 for the sum assured amount of Rs.10,00,000/- and paid a sum of Rs.27,782/- as insurance premium for the said policy and got insured himself and his father Shri Dalbir Singh and mother Smt. Ranjit Kaur. That in January, 2022, the father of complainant Shri Dalbir Singh fell ill and he was got examined at Dr. Bhanwar Singh Hospital, Sirsa where he was admitted as indoor patient on 23.01.2022 and remained admitted up to 28.01.2022. Thereafter he remained under follow up treatment of said doctor and again he remained in said hospital from 17.04.2022 to 19.04.2022 and from 24.04.2022 to 28.04.2022 and a sum of Rs.2,70,000/- was spent on the treatment of his father. It is further averred that thereafter complainant lodged his claims with the ops and supplied all the documents and information as required by ops but however very strangely the ops vide their letter dated 20.04.2022, 16.05.2022 have repudiated his claim as per exclusion code Excl. 12 of the policy on the ground that company is not liable to make any payment in respect of expenses incurred at hospital for treatment for alcoholism, drug or substance abuse of any addictive condition and consequences thereof. The complainant was shocked to know the repudiation of his claim due to above imaginary reason developed by ops because before issuance of the policy, the ops had got medically examined the insured Shri Dalbir Singh and got assessed his entire health parameters and after fully satisfying with the same, the ops had issued the policy. It is further averred that Dr. Bhanwar Singh vide his certificate dated 26.04.2022 had categorically clarified that in progress notes dated 28.01.2022 alcoholic liver disease was mentioned by mistake and patient had no history of alcoholism, he was diagnosed as CLD first time in hospital and had no past history of disease said certificate was also supplied by complainant to the ops. It is further averred that complainant approached the ops and requested them to make payment of the aforesaid claim amount alongwith interest but the ops did not pay any heed to the same and ultimately the complainant got served a legal notice to the ops on 02.06.2022 but of no use. The claim of complainant has been repudiated in an illegal and unlawful manner by the ops and they have caused unnecessary harassment and deficiency in service towards complainant. Hence, this complaint.
3. On notice, ops appeared and filed written version raising certain preliminary objections. It is submitted that complainant lodged the claim before the company and submitted documents for reimbursement towards the treatment of Live Cirrhosis Decompnsated of his father Dalbir Singh. The insured Sh. Dalbir Singh was hospitalized at Dr. Bhanwar Singh Gastro & Liver Hospital Sirsa from 23.01.2022 to 28.01.2022. On scrutiny of the claim documents, query letter dated 12.02.2022 was sent to submit the required additional documents for further processing of the claim i.e. letter from the treating doctor regarding exact duration of chronic liver disease, probable cause, prior consultation report and treatment details, any past history of hospitalization for similar episode” if yes, kindly provide treatment details. As per Comdition no.18 of the policy, the insured person/s shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim is based and shall also give the company such additional information and assistance as the company may require in delaing with the claim. But the insured has not submitted the documents required by the company which amounts to violation of condition no.18 of the insurance policy, hence claim of insured has been repudiated/ rejected vide letter dated 29.03.2022. Subsequently, the insured approached for reconsideration of the claim and same was repudiated vide letter dated 20.04.2022. It is further submitted that insured was hospitalized on 17.04.2022 at said hospital for the treatment of liver cirrhosis and was discharged on 19.04.2022. The insured raised a pre-authorization request to avail cashless facility and same was denied and communicated to the insured and the treating hospital vide copy of letter dated 19.04.2022. Subsequently the insured submitted medical documents in support of his claim during reimbursement of medical expenses and same was repudiated and communicated to the insured vide letter dated 16.05.2022. It is further submitted that insured was hospitalized on 24.04.2022 at above said hospital for the treatment of liver cirrhosis and was discharged on 28.04.2022 but pre authorization request of insured to avail cashless facility was denied vide copy of letter dated 24.04.2022 and subsequent request for reimbursement of medical expenses was also repudiated and communicated to the insured vide letter dated 16.05.2022. It is further submitted that as per progress notes of Dr. Bhanwar’s Gastro & Liver Hospital, Sirsa dated 28.01.2022, the insured patient has complaints of Alcoholic Liver Disease and has undergone treatment for the same. As per exclusion clause 3 No.12 of the policy, the company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of treatment for alcoholism, drug or substance abuse or any addictive condition and consequences thereof. Moreover, as per exclusion 3- specified disease/ procedure waiting period- Code Excl 02(a)(f)(5) of the policy the company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of expenses related to the treatment of the following listed conditions, surgeries/ treatments shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy. This exclusion shall not be applicable for claims arising due to an accident, all treatments (conservative, interventional, laparoscopic and open) related to Hepato-pancreato- biliary diseases including Gall bladder and Pancreatic calculi, all types of management for kidney calculi and Genitourinary tract calculi. It is further submitted that in fact the insured is guilty of deliberate violation to the terms and conditions of insurance policy. The complainant has intentionally and deliberately not disclosed the previous treatment taken by Dalbir Singh. With these averments, dismissal of complaint prayed for. However, it is also submitted that in case it is found that company is liable to pay the claim in terms of the contract of insurance, then the maximum quantum of liability under the terms of the policy shall be Rs.1,35,039/- in claim no. CIR/2022/211121/3828688, Rs.25,358/- in claim no. CIR/2023/211121/0068414 and Rs.87,407/- in claim no. CIR/2023/211121/0095351.
4. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C51.
5. On the other hand, ops have tendered affidavit of Sh. P.C. Tripathi, Zonal Manager as Ex. RW1/A and documents Ex.R1 to Ex.R37.
6. We have heard learned counsel for the parties and have gone through the case file.
7. From the policy documents Ex.C1, it is evident that complainant purchased above said health insurance policy from ops for his father Dalbir Singh and mother Smt. Ranjit Kaur for the sum insured amount of Rs.10,00,000/- for the period 17.08.2021 to 16.08.2022 by paying insurance premium amount of Rs.27,782/-. Admittedly, the father of complainant namely Dalbir Singh during the period of above said policy remained admitted in the above said hospital from 23.01.2022 to 28.01.2022, 17.04.2022 to 19,.04.2022 and 24.04.2022 to 28.04.2022 for the treatment of disease of liver cirrhosis. However, the pre authorization request of complainant for cashless treatment as well as claim regarding reimbursement of expenses of medical treatment for the above said period has been rejected by the ops on the ground that as per terms and conditions of the policy, the company is not liable to make any payment in respect of expenses incurred at hospital for treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof and as per progress notes of Dr. Bhanwar’s Gastro & Liver Hospital, Sirsa dated 28.01.2022, the insured patient has complaints of alcoholic liver disease and has undergone treatment for the same. We are of the considered opinion that ops have wrongly and illegally repudiated the claim of complainant on just false baseless and flimsy grounds because Dalbir Singh father of complainant remained admitted in the above said hospital for first time from 28.01.2022 to 28.01.2022 and in the discharge summary of said hospital dated 28.01.2022 Ex.C4, in the personal history of patient Dalbir Singh it is mentioned that Non Alcoholic, non smoker. Further in the Initial Assessment OPD/ IPD/ Emergency card dated 23.01.2022 Ex.C6, it is mentioned that No addiction to alcohol and smoking and in subsequent progress notes also it is mentioned that no addiction to alcohol and smoking. The complainant has also placed on file certificate of Dr. Bhanwar Singh as Ex.C27 in which said doctor has duly clarified/ certified that in progress notes dated 28.01.2022 it was mentioned alcoholic liver disease by mistake. In whole of the treatment record of father of complainant Dalbir Singh, there is no mention that he is alcoholic, smoker or addictive to alcohol or any other drug and as such in the progress note dated 28.01.2022 the alcoholic liver disease was mentioned due to mistake which fact is also confirmed/ clarified by the concerned doctor. In these circumstances, it is proved on record that ops have wrongly and illegally repudiated the claims of complainant taking advantage of one mistake in the whole treatment record of insured Dalbir Singh which is unfair act on the part of ops. The ops have wrongly repudiated all the three claims of complainant on false ground and the above said clauses relied upon by ops are not applicable to the case of the complainant and disease of the father of complainant because it is proved on record that disease of liver cirrhosis of father of complainant was not due to alcoholic and same was also not a pre existing disease and same is also not mentioned in the list of specified disease having waiting period. The complainant is entitled to the amounts of Rs.1,35,039/-, Rs.25,358/- and Rs.87,407/- as assessed and admitted by the ops against the claims of the complainant as it is duly proved on record that complainant has spent more amount i.e. amount of Rs.2,70,000/- on the treatment of his father Dalbir Singh insured and the bills/ receipts of the expenses are also placed on file by complainant. Non payment of the same clearly amounts to deficiency in service on the part of ops.
8. In view of our above discussion, we allow the present complaint and direct the opposite parties to make payment of total claim amount of Rs.2,47,804/- as assessed by ops to the complainant (i.e. in round figure Rs.2,47,800/-) alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 01.07.2022 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.10,000/- as composite compensation for harassment and litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 06.11.2024. District Consumer Disputes
Redressal Commission, Sirsa.
