District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.95/2023.
Date of Institution:08.02.2023.
Date of Order: 02.02.2024.
Ram Kishan son of Shri Hansraj of 61 years, residing at village Allipur Shikhargah, Tigaon road, Faridabad, Haryana, Aadhar card 3125 2773 0893 phone No. 98187 40027
…….Complainant……..
Versus
1. Care Health Insurance Limited (formerly known as Religare Health Insurance Company Limited) having its registered office at: Unit No. 604-607, 6th floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram, Haryana – 121001 Email:resolve 1 @careinsurance.com through its Grievance Redressal Officer.
2. Care Health Insurance Limited, 5th floor, 19, Chawla House, Nehru Place, New Delhi – 110 019 through its Manager Customer Service.
3. Care Health insurance Limited, Vipul Tech Square, Tower C, 3rd floor, Gold Course Road, Secator-43, Gurugram – 122009 (Haryana) through its Regional Manager/Manager.
4. Care Health Insurance Limited, Area Office: Ist floor, Plot No. 37BP, WG Tower, Neelam Bata Road, NIT, Faridabad, Haryana – 121001, Phone: 9289454696 through its Area Manager.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Mahinder Singh, counsel for the complainant.
Sh. N.K.Garg, counsel for opposite parties.
ORDER:
The facts in brief of the complaint are that Mr. Ram Kishan (hereafter would be named as the complainant) purchased a cashless health policy No. 39840833 valid for the period 01.03.2022 to 28.02.2026 from Care Health Insurance Limited. The complainant purchased the cashless health policy No. 39840833 from Care Health Insurance which was valid till 28.02.2026 and paid the premium of the policy as per the terms and conditions of the insurer company. At the time of issuing of the policy it was well mentioned to the complainant that the policy was a cashless policy and claim would be settled without any problem. On 27.06.2022 the complainant was admitted to the hospital named as Shankar Medicate Hospital situated at 1251, Sector-28, Faridabad, Haryana – 121008 with High Grade Fever and other health problems (mentioned in details in the discharge summary and other medical reports). The complainant went under the medical treatment and was discharged on 04.07.2022 on the opinion of the doctor after he was diagnosed by giving due course of treatment in the hospital. The hospital intimated about the admission of the complainant to the opposite party through email dated 27.06.22 at 7:15p.m. the insurer company confirmed the receiving of the email about the admission of the complainant through its email dated 27.06.2022 at 7:49p.m and allotted an email communication NO E0009853670. Thereafter the hospital staff sent all the required documents asked by the insurance company and followed each and every procedure set by the insurance company to settle the cashless claim of the complainant but the insurance company denied the cashless claim of the complainant on 04.07.2022 and asked the complainant for the reimbursement of the claim with all the documents and reports after the discharge from the hospital. The insurance company denied the cashless claim of the complainant which was breach of contract between the complainant as a consumer and the insurer company as a retailer/service service provider and was also a violation of the right of the consumer. During the hospitalization the complainant made cash payments to the hospital for all the hospital expenses, tests and reports, medicines and all other expenses which were the liabilities of the insurance company as per the terms and conditions of the policy. The complainant sent legal notice dated 04.07.2022 to the opposite parties but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay Rs.1,10,706/- as per calculation chart submitted with interest @ 18% p.a. from the date of making claim till the date of filing the complaint to the complainants.
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) Pay Rs.50,000/- as litigation expenses.
2. Opposite parties Nos.1 to 4 put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 to 4 refuted claim of the complainant and submitted that the opposite party company issued a Group health insurance policy namely “Sarva Haryana Gramin Bank” bearing policy No. 18498780 under the Certificate No. 39840833 from 01.03.2022 till 28.02.2026 covering only the complainant for a sum insured upto Rs.5,00,000/-.
Reimbursement (92476690-00)
a) a reimbursement claim was filed for hospitalization of complainant at Shankar Medicare Canter, Faridabad form 30.01.2022 till 06.02.2022 and as per the discharge summary he was diagnosed with ALA Enteric Fever.
b) Upon receipt of the claim a query vide letter dated 15.07.2022 was raised and the complainant was asked to provide
Personalized cancelled cheque in the name of proposer/primary member or Neft mandate form signed and stamped by Bank Authorities.
Complete indoor case papers with admission notes, history sheet, doctors notes ,nursing notes and vital chart.
c) Upon receipt of the claim an internal investigation was also triggered to check the veracity of the claim. It was found that:
- There was no stamp of lab test report.
-No GST number mentioned on final bill of hospital
-Insured had not provided any documents relation to pre-hospitalization
-As per the discharge summary data of admission was 27.06.2022, but as per the ICP treatment was started form 28.06.2022.
-while consider the ICP there was no medicine chart and vital chart were provided with ICP.
d) Therefore, the claim was rejected on the basis of discrepancy in medical documents and rejection was communicated vide denial letter dated 26.08.2022.
Opposite parties Nos. 1 to 4 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties–Care Health Insurance Co. Ltd. with the prayer to: a) pay Rs.1,10,706/- as per calculation chart submitted with interest @ 18% p.a. from the date of making claim till the date of filing the complaint to the complainants. b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c) Pay Rs.50,000/- as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW-1/A – affidavit of Ram Kishan,, Ex.C-2 - receipt, Ex.C-3 - Broad Guidelines for claim process, Ex.C-4 – discharge summary, Ex.C-5 – email, Ex.C-6 – letter dated June 27,2022,, Ex.C-7(colly) – bill of supply cum receipt, Ex.C-8 – claim denial letter dated 26.08.2022,, Ex.C-9 – claim form.
On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties Ex.RW1/A – affidavit of Shri Garvit Saini, Manager Legal at Care health Insurance Limited at Vipul; Tech Square, Tower C, 3rd floor, sEctor-43, Gold Course Road, Gurgaon , Ex.r-1 – insurance alongwith terms & conditions, Ex.R-2(colly) – Claim form, Ex.R-3 – Deficiency letter dated 15.07.2022, Ex.R-4 – reminder I letter dated 22.07.2022, Ex.R-5 –claim denial letter.
6. After going through the evidence led by both the both the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties Nos.1to 4 are directed to process the claim of the complainant, subject to submission of the documents as required by the opposite parties in their letters dated 15.07.022 vide Ex.R-3 & letter dated 22.07.2022 vide Ex.R-4 and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing complaint till its realization. The opposite parties are also directed to pay Rs.5500/- as compensation on account of mental tension, agony and harassment alongwith Rs.5500/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 02.02.2024. (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
