Haryana

Fatehabad

CC/76/2021

Suresh Kumar - Complainant(s)

Versus

Care Health Insurance Company Limited - Opp.Party(s)

Manjeet Kajla

16 Nov 2023

ORDER

BEFORE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FATEHABAD.

 

                                      Sh.Rajbir Singh, President.                                               Dr.K.S.Nirania and Smt.Harisha Mehta, Members

 

                                             Complaint Case No.: 76 of 2021.

                                             Date of Institution:      02.03.2021

                                                        Date of order:            16.11.2023.

         

Suresh Kumar son of Satpal resident of House No.146/3, Block No.2, village & Post Office Bhodia Khera Tehsil & District Fatehabad.

 

                                                                          ….. Complainant.

                            

                                      Versus

 

                                                          

1.Care Health Insurance Company Limited (Formerly Religare Health Insurance Company Limited), 5^th Floor, 19 Chawla House Nehru Place, New Delhi 110019 through its Chairman-cum-Managing Director/Managing Director.

 

2.Care Health Insurance Company Limited (Formerly Religare Health Insurance Company Limited), Service Branch, Vipul Tech Square Tower-C, Third Floor, Sector 43, Gold Course Road, Gurugram-122009 through its Chairman-cum- Managing Director/Managing Director/Divisional Manager/ Authorized person.

 

….Opposite parties.

 

Complaint U/s 35 of the Consumer Protection Act,2019

                                                                                

Present:          Shri Manjeet Kajla, Advocate for the complainant.

                  Shri Sudhir Kumar, Advocate for the opposite parties.

 

 

 

ORDER

SMT.HARISHA MEHTA, MEMBER

                   Brief facts of the present complaint are that the complainant had obtained an insurance policy bearing No.14711297 having validity from 30.08.2020 to 29.08.2021 under care cover type individual plan; that he made insurance premium amounting to Rs.14892/- to Ops for sum assured of Rs.5,00,000/-; that the wife of the complainant namely Smt.Neetu Bala felt ill on 21.10.2020 and was remained admitted in Sanjeevani Multispeciality, Hospital, Fatehabad and was discharged on 29.10.2020 and spent Rs.1,16,247/- on her treatment and hospitalization; that the complainant had submitted all the requisite documents besides serving of legal notice upon the Ops for reimbursement of the total amount of Rs.1,16,247/- but despite that the amount has not been released till date.  The act and conduct of the Ops clearly amounts to deficiency in service on their part. Hence, this compliant.

2.                          On notice, Ops appeared and filed their joint written statement wherein several preliminary objections such as cause of action, locus standi, concealment of material facts from this Commission, maintainability, estopal and jurisdiction etc. have been taken. It has been further submitted that as per discharge summary the wife of the complainant was diagnosed with Antiviral Hepatits. In order to properly analyses the claim, the Ops had raised deficiency letter dated 02.12.2020 and reminders dated 05.12.2020, 08.12.2020, 02.01.2021 and the following documents were demanded:

                   1.Recent Passport size photograph of proposer/nominee Suresh               Kumar

                   2.Pre Hospitalization OPD treatment record

                   1.Registration certificate’s with copy of hospital with number                             of beds.

                   2.Teating Doctor’s certificate for Etiology of present ailment.

                   3.Treating Doctor’s Certificate justifying the prolonged/need of                hospitalization.

 

 

that there were some discrepancies in the medical documents, therefore, the claim was denied vide letter dated 13.01.2021 as per Clause 7.1 of Terms and conditions, which is reproduced as under:

If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or any material  particulars or any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by the policy holder or the insured person or anyone acting on his/their behalf, the company shall have no liability to make payment of any claims and the premium paid shall be forfeited ab initio to the company.

 

Other contentions have been controverted and in the end, a submission was made for dismissal of the complaint.

3.                          In evidence, learned counsel for the complainant has tendered affidavit of complainant Ex.CW1/A and documents Annexure C1 to Annexure C10 and then closed the evidence. On the other hand, learned counsel for the appearing Ops tendered affidavit Ex.RW1/A and documents Annexure R/A to Annexure R/I in evidence and closed the same.

4.                          We have heard oral final arguments from both sides. We have also perused the case file minutely.

5.                          It is not disputed that the complainant had obtained Care Cover Type Individual policy (Annexure C1) having validity for the period from 30.08.2020 to 29.08.2020 from the Ops and also paid the premium thereof.  As per the complainant a sum of Rs.1,16,247/- was spent on the treatment of his wife namely Smt.Neetu and as per the terms and conditions of the policy, so obtained by the him, the insurance company had to reimburse the amount spent on the treatment of his wife because she was hospitalized during the subsistence of the policy in question but instead of reimbursing the incurred amount, the Ops have repudiated the claim wrongly and illegally. On the other hand, learned counsel for the Ops has argued that some quarries were put to the complainant and but he did not fulfill the same, therefore, the claim in question was rightly repudiated vide letter dated 13.01.2021 (Annexure RG).

6.                          The material question which this Commission has to decide is as to whether the OPs have legally repudiated the claim of the complainant or not and as to whether there was any deficiency in service on the part of Ops.

7.                          It is worthwhile to mention here that health/medical insurance is a type of insurance that financially protects the insured during medical emergencies. It covers medical expenses related to illness/ hospitalization. A health/care plan covers doctor consultation fees, surgery costs, hospitalization expenses, cost of medicines, ambulance charges, day care procedures, mental healthcare and many more, thereby, protecting the insured from financial strain. In the present complaint, the motive of purchasing the policy in question from the Ops by the complainant must be the same because he had paid the premium for financially protection during medical emergencies.

8.                          Learned counsel for the Ops drew the attention of this Commission towards clause 7 (1) of terms and conditions (Annexure RC) and submitted that on being failure of the complainant in submitting the demanded documents, the claim of the complainant was repudiated vide letter dated 13.01.2021 (Annexure RG) with remarks Discrepancy in medical documents.

9.                          After going through the material available on the case file, we have no hitch to say that the insurance company has become too technical while settling the claim of the complainant and has acted arbitrarily. The insurance company should have worked on merits and good spirit of the terms and conditions of the policy without compromising on bad claims but in the present complaint, the complainant has been asked to furnish some documents which were beyond his control to procure and furnish. More-so, these documents are not appearing to be vital which could be the base of rejection of the genuine claim. Once, there was a valid insurance on payment of huge sum by way of premium and the insured had fallen ill during the subsistence of the policy and spent amount on his treatment, the insurance company ought not to have become too technical and ought not to have refused to settle the claim on non-submission of the some documents which were beyond the control of complainant. Learned counsel for the Ops has also failed to prove on the case file that the complainant has ever acted fraudulently and lodged the false claim. The Ops vide Annexure C2 demanded Pre-hospitalization OPD Treatment Record from the complainant and stressed hard on the clause 7.1 of the Terms and Conditions (Annexure RC). The plea raised by the Ops is not tenable because there is nothing on the case file to show that the wife of the complainant has ever taken treatment from any hospital and even in Annexure C3, the treating doctor has mentioned in his report that there was No significant past history of the patient. Hence, this plea is hereby declined and clause 7.1 of the terms and conditions is not applicable in the case in hand.  We are of the considered view that the end of justice would be met if we allow the complaint with a direction to the appearing Ops/insurance company to pay a sum of Rs.1,16,247/- to the complainant (Annexure C3 treatment bills).

10.                        Keeping in view the above facts and circumstances of the case, this Commission is of the considered view that the present complaint deserves acceptance because the Ops have indulged in the unfair trade practice as well as dis-service to the complainant, as discussed above. Accordingly, we allow the present complaint with a direction to the appearing Ops to pay Rs.1,16,247/- (Rs.One Lac Sixteen Thousand Two Hundred Fourty seven only) alongwith interest @ 6 % per annum from the date of filing of the complaint till its realisation. We further allow Rs.11,000/-, (Rs. Eleven Thousand) in lump sum, towards mental harassment and agony suffered by the complainant and also towards litigation expenses. The liability of the Ops is joint as well as several. The order be complied within a period of 45 days from today failing which the awarded amount would carry interest @ 9 % per annum from the date of filing of the compliant till its realization.

11.                        In default of compliance of this order, proceedings against respondents shall be initiated under Section 72 of Consumer Protection Act, 2019 as non-compliance of court order shall be punishable with imprisonment for a term which shall not be 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 one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. This order be also uploaded forthwith on website of this Commission, as per rules, for perusal of parties herein. File be consigned to the record room after due compliance.     

Announced in open Commission.                                                            Dated: 16.11.2023

 

                                                                                                        

          (K.S.Nirania)                       (Harisha Mehta)                (Rajbir Singh)                             

 

Member                               Member                                           President