PER:
Charanjit Singh, President
1 The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 34, 35 and 36 against the opposite party on the allegations that the complainant had got himself and his family insured with Health Insurance of the opposite party vide insurance policy No. P/211111/01/2023/01/2004 valid from 9.10.2022 to 8.10.2023 by paying the insurance premium to the opposite party No. 1. The family of the complainant who were covered qua this policy include Nazia Dhawan wife of the complainant and their son Rajbir Dhawan. The opposite party No. 2- Promod Kumar who is registered agent of the opposite party No. 1 and had recommended the above said policy to the complainant as he works at the village of the complainant and he had some faith on this person that he will recommend a good insurance company with the good policy that will cover the medical expenses risk of the complainant, so believing the opposite party No. 2 the complainant opted for the above said policy and the opposite party No. 1 issued the policy to the complainant bearing above mentioned number. The wife of complainant namely Nazia Dhawan suddenly fell ill with high fever and other medical complicacies and as such she visited the Chopra Hospital & Nursing Home at Bhikhiwind, where she was diagnosed with Chikungunya fever and she was admitted by the above said hospital on 20.2.2023 and she was given treatment for the above said fever by the doctors of the hospital. Before the admission in the hospital, the complainant had informed the hospital authorities that his wife is covered with the medical insurance mentioned above and as such, she is eligible for cashless treatment in the hospital so the hospital authorities called the representatives of the opposite party No. 1 and applied for the approval for the cashless treatment of wife of the complainant. Initially, the opposite party No. 1 gave the approval of the treatment but withdrew it subsequently without any reason and as such, the complainant had paid all the expenses of the treatment from his wife from his own pocket amounting to near about Rs.64,000/-. After the wife of the complainant was discharged from the hospital on 26.2.2023, the complainant immediately approached the opposite party No. 2 and requested him to lodge the insurance claim with the opposite party No. 1 and also handed over all the required documents as required by this party including the bills of payments of treatment and medicine and also summary of the discharge treatment and on receipt of these documents, the opposite party No. 2 immediately lodged the reimbursement insurance claim with the opposite party No. 1. The opposite party No. 2 assured the complainant that reimbursement of Rs. 64,000/- will be made to the complainant within a fortnight so the complainant awaited for this time for receiving the insurance reimbursement. The complainant was embarrassed and astonished when he received a letter dated 11.7.2023 addressed to him from the opposite party No. 1 whereby this party has declined the reimbursement claim to the complainant by giving vague reasons of not lodging the reimbursement within 15 days from discharge from the hospital, so on receipt of this letter the complainant approached the OP No. 2 who told the complainant that the reimbursement insurance claim was lodged by him within a couple of days on receiving the documents from the complainant i.e. within about 5 days of complainant’s discharge from the hospital, so the opposite party No. 1 cannot deny the reimbursement on this false ground, so this party No.2 assured the complainant that he will pursue the reimbursement matter with the opposite party No. 2 as he is registered agent of the opposite party No. 1 and he can prove lodging of the claim within time with opposite party No. 1 and as such believing his worlds the complainant awaited for the response from the opposite parties. Inspite of waiting for more than a month from receiving the letter dated 11.7.2023, the complainant again approached the opposite party No. 2 who had told that he is pursuing the matter with the opposite party No.1. The complainant has prayed the following relieves:-
- The opposite parties may kindly be directed to release the reimbursement insurance claim of Rs. 64,000/- to the complainant immediately.
- The opposite parties may kindly be directed to pay compensation of Rs. 50,000/- for causing harassment of the complainant
- The opposite party may kindly be directed to pay litigation expenses of Rs. 50,000/- to the complainant.
Alongwith the complaint, the complainant has placed on record affidavit of complainant Ex. C-1, self attested copy of Insurance policy Ex. C-2, Self attested copy of Summary of treatment record Ex. C-3, self attested copies of the Bills of treatment Ex. C-4, Self attested copy of Denial letter Ex. C-5, Self attested copy of Adhar Card of complainant Ex. C-6.
2 Notice of this complaint was sent to the opposite parties and opposite part No. 1 appeared through counsel and filed written version by interalia pleadings that the complainant has not approached this commission with clean hands and the complaint contains misleading statements, averments and suppression of material facts, hence the case deserves to be dismissed. The insured availed Young Star Insurance Policy vide policy No. P/211111/01/2023/012004 covering Mr. Sumit Dhawan self, Mrs. Nazia Dhawan-spouse and Mr. Rajbir Dhawan dependent child for a sum of Rs. 5,00,000/-. Details of previous policies is as under:-
P/211111/01/2021/010088 for the period of 11/09/2020 to 10/09/2021for sum insured of Rs. 5,00,000/-
P/211111/01/2022/008491f or the period of 11/09/2021 to 10/09/2022 for sum insured of Rs. 5,00,000/-
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 clearly stated in the policy schedule “The Insurance Under this policy is subject to conditions, clauses, Warranties, Exclusions etc. attached” . The policy is contractual in nature and claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the Policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form. The complaint is vague, improper and illegal and against the facts, hence the same is not maintainable in the eyes of law and the same deserves to be dismissed. The complainant has moved the present complaint with malafide intention and ulterior motives to grab illegal amount from the opposite party. Hence, the complaint is not maintainable in the eyes of law and the same deserves to be dismissed. The opposite party had rendered all possible services to the complainant, and there was/ is no deficiency in services on the part of the insurance company, as such the complaint deserves to be dismissed. The opposite party No. 1 observed from the submitted medical records that the claim documents have been submitted to it after 15 days of discharge from the hospital. The admission date was 20.2.2023 and the date of intimation to the opposite party No. 1 was 25.4.2023. Therefore, as per policy terms and conditions -Standard conditions- clause C for reimbursement of claims the claim must be filed within 15 days of the date of discharge from the hospital. The opposite party No. 1 being unable to settle the claim under the above policy repudiated the same as per terms and conditions of the policy and intimation in this regard was given to the complainant vide letter dated 11.7.2023. The relevant policy condition for claim rejection is as under:-
Condition-Standard Conditions- Clause C for reimbursement of claims time limit is claim must be filed within 15 days from the date of discharge from the hospital.
It may be stated that, Rights and liabilities of both insured and insurer are strictly governed by policy of insurance. No exception or relaxation can be made on ground of equity. Upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy, its terms have to be strictly construed to determine the extent of liability of the insurer. For the sole purpose of harassing the opposite parties with the intention for getting unlawful enrichment from the opposite parties who are dealing with public money and functioning under the guidelines of IRDA controlled by the Government of India. As public money is held in trust, the company must exercise abundant caution in dealing with the claims by applying all conditions correctly. Cashless settlement/ facility are not a part of contractual obligation as per the terms and conditions of insurance policy contract. It is more than the commitment given under the contract of insurance and meant for extra comfort level for the customer. It is a facility extended to those cases where the liability of insurance company under the policy is established beyond any doubt. In all other cases, the insured has to submit a completed claim form for reimbursement with all supporting treatment documents to enable the company to understand and process the claim on its merit. The complainant is estopped by his own act and conduct from filing the present complaint as the complaint has been filed without any cause of action. The complainant has got no locus standi to file the present complaint. The complaint has been filed without any cause of action against the opposite parties. The opposite party No. 1 has denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite party No. 1 has placed on record affidavit of Sumit Kumar Sharma Senior Manager Ex. OP1/1, Self attested copy of authority letter Ex. OP1/2, Self attested copy of Police Ex. OP1/3, Self attested copy of terms and conditions Ex. OPO1/4, Self attested copy of claim intimation details Ex. OP1/5, self attested copy of claim form Ex. OP1/6, Self attested copy of discharge summary (including ICP, Reports etc.) Ex. OP1/7, Self attested copy of repudiation letter Ex. OP1/8, Self attested copy of proposal form Ex. OP1/9 and prayed that the present complaint may be dismissed.
3 Notice issued to the opposite party No.2 and has not filed written version and during the pendency of the present complaint, opposite party No. 2 did not come present in this commission and proceeded against exparte.
4 The complainant has filed rejoinder to the written version filed by the opposite party No. 1 and denied all the pleas taken in the written version and reiterated the stand as taken in the complaint and pleaded that the case of reimbursement claim was raised with the opposite party No. 1 within the stipulated period i.e. 5 days from the discharge from the hospital. The wife of opposite party No. 2 namely Shashi Kala is registered agent of opposite party No. 1 and her husband opposite party No. 2 actively assist her in her job as a registered agent of opposite party No. 1 and her agent Number is BA0000266125. Both these people have certified that the reimbursement claim of complainant was raised and lodged with the opposite party No. 1 within 5 days of discharge of Nazia Dhawan from Chopra Hospital and they had themselves submitted the requisite documents with the representatives of the opposite party No. 1 and in this regard they have issued a certificate dated 2.3.2024. Alongwith the rejoinder, the complainant has placed on record self attested copy of Certificate dated 2.3.2024 Ex. C-7.
5 We have heard the Ld. counsel for the complainant and opposite party No. 1 and have carefully gone through the record placed on the file.
6 Ld. counsel for the complainant contended that the complainant had got himself and his family insured with Health Insurance of the opposite party vide insurance policy No. P/211111/01/2023/01/2004 valid from 9.10.2022 to 8.10.2023 by paying the insurance premium to the opposite party No. 1. The family of the complainant who were covered qua this policy include Nazia Dhawan wife of the complainant and their son Rajbir Dhawan. The opposite party No. 2- Promod Kumar who is registered agent of the opposite party No. 1 and had recommended the above said policy to the complainant as he works at the village of the complainant and he had faith on this person that he will recommend a good insurance company with the good policy that will cover the medical expenses risk of the complainant. So believing the opposite party No. 2 the complainant opted for the above said policy and the opposite party No. 1 issued the policy to the complainant bearing above mentioned number. He further contended that the wife of complainant namely Nazia Dhawan suddenly fell ill with high fever and other medical complicacies and as such she visited the Chopra Hospital & Nursing Home at Bhikhiwind, where she was diagnosed with Chikungunya fever and she was admitted by the above said hospital on 20.2.2023 and she was given treatment for the above said fever by the doctors of the hospital. Before the admission in the hospital, the complainant had informed the hospital authorities that his wife is covered with the medical insurance mentioned above and as such, she is eligible for cashless treatment in the hospital so the hospital authorities called the representatives of the opposite party No. 1 and applied for the approval for the cashless treatment of wife of the complainant. Initially, the opposite party No. 1 gave the approval of the treatment but withdrew its subsequently without any reason and as such, the complainant had paid all the expenses of the treatment of his wife from his own pocket amounting to near about Rs.64,000/-. After the wife of the complainant was discharged from the hospital on 26.2.2023, the complainant immediately approached the opposite party No. 2 and requested him to lodge the insurance claim with the opposite party No. 1 and also handed over all the required documents as required by this party including the bills of payments of treatment and medicine and also summary of the discharge treatment and on receipt of these documents, the opposite party No. 2 immediately lodged the reimbursement insurance claim with the opposite party No. 1. The opposite party No. 2 assured the complainant that reimbursement of Rs. 64,000/- will be made to the complainant within a fortnight, so the complainant awaited for this time for receiving the insurance reimbursement. He further contented that the complainant was embarrassed and astonished when he received a letter dated 11.7.2023 addressed to him from the opposite party No. 1 whereby this party has declined the reimbursement claim to the complainant by giving vague reasons of not lodging the reimbursement within 15 days from discharge from the hospital, so on receipt of this letter the complainant approached the OP No. 2 who told the complainant that the reimbursement insurance claim was lodged by him within a couple of days on receiving the documents from the complainant i.e. within about 5 days of complainant’s discharge from the hospital, so the opposite party No. 1 cannot deny the reimbursement on this false ground, so this party No.2 assured the complainant that he will pursue the reimbursement matter with the opposite party No. 2 as he is registered agent of the opposite party No. 1 and he can prove lodging of the claim within time with opposite party No. 1 and as such believing his worlds the complainant awaited for the response from the opposite parties. He further contended that inspite of waiting for more than a month from receiving the letter dated 11.7.2023 and prayed that the present complaint may be allowed.
7 On the other hands, Ld. counsel for the opposite party No. 1 contended that the complainant has not approached this commission with clean hands and the complaint contains misleading statements, averments and suppression of material facts, hence the case deserves to be dismissed. He further contended that the insured availed Young Star Insurance Policy vide policy No. P/211111/01/2023/012004 covering Mr. Sumit Dhawan self, Mrs. Nazia Dhawan-spouse and Mr. Rajbir Dhawan dependent child for a sum of Rs. 5,00,000/-. Details of previous policies is as under:-
P/211111/01/2021/010088 for the period of 11/09/2020 to 10/09/2021for sum insured of Rs. 5,00,000/-
P/211111/01/2022/008491f or the period of 11/09/2021 to 10/09/2022 for sum insured of Rs. 5,00,000/-
He further contended that 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 clearly stated in the policy schedule “The Insurance Under this policy is subject to conditions, clauses, Warranties, Exclusions etc. attached” . The policy is contractual in nature and claims arising therein are subject to the terms and conditions forming part of the policy. The opposite party had rendered all possible services to the complainant, and there was/ is no deficiency in services on the part of the insurance company. The opposite party No. 1 observed from the submitted medical records that the claim documents have been submitted to it after 15 days of discharge from the hospital. The admission date was 20.2.2023 and the date of intimation to the opposite party No. 1 was 25.4.2023. Therefore, as per policy terms and conditions -Standard conditions- clause C for reimbursement of claims the claim must be filed within 15 days of the date of discharge from the hospital. The opposite party No. 1 being unable to settle the claim under the above policy repudiated the same as per terms and conditions of the policy and intimation in this regard was given to the complainant vide letter dated 11.7.2023 and prayed that the present complaint may be dismissed.
8 We have gone through the rival contents of Ld. counsels for both the parties.
9 In the present case it is not disputed that the complainant has obtained Health insurance policy from the opposite party for himself and for his family members. It is also not disputed that the wife of the complainant namely Nazia Dhawan has taken the treatment from Chopra Hospital and Nursing Home at Bhikhiwind during the currency period of insurance policy. It is also not disputed in the present case that an amount of Rs. 64,000/- were spent for the treatment of Nazia Dhawan wife of complainant. Moreover, the complainant has placed on record Policy Ex. C-2 and the policy is effective from 9.10.2022 to 8.10.2023 and sum assured in the said policy is Rs. 5,00,000/-. The wife of the complainant namely Nazia Dhawan has taken the treatment during the currency period of said policy i.e. on 20.2.2023. The complainant has also placed on record medical bills Ex C-4.
10 That the opposite party No. 1 has repudiated the claim of the complainant only on the ground that “It is observed from the submitted medical records that the claim documents have been submitted to us after 15 days of discharge from the hospital”. As such the opposite party No. 1 has rejected the claim of the complainant vide repudiation letter dated 11.7.2023 Ex. OP1/8. But according to the opposite party No. 1 the complainant has lodged the claim after 15 days from the date of discharge. But according to complainant, he has raised and lodged the claim with the opposite party No. 1 within 5 days of discharge of Nazia Dhawan from Chopra Hospital. To prove his contention the complainant has placed on record one certificate of Shashi Kala registered agent of Star Health Insurance company which is reproduced as follows:-
“I Shashi Kala registered agent of Star Health Insurance Company having agent No. BA0000266125 alongwith my husband Promod Kumar, do hereby certified that we had deposited and submitted the requisite documents within a period of 5 days from discharge of Nazia Dhawan from Chopra Hospital and Nursing Home Bhikhiwind with Sandeep Tondan SBA at D-Block Ranjit Avenue, Amritsar, office of Star Health Insurance Company Ltd. in regard to reimbursement claim case in regard to insurance policy No.P/211111/01/2023/012004 of policy holder Sumit Dhawan so of Ashok Kumar Dhawan and the dealing hand at that time namely Sandeep Tondon had assured us that these will be forwarded to the claim department of Star Health Insurance Company Ltd. on his responsibility as having received the requisite documents within the statutory time frame.”
The above said certificate is placed on record as Ex. C-7 and the same is duly signed by Shashi Kala and her husband Promod Kumar and the said certificate is dated 2.3.2024. According to agent of insurance company the complainant has submitted the documents within 5 days from the discharge of Nazia Dhawan and same have been deposited and submitted to Sandeep Tondon SBA at D Block Ranjit Avenue Amritsar, office of Star Health Insurance Company Ltd. As such it shows that the complainant has submitted the documents well within time. As such the ground for repudiated the claim of the complainant is not genuine and the opposite party No. 1 has wrongly repudiated the genuine claim of complainant. Otherwise also, a circular dated 20.9.2011 was issued by IRDA, referred to all the insurance companies, which reads as under:-
“Circular
To: All Life Insurers and non-life insurers
Re: Delay in claim intimation/ documents submission with respect to
i) All life insurance contracts and
ii) All Non-life individual and group insurance contracts.
The Authority has been receiving several complaints that claims are being rejected on the ground of delayed submission of intimation and documents.
The current contractual obligation imposing the condition that the claims shall be intimated to the insurer with prescribed documents within a specified number of days is necessary for insurers for effecting various post claim activities like investigation, loss assessment, provisioning, claim settlement etc. However, this condition should not prevent settlement of genuine claims, particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances. The insurers’ decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such intimation clause does not work in isolation, and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policy holders losing confidence in the insurance industry, giving rise to excessive litigation.
Therefore, it is advised that all insurers need to develop a sound mechanism of their own to handle such claims with utmost care and caution. It is also advised that the insurers must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the insurers should satisfy themselves that the delayed claims would have otherwise been rejected even if reported in time.
The insurers are advised to incorporate additional wordings in the policy documents, suitably enunciating insurers’ stand to condone delay on merit for delayed claims where the delay is proved to be for reasons beyond the control of the insured.
J. Harinarayan
Chairman”:
A bare reading of circular shows that if the claim is otherwise payable then it should not be repudiated or rejected simply on the ground of delay and delay is only to be considered when claim is otherwise not made out and is liable to be rejected even if the matter has been reported in time. In case titled as National Insurance Company Limited Vs. Kulwant Singh 2014(IV) CPJ page 62 (NC) the Hon’ble National Commission observed that the insurance company should not have repudiated the claim merely on account of delay in giving the information to insurance company particularly when there was absolute no delay in lodging the FIR with the police. In the case in hand also, the theft took place on 16.9.2014 and intimation to the police was also given on the same day i.e. 16.9.2014 and as such, there was no delay at all for giving the intimation to the police. Moreover, in similar case titled as Reliance General Insurance Company Limited- Petitioner Vs. Sri Avvn Ganesh-Respondent 2012(1) CPJ page 176 in case under Consumer Protection Act, 1986 the intimation of death was given to the insurer with delay and claim was repudiated on the ground that death of insured was intimated after 4 months as against stipulated period of one month. The complainant filed complaint on the allegation of deficiency in service by insurance company, but the same was dismissed, but appeal filed by the complainant was allowed by Hon’ble State Commission. On revision, the Hon’ble National Commission, New Delhi observed that all the conditions for acceptance of insurance claim except point of reporting loss within one month of its occurrence had been substantially fulfilled and delayed intimation of death of insured due to injuries he suffered on account of accident could not be held to be destructive to insurance claim because the facts and circumstances of death were clearly established on the basis of medical on records as well as deposition of doctor who attended the insured and it was observed that like in case of theft of moveable insured property, delay in intimation was not prejudicial to the insurer because in such cases, Insurance company was not prevented, because of delay, from carrying out any investigation into the facts and circumstances as to whether the accident and consequent loss fell within the substantive condition of insurance policy and no infirmity was found in the order and revision petition was dismissed. In the case in hand also, the theft of vehicle in question was reported to the police on the very next day by the complainant. As such by repudiating the genuine claim of the complainant, the opposite party No,1 has committed deficiency in service and unfair trade practice.
11 Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.UshaYadav& Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
12 In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant and against the Opposite Party No.1. The opposite Party No. 1 is directed to make the payment of Rs. 64,000/- to the complainant. The complainant has been harassed by the opposite party No. 1 unnecessarily for a long time. The complainant is also entitled to Rs. 7,500/- as compensation on account of harassment and mental agony and Rs 5,000/- as litigation expenses. Opposite Party No. 1 is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. The present complaint against the opposite party No. 2 is dismissed. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission. Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.
Announced in Open Commission
13.06.2024
