State Consumer Disputes Redressal Commission
Deepak Bansal vs M/S Star Health & Allied Insurance ... on 12 January, 2023
FA/84/2019 D.O.D.: 12.01.2023
MR. DEEPAK BANSAL VS. M/S STAR HEALTH & ALLIED INSURANCE COMPANY
IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL
COMMISSION
Date of Institution: 23.01.2019
Date of hearing: 19.09.2022
Date of Decision: 12.01.2023
FIRSTAPPEAL NO.-84/2019
IN THE MATTER OF
MR. DEEPAK BANSAL,
S/OM. L. BANSAL,
R/O 501, BLOCK C2C,
GOLF LINKS RESIDENCY,
SECTOR 18B, DWARKA, DELHI-110078.
(Through: Shubham Mahajan, Advocate)
...Appellant
VERSUS
M/S STAR HEALTH & ALLIED INSURANCE CO.,
HAVING REGISTERED OFFICE AT:
1ST FLOOR, HIMLAYA HOUSE,
23, KASTURBA GANDHI MARG,
DELHI-110001.
(Through: Mr. B. S. Dhir & Sukhneet Kaur Dhir, Advocates)
...Respondent
ALLOWED PAGE 1 OF 8
FA/84/2019 D.O.D.: 12.01.2023
MR. DEEPAK BANSAL VS. M/S STAR HEALTH & ALLIED INSURANCE COMPANY
CORAM:
HON'BLE JUSTICE SANGITA DHINGRA SEHGAL
(PRESIDENT)
HON'BLE MS. PINKI, MEMBER (JUDICIAL)
Present: Mr. Karan Rajpurohit, proxy counsel for Mr. Ravish
Thukral, counsel for Appellant.
Mr. B. S. Dhir along with Sukhneet Kaur Dhir, counsel
for Respondent.
PER: HON'BLE JUSTICE SANGITA DHINGRA SEHGAL,
PRESIDENT
JUDGMENT
1. The facts of the case as per the District Commission record are:
"Complainant, Deepak Bansal, took Star Senior Citizens Red Carpet Insurance mediclaim policy from Star Health and Allied Insurance Co. Ltd./ OP from 24/11/20107 to 23/11/2008 for a sum insured One Lac vide policy no. P/161100/01/2008/00768 for his mother Smt Satyavati Bansal which was renewed from 02/12/2008 to 01/12/2009 and till 01/12/2011 vide policy no. P/61111/01/2011/003770 under one lac sum assured and declared high blood pressure and Glaucoma which she had prior to inception in policy proposal form, so OP had put these ailments under permanent exclusion, which was continued. Complainant enhanced her mother's mediclaim policy for 3 lacs from one lac from 02/12/2011 to 01/12/2012 (Ex CW1/1 & 1A) in policy no. P/161111/01/2011/003770 and renewal policy was issued with all terms and conditions in policy P/161111/01/2012/004329 having tenure 02/12/2011 to 01/12/2012.
It was stated that his mother was admitted at Atul Nursing Home, Agra for Fracture Right Hip joint on 11/11/2011 and was discharged on 13/11/2011. The hospital bill Rs 6802/- was claimed, but OP paid only Rs 4200/-(Ex CW1/3) which was credited in the account of complainant for Fracture Right Femur. It was stated that his mother was readmitted to Batra Hospital Delhi on 28/11/2011 and was discharged on 13/12/2011 for "Arthroplasty in Fracture Right Femur" (Ex CW1/4). The complainant claimed treatment Rs. 2,80,257/ under the existing ALLOWED PAGE 2 OF 8 FA/84/2019 D.O.D.: 12.01.2023 MR. DEEPAK BANSAL VS. M/S STAR HEALTH & ALLIED INSURANCE COMPANY claim policy of 2010-2011 vide policy no.
P/161111/01/2011/003770 having sum insured amount Rs One Lacs, but OP cleared bill for Rs 59,5000/-(Ex CW1/4A). After some time, his mother was again admitted in Kailash Hospital, Noida for Gastritis and remained admitted from 19/01/2012 to 21/01/2012. The hospital bill of a sum Rs 16367/- was claimed which was cleared for Rs 7508/-(Ex CW1/5).
Complainant stated that he was not satisfied by the attitude of OP for maximum deductions in his father's claim and all three claims of his mother, so he filed his complaint for his father to Insurance Ombudsman, Delhi on 14/11/2011 vide case no. GI/378/Star/11 against OP as his father had undergone CABG at Delhi hospital and claimed under policy no. P/16111/01/11/003771, which was settled by OP. The complainant filed his mother's case before Delhi Ombudsman vide case no. G/25/Star/12 on 04/05/2014. The case was disposed on 11/11/2014 with order that "We (Delhi Ombudsman) were satisfied by OP services in claim process. If you (the complainant) were not satisfied, may approach to any Forum for redressal". By seeing callous attitude of OP and outcome of order of Ombudsman, filed this complaint for the reimbursement from OP by claiming Rs 2,16,000/-and compensation for mental and physical harassment Rs 2 lacs with legal expenses Rs 50,000/-."
2. The District Commission after taking into consideration the material available on record passed the order dated 11.07.2018, whereby it held as under:
"It has been noted that complainant is a proposer of the policy for his mother Smt Satyavati Bansal, but not a claimant or insured, so this means there is no contract between insured and OP. In this context, a proposer cannot be said to be insured or claimant, but could be a power of attorney holder or authorised person to take part in the proceedings, but complaint has filed this complaint and also singed affidavit. There were nowhere signatures of insured/claimant, Smt Satyavati Bansal, so how a proposer can enter under the contract and a direct beneficiary of OP. More so, there were no hospitals break up bills, treatment papers, medicines bill, lab reports except documents pertaining to Ombudsman ALLOWED PAGE 3 OF 8 FA/84/2019 D.O.D.: 12.01.2023 MR. DEEPAK BANSAL VS. M/S STAR HEALTH & ALLIED INSURANCE COMPANY proceedings and their orders. Complainant had not filed any claim details from OP taken earlier to Nov. 2011. Complainant also could not file any evidence to show that clubbing of sum insured under policy was evidence under policy terms and conditions in policy. Also complainant could not prove that being a proposer he has locus standi to file the complaint and take benefit from OP in absence of contract and insurable interest. Complainant also submitted Ex CE1/3 as enhanced sum insured policy of three lacs from one lacs vide policy no. P/161111/01/2012/004329 for 02/12/2011 to 01/12/2012. Complainant also stressed on bill Assessment Sheet of OP pertaining to Batra Hospital, Delhi where he claimed bill of Rs 2,80,257/- and OP approved Rs 59,5000/-only under policy P/16111/01/2011/003770 with sum insured One Lacs and another evidence as Ex CE1/5 under policy no. P/161111/01/2012/004329. Hence, it was stated on oath that the exhibited evidences were correct.
OP also submitted their evidences by way of affidavit through Mr Rajnish Kohli working as Assist. Vice President claims with OP stated that all their evidences and replies to the complaint were correct and true, It was also stated that policy was issued on the basis of good faith. OP stated that all two claims pertaining to policy no. P/16111/01/2011/003770 (EX OPE1/1) were processed under claims 123597 and 93016. It was submitted that if claim made between two policy periods as in this case where previous policy had one lacs sum insured and was enhanced to three lacs, but OP had paid for the same ailment under the same policy then enhanced claim would not be considered under any policy terms and conditions. The Batra Hospital bill claimed by the complainant for sum assured Four lacs had no weight as there was only ONE policy of ONE Lacs sum insured for Smt Satyavati vide policy no. P/16111/01/2011/003770 having tenure from 02/12/2010 to 02/12/2011. Under this policy, sum assured was enhanced to THREE Lacs from 02/12/2011 to 01/12/2012 vide policy no. P/161111/01/2012/004329. Whereas complainant had claimed as two policies and sum insured had to be clubbed for ALLOWED PAGE 4 OF 8 FA/84/2019 D.O.D.: 12.01.2023 MR. DEEPAK BANSAL VS. M/S STAR HEALTH & ALLIED INSURANCE COMPANY claim purposes which did not support with any terms and condition of the policy.
OP stated that, as per Ex OPE1/3, complainant was issued Star Senior Citizen's Red Carpet Inurance Policy where payable clauses were enhanced as a special benefits under this policy which were as under-
i- Room charges were enhanced to 4000/- per day instead of 1% to sum insured.
ii-ICU charges were enhanced to 2% to sum insured instead of 1%.
iii-Medical services to 25% of sum insured.
Thus, we find no merit in this complaint and complaint deserves to be dismissed so dismissed with cost Rs 2000/- which will be deposited with the Legal Service Authority of East Delhi, Karkarduma, Delhi 32 within 30 days from the date of order and the acknowledgment be submitted in the record file."
3. Aggrieved by the aforesaid judgment of the District Commission, the Appellant/ Complainant has preferred the present appeal contending that the District Commission failed to appreciate that the Appellant was claiming the insurance amount under both policy i.e. the old policy and the renewed policy. The Appellant further contended that the Respondent erroneously settled the claim no. 99807 in accordance with the sum insured in the existing policy and made maximum illogical deductions in the claim of Appellant without giving any valid reason for the same. Pressing the aforesaid contentions, the Appellant prayed for setting aside the impugned judgment.
4. Notice of the present Appeal was served to the Respondent and was directed to file reply to the present appeal. However, despite multiple opportunities, the Respondent failed to file the reply. Thereafter both the parties were directed to file written submissions which were filed by the contesting parties, wherein the Appellant has reiterated the facts of the ALLOWED PAGE 5 OF 8 FA/84/2019 D.O.D.: 12.01.2023 MR. DEEPAK BANSAL VS. M/S STAR HEALTH & ALLIED INSURANCE COMPANY Appeal. The Respondent on the other hand, denied all the allegations of the Appellant and submitted that there is no error in the impugned judgment as the Respondent has settled the claim of the Appellant as per the exclusions and deductions given in the terms and conditions of the policy.
5. We have perused the material available on record and heard the counsel appeared on behalf of both the parties.
6. The first question for consideration before us is whether the District Commission failed to consider that both the policy of Appellant should be clubbed for the purpose of claim settlement.
7. To resolve this issue, we have perused the material available on record and found that the Appellant's mother was insured under the policy bearing no. P/161111/01/2011/003770 for a sum of Rs.1,00,000/- for the period starting from 02.12.2010 to 01.12.2011. Further, the sum insured in the policy was enhanced from Rs. 1,00,000/- to Rs. 3,00,000/- which was renewed for the period starting from 02.12.2012 to 01.12.2013 from the Respondent.
8. The Appellant through the present Appeal contended that both the policies should be clubbed for claim purpose. However, it is clear from the record that the existing policy got renewed by the Appellant for the period 2012-2013. Therefore, the contention of the Appellant that both the policy should be clubbed for the claim purpose holds no merit as no insurance company can club the sum insured in the existing policy and renewed policy for the purpose of settlement of claim.
9. The next question for consideration before us is whether the District Commission right in dismissing the complaint of the Appellant on the ground that the claim no. 99807 has been settled on the basis of exclusions provided in the terms and conditions of the policy.
ALLOWED PAGE 6 OF 8 FA/84/2019 D.O.D.: 12.01.2023
MR. DEEPAK BANSAL VS. M/S STAR HEALTH & ALLIED INSURANCE COMPANY
10. We have carefully perused the material available on record and find that the Appellant has raised a claim of Rs. 2,80,257/- from the Respondent vide the renewed policy no. P/161111/01/2012/004329 and the Respondent had settled the claim no. 99807 of the Appellant in accordance with the sum insured in the existing policy and the deductions made by the Respondent was done accordingly while settling the claim of the Appellant.
11. However, it is clear from the terms and conditions of the policy that as per clause 6 of the Conditions of the policy under the head of 'cashless treatment' clearly states that "Where any admissible claim falls under 2 policy periods, the renewal policy sum insured shall be taken into account for claims settlement. Where the policy is not renewed then the applicable renewed premium shall be deducted from the claim and the claim shall be processed taking both policy sum insured."
12. Further, the record reflects that the sum insured for the policy bearing no. P/161111/01/2012/004329, renewed for the period 02.12.2012 to 01.12.2013, was Rs. 3,00,000/-. However, the Respondent wrongly ascertained the sum insured as Rs. 1,00,000/- for assessing the claim of the Appellant.
13. From the above discussion, we are of the view that the District Commission erred in holding that there exists no deficiency on the part of the Respondent and failed to appreciate the fact that the Respondent was deficient in assessing the claim to the tune of Rs. 63,700/- which was assessed as per the old/existing policy.
14. Therefore, keeping in view the facts of the present case, we set aside the judgment dated 11.07.2018 passed by the District Consumer Disputes Redressal Commission (East), Saini Enclave, Delhi - 110092. Accordingly, the present Appeal stands allowed.
ALLOWED PAGE 7 OF 8 FA/84/2019 D.O.D.: 12.01.2023
MR. DEEPAK BANSAL VS. M/S STAR HEALTH & ALLIED INSURANCE COMPANY
15. Further, we direct the Respondent to assess the claim no. 99807 in accordance with the sum insured in the policy bearing no. P/161111/01/2012/004329 within a period of 30 days from the date of present judgment i.e. 12.01.2013 and to pay the balance amount after deducting it from the existing assessed amount i.e. Rs. 63,700/- alongwith the interest @ 6% p.a. from 28.01.2012 (being the date on which the said claim was assessed by the Respondent) till the actual realization of the amount.
16. In case, if the Respondent fails to pay the said amount on or before 11.02.2023, the 'balance assessed amount' is to be refunded along with an interest @ 9% p.a. calculated from 28.01.2012 till the actual realization of the amount.
17. Application(s) pending, if any, stand disposed of in terms of the aforesaid judgment.
18. A copy of this judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986. The judgment be uploaded forthwith on the website of the commission for the perusal of the parties.
19. File be consigned to record room along with a copy of this Judgment.
(JUSTICE SANGITA DHINGRA SEHGAL) PRESIDENT (PINKI) MEMBER (JUDICIAL) Pronounced On:
12.01.2023 ALLOWED PAGE 8 OF 8