Delhi

North East

CC/161/2021

Vipin Jain - Complainant(s)

Versus

Care Health Insurance Co. Ltd. - Opp.Party(s)

06 Nov 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No.161/21

In the matter of:

 

	Sh. Vipin Jain, S/o Sh. Bhushan Lal Jain, R/o H.No. 1/6005B, Near Sant Nirankari Bhawan, Kabool Nagar, Shahdara, Delhi 110032	Complainant
	Versus
	Care Health Insurance Ltd. (Formerly Known as Religare Health Insurance Co. Ltd.) Having Registered Office at:- 5th floor, Chawla House, 19, Nehru Place, New Delhi 110019	Opposite Party

DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                           DATE OF ORDER:

27.10.21 04.07.24 06.11.24

 

CORAM:

Surinder Kumar Sharma, President

Ms. Adarsh Nain, Member

ORDER

 

Ms. Adarsh Nain, Member

 

The Complainant has filed the present complaint under Consumer Protection Act.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that Complainant has been covered for medical insurance since 2016 and had renewed mediclaim policy from the Opposite Party for the period 04.10.19 to 03.10.20. On 11.02.20,Complainant was admitted to Max Super Specialty Hospital, Vaishali with chest heaviness, fever of high grade, cough and sputum and breathlessness.  Complainant made request for preauthorization of cashless hospitalisation to Opposite Party but Opposite Party denied the request of Complainant through letter dated 13.02.20 on flimsy ground “Discrepancy found in Medical Documents” through an email. Complainant called the Opposite Party on phone and was told that the cashless authorization was denied due to absence of pre hospitalisation OPD documents. Complainant sent email on 14.02.20 stating that the Complainant was directly admitted to emergency ward in the hospital due to severe breathlessness. The Complainant was discharged on 14.02.20 and paid Rs. 1,32,575/- towards hospital expenses because Opposite Party refused the cashless facility for treatment of the Complainant and it was also mentioned in the discharge summary that  Complainant was diagnosed with high level of blood sugar during treatment at the hospital. Thereafter Complainant filed reimbursement claim with Opposite Party for the amount paid for treatment and claim form was received by Opposite Party on 22.02.20. Opposite Party sought some documents from the Complainant vide Deficiency Letter Dated 06.03.20. The Complainant had already submitted all the records. As such the Complainant wrote email dated 25.03.20 to the Opposite Party. The Opposite Party reverted to the said mail dated 26.03.20 and affirmed that query has been forwarded to internal team for further processing the claim. Thereafter Opposite Party rejected the claim of Complainant vide email dated 28.02.20 on the ground of “Discrepancy in Medical Documents”. Though no discrepancy/deficiency was mentioned in email or the attached letter. Complainant wrote email dated 10.06.20 to the Opposite Party seeking review of the claim no. 91297973-00. The Opposite Party reverted with an email 11.06.20 stating that the claim has been rejected on the ground of “Discrepancy in Medical Documents” which cannot be disclosed by them due to confidentiality. Thereafter Complainant requested to return all original documents submitted by him vide email dated 14.06.20. The Opposite Party reverted vide email dated 14.06.20 and stated that the concern has been escalated to respective team.Thereafter the Complainant suffered from Covid 19 and had to be hospitalized. The expense of Rs. 1,38,819/- on treatment was paid by the Opposite Party. The Complainant sought review of the claim rejected by the Opposite Party in June 2020. Complainant also submitted the requisite documents along with the application. There has been no response from the Opposite Party till date. Hence, this shows deficiency in service on behalf of Opposite Party. The Complainant has prayed for Rs. 1,32,575/- with interest @ 15 % p.a. from 14.02.20 till the date of payment and further pendent-lite and future interest @ 15 % p.a. from the date of filing of this complaint.  He further prayed for Rs. 1,00,000/- towards compensation for harassment  and Rs. 1,00,000/- towards cost of litigation.

 

Case of the Opposite Party

2. The Opposite Party contested the case and filed written statement. While admitting the subject health Insurance policy was renewed, Opposite Party has objected to the complaint on the ground that no pre-existing disease was disclosed by the policy holder at the time of proposal to the Opposite Party. It is also submitted by the Opposite Party that subject policy was ported from HDFC Ergo General Insurance company wherein his first enrolment was in the year 2016. It is contended that as per the investigation report, Complainant in his statement stated that his blood sugar was high at the time of admission and was administered insulin and as per the progress note dated 11.02.2020, he was given S.H Actropid according to blood sugar. Therefore, the cashless claim of complainant was rejected on the ground of discrepancy and asked to put papers for reimbursement for reconsideration. When the Complainant approached the Opposite Party with reimbursement claim, the Opposite Party procured complete indoor case papers with Admission Notes, History Sheet, Doctor’s Notes, Nursing Notes and Vital Chart and past treatment record from the complainant and evidences were found in respect to the discrepancy in the claim. Opposite Party rejected the claim vide denial letter dated 28.03.2020 on the ground of discrepancy in medical documents. It is contended that the history of DM was relevant and it was not disclosed in the proposal form by the Complainant despite given opportunity. If the complainant had disclosed his true, correct and complete medical history, Opposite Party would have issued the policy on different terms and conditions. Under such circumstances, there is no deficiency in service on the part of Opposite Party in rejecting the claim of Complainant and the present complaint is liable to be dismissed.

Rejoinder to the written statement of Opposite Party

3. The Complainant filed rejoinder to the written statement of Opposite Party wherein the Complainant has denied the objection raised by the Opposite Party and has reiterated the assertion made in the complaint.

Evidence of the Complainant

4. The Complainant in support of his complaint filed his affidavit wherein he has supported the averments made in the complaint.

Evidence of the Opposite Party

5. In order to prove its case Opposite Party has filed affidavit of Sh. Ravi Boolchandani, Manager Legal at Care Health Insurance Ltd. wherein the averments made in the written statement of Opposite Party has been supported.

Arguments & Conclusion

6. We have heard the Ld. Counsel for the Complainant. We have also perused the file and the written arguments filed by the parties.
7. The case of the complainant is that the Complainant is covered under medical Insurance since 2016 and renewed his policy from Opposite Party for a period 04.10.19 to 03.10.20. It is alleged that the complainant’s medi-claim (subject matter of this complaint) was rejected by the Opposite Party on the ground of discrepancy in medical documents. The claim was wrongly rejected by Opposite Party saying that the complainant did not disclose pre-existing disease in the proposal form. It is submitted by the complainant he never had a history of Diabetes and Opposite Party is liable for deficiency in services.
8. On the other hand, the contention of the Opposite Party is that pre-existing disease was not disclosed by the policy holder at the time of proposal to the Opposite Party. It is contended by the Opposite Party that during investigation of the said claim, it was found that while undergoing treatment, the complainant was administered insulin and as per the progress note dated 11.02.2020, he was given S.H Actropid according to blood sugar. It is contended that the complainant was asked to submit the relevant medical record to ascertain the said fact and from the medical record of complainant revealed evidence of diabetes and also discrepancy in the medical record. It is also submitted that as per the investigator’s survey of medical stores, the complainant was purchasing medicines for sugar for the past four years.
9. Opposite Party has failed to produce any evidence in support of its contention that the complainant had a history of diabetes. The perusal of the Investigation report relied upon by the Opposite Party shows that the said document holds no value as the same is unsigned and not proved. The Opposite Party has not been able to prove the manipulation in the medical record which led them to reject the claim of the complainant. In such case, the contentions of the Opposite Party are rejected.
10. Moreover, it is an undisputed fact that the subject policy was ported from HDFC Ergo and renewed from Opposite Party and the Complainant is covered under medical Insurance since 2016.
11. In this context, it is to be noted that as per the terms and conditions of the policy relied upon by the Opposite party, Portability defined in definitions section as below:

“1. Definitions

1.  Portability means transfer by an individual health insurance policyholder (including family cover) of the credit gained for pre-existing conditions and time bound exclusions if he/she chooses to switch from one insurer to another.”

12. It is clear from the above wordings that with the portability, the policy holder becomes entitled to credit gained for pre-existing conditions and time bound exclusions if he/she chooses to switch from one insurer to another.Hence, the contention of the Opposite Party deserves to be rejected that they did not have the knowledge of pre-existing disease.
13. Therefore, in view of the above, we are of the considered opinion that the Opposite party has wrongly rejected the claim of the complainant, hence, has been deficient in services by rejecting the genuine claim of the complainant, causing mental agony and torture to the complainant.
14. Thus, we allow the complaint and direct the Opposite Party to pay to the complainant the claim amount of Rs. 1,32,575/-, with interest @9% per annum from the date of institution of the complaint. The Opposite Party is also directed to pay Rs. 25,000/- towards compensation and Rs.10,000/- towards litigation cost along with interest @ 9% per annum from the date of this order till its recovery.
15. Order announced on 06.11.24.

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Adarsh Nain)		(Surinder Kumar Sharma)
(Member)		(President)