Haryana

Charkhi Dadri

CC/50/2023

SHYAM SUNDER - Complainant(s)

Versus

CARE HEALTH INSURANCE CO LTD THROUGH ITS AUTHORIZED REPRESENTATIVE - Opp.Party(s)

Sh. Amandeep Phogat

03 Dec 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, CHARKHI DADRI

Consumer Complaint No. 50/2023. Date of Institution:  27.03.2023.

Date of Order:          03.12.2024   .

 

1. Shyam Sunder aged about 43 years S/o Chote Lal, R/o VPO Khedi Batter, Teh. & Distt. Charkhi Dadri, PH-7357228108
2. Ishu aged about 20 years S/o Shyam Sunder R/o VPO Khedi Batter, Tehsil & District Charkhi Dadri

                                                                           ...Complainant.

                                                Versus

 

1. Care Health Insurance Co. Ltd. through its authorized representative having its registered office at 5^th Floor, 19 Chawla House, Nehru Place, New Delhi 110019.
2. Care Health Insurance Co. Ltd. through its authorized representative having its office at near  Bikaner Misthan Bhandar, Charkhi Dadri.

…Opposite parties.

             Complaint under section 35 of the Consumer Protection Act, 2019.

CORAM:             Hon’ble Sh.Manjit Singh Naryal, President

                             (Proceeded under Section 64 of the Consumer Protection Act, 2019)

 

PRESENT:          Shri Amandeep Phogat, Adv. for complainants.

Shri Rajat Sheoran, Adv. for opposite parties.

ORDER            

                  The brief facts of the complaint are that the complainant had taken a Group insurance policy from the opposite party vide policy No. 18498780 dated 09.06.2022 and the family members of the complainant were part of this policy. The said policy was effected from 09.06.2022 to 08.06.2023 midnight. It was further submitted that on dated 06.10.2022, Ishu son of the complainant admitted in J.B.Gupta Hospital, Bhiwani and discharged on 10.10.2022. It was further submitted that the complainant spent an amount of Rs. 38,068/- on his medical treatment. It was further submitted that after submission of documents claim was not passed by opposite parties and the same was denied without any justified reason and repudiate the claim of the complainant. The aforesaid act of opposite party amounted to deficiency in service and hence this complaint.

2.                Notice of the complaint was given to the opposite party which appeared and filed reply. On merits, it has been submitted that insurance company issued a health insurance policy bearing group policy no. 18498780 with certificate of insurance no.44100193 in favour of the complainant Mr. Shyam Sunder for providing policy coverage to himself, his spouse, 2 daughters and a son Mr. Ishu. The said policy was issued w.e.f. 09.06.2022 to 08.06.2023 for a sum insured of Rs. 5,00,000/-. It is submitted that complainant had approached the OPs with a reimbursement claim no. 92817070 for insured’s hospitalization at JB Gupta Hospital, Bhiwani from 06.10.2022 till 10.10.2022. As per medical documents and discharge summary, the insured was diagnosed with fever with thrombocytopenia/Carditis/Cholecystitis. It is also contended by the OPs that from the medical documents and as per discharge summary the insurance company found certain discrepancies in medical bills of the complainant’s illness was not so serious that it required admission and to get the false claim from insurance he admitted falsely and got prepared the fake bill.  It is further alleged that because of above discrepancies in bills, the OP company repudiated the claim letter dated 10.01.2023. Hence, the claim of the complainant was rejected by the opposite parties as per terms and conditions of the policy. The opposite parties denied rest of the allegations leveled in the complaint and prayed for dismissal of the present complaint with special costs.

3.           In the evidence, the complainant Shyam Sunder tendered affidavit as Ex. CW-1/A alongwith affidavit of Ishu son of Shri Shyam Sunder as Ex. CW-2/A and documents Ex. CW-1/1 to Ex. CW-1/3 and closed the evidence.
4.           On the other hand, the learned counsel for the opposite parties have tendered into evidence affidavit of Sh. Lakshay Juneja, Corporate Manager- Legal at Care Health insurance Limited as Ex.RW-1/A and closed the evidence.
5.           I have heard the arguments of learned counsel of both the parties and has gone through the entire evidence placed on record by the complainant very carefully and minutely.
6.           On hearing the arguments and going through the evidence on file carefully, it is proved that the complainant purchased Group policy No.18498780 dated 09.06.2022 with basic Floater Sum assured of Rs. 5,00,000/- . The complainant paid total premium of Rs. 7172/-. Sh. Shyam Sunder, Mrs. Meera, Ishu, Sukhwanti and Shobhawati were insured with their respective client IDs. It has come on record that on 06.10.2022 ISHU (Member ID 42597402) was admitted to J.B.Gupta, Hospital, Bhiwani. The bill of Rs.38,068/-, Ex.CW-1/2 shows that Ishu was admitted on 06.10.2022 at 3:33PM and discharged on 10.10.2022 at 02:22PM. The said claim was processed by the opposite party but the claim was repudiated vide letter dated 10.01.2023 stating that “Discrepancy in medical documents”. As per Ex.CW-1/2 the doctor of JB Gupta hospital, Bhiwani had issued the opinion mentioning that Ishu was admitted on 06.10.2022 at 03:33 pm with UHID No. 70467. This Commission finds no reason to disbelieve the statement of doctor of JB Gupta Hospital, Bhiwani nor the opposite parties have brought on record any specialist opinion which could counter the purpose of admitting the patient Ishu. Hence, the opposite parties have caused deficiency in service.
7.           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”.

8.           Keeping in view the ratio of the law laid down in the abovesaid judgments and the facts and circumstances of the complaint, I am of the considered view that the act of the OPs amounts to deficiency in service and unfair trade practice while repudiating the claim of the complainants in toto.
9.           To do complete and substantial justice between the parties, the opposite parties are directed to pay Rs. 38,068/- as treatment charges to the complainant alongwith interest @ 9% per annum from the date of filing of the complaint i.e.27.03.2023. Besides, the opposite parties are directed to pay Rs. 60,000/- (Sixty thousand only) as compensation towards pain suffering, mental harassment and Rs. 15,000/- (Fifteen thousand only) as litigation expenses. The opposite parties shall deposit the said amount within 45 days from today, failing which the insurer shall be liable to pay interest on the said amount @ 12% per annum from the date of filing of the complaint till its actual realization.
10. If the order of this Commission is not complied with, then the complainant shall be entitled to file execution petition under section 71 of Consumer Protection Act, 2019 and in that eventuality, the defaulting party may also be liable for prosecution under Section 72 of the said Act which provides punishment of imprisonment for a term which shall not less than one month, but which may extend to three years or with fine, which shall not be less than twenty-five thousand rupees, but which may extend to Rs. one lac or with both. Copies of this order be sent to the parties free of costs as per rules and this order be promptly uploaded on the website of this Commission.  File be consigned to the record room after due compliance