Complainant Alambir Singh has filed the present complaint against the opposite parties U/S 12 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite parties to reimburse the claim of Rs.65,300/- as expenses borne and paid by him in the hospitals while getting the treatment alongwith interest @ 18% per annum from the date of filing this complaint till its realization. Opposite parties be further directed to pay compensation amounting to Rs.50,000/- on account of mental agony and physical harassment alongwith Rs.10,000/- as litigation expenses, in the interest of justice.
2. The case of the complainant in brief is that he alongwith his wife Mrs.Sukhdeep Kaur (Policy Holder) and his minor son Mehtab Singh got insured with the opposite party namely Care Health Insurance Company (Formerly known as Relegare Health Insurance Company Ltd.) vide Policy No.14159941 on 10th May, 2019 by paying the premium of Rs.13,465/- and this policy was subsequently renewed by paying the premium of Rs.14,112/- and insured amount is upto Rs.5,00,000/- and further they did not make any claim during the first year of the insurance due to which upon subsequent renewal bonus of Rs.50,000/- to each insured was awarded. It was further pleaded that on 10th October 2020, he slipped from his motor bike and suffered from spine injury leading to extreme pain in the spine, due to which he was admitted on the same day at Simran Hospital, near bye pass, G.T.Road, Gurdaspur and due to this, he had to stay there for the next six days i.e. till 16th October 2020 and he was discharged, post treatment on 16.10.2020. His entire treatment which included charges for the period of stay, medication, nursing charges, tests, etc. cost of Rs.65,300/-. He had sent all requisite documents to the opposite party more than five times electronically and had also sent hard copy at the branch office of opposite party at Amritsar via courier and receipt of the same was duly supplied through e-mail dated 21.01.2021. However, till date not even a single penny had been paid and his bonafide claim is being unlawfully delayed by demanding same/similar type of documents time and again. He had also issued registered Legal Notice dated 3.2.2021 through his counsel to the opposite party, but the opposite party did not make the payment of said claim. Thus, there is deficiency in service on the part of the opposite party. Hence this complaint.
3. Notice of the complaint was issued to the opposite party who appeared through its counsel and filed its written reply by taking the preliminary objections that the correct name of the opposite party is Care Health Insurance Co. Ltd. (Formerly known as Relegare Health Insurance Co. Ltd.); the complaint of the complainant is not maintainable in the present form; the complainant has no cause of action and locus standi to file the present complaint; the insurance is a contract between two parties. Both parties are bound with the terms and conditions of the policy; there is no deficiency in services on the part of the insurance company. The matter of the fact is that the company issued a health insurance policy bearing Policy No.14159941 to the policy holder i.e. Mrs.Sukhdeep Kaur w.e.f. 10.05.2019 till 9.5.2020 for a sum insured of Rs.5 lakhs. The policy was renewed till 1.6.2021 and further till 1.6.2022. In the present case the Insurance Company rejected the claim vide letter dated 2.2.2021 with the following observations "THE CLAIM REPUDIATED AS TWO YEARS WAITING PERIOD FOR TREATMENT OF SPINAL DISORDERS AND TWO YEAR WAITING PERIOD FOR ARTHRITIS (IF NON-INFECTIVE) OSTEOARTHRITIS AND OSTEOPORSIS GOUT, RHEUMATISM AND SPINAL DISORDERS, JOINT REPLACEMENT SURGERY." Since the policy was in its second year and the treatment related to spinal disorders are only covered after two years since the policy inception and as such the claim has been rejected because the period of two years has not been elapsed, when the treatment has been taken. Further complainant sent the legal notice dated 3.2.2021 which has been duly replied vide letter dated 19.03.2021 thereby explaining the reason of rejection. On merits, it was submitted that the liability of the insurance company is only as per the terms and conditions o the insurance company. It was further submitted that it was wrong and specifically denied that on 10.10.2020 the complainant slipped from his Motorbike and suffered from spine injury and due to which he was admitted at Simran Hospital. The story made is false and frivolous. No such alleged accident ever took place. It was next submitted that the claim has been intimated and the relevant documents have been demanded by the insurance company. The claim has been rejected vide repudiation letter dated 02.02.2021, as the treatment was not covered for the period of two years waiting period for the treatment of spinal disorder etc. The detailed fact regarding the policy terms and conditions in this regard had been duly given. So, there is no liability of the insurance company and the claim has rightly been repudiated. All the claims are processed as per policy terms and conditions and not on an arbitrary basis. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.
4. Alongwith the complaint, complainant has filed his own affidavit Ex.W-1 alongwith copies of documents Ex.C-1 to Ex.C-19 including Ex.C-1/a, Ex.C/B, Ex.C-3/a, Ex.C-3/B, Ex.C-4/a,, Ex.C-5/a to Ex.C-5/D.
5. Ld. counsel for the opposite party tendered into evidence affidavit of Sh.Ravi Boolchandani, authorized representative Ex.OPW-1/A alongwith copies of documents Ex.OP-1 to Ex.OP-7.
6. Rejoinder filed by the complaint.
7. Written arguments filed by complainant.
8. We have carefully gone through the pleadings of counsel for the parties; oral arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsel for the parties for the purposes of adjudication of the present complaint.
9. Present complaint has been filed by complainant Alambir Singh against the Care Health Insurance Company. In this case complainant Alambir Singh his wife Mrs.Sukhdeep Kaur (Policy Holder) and his minor son Mehtab Singh had got medical claim vide policy No.14159941 by purchasing the same on 10.05.2019 for which premium of Rs.13,465/- was paid for the first year for insurance cover of Rs.5,00,000/- and on subsequent renewal a premium of Rs.14,112/- was paid for insurance cover of Rs.5,50,000/- on 10.10.2020. Complainant Alambir Singh slipped from his motor cycle and was hospitalized at Simran Hospital Gurdaspur for six days vide Ex.C-2 to Ex.C-10. On discharge from hospital medical claim was lodged by Mrs.Sukhdeep Kaur wife of complainant Alambir Singh vide claim form Ex.C1 for Rs.65,300/-. Opposite party declined the said claim vide their letter dated 02.02.2021 Ex.C13 on the ground that said injury is not covered under the said insurance for the initial period of two years. Aggrieved by this denial letter complainant got issued legal notice through his counsel to the opposite party which was duly replied by the opposite party which is Ex.C-15 wherein in the para 4.1has stated that "Any treatment related to Arthritis (if, non-infective), Osteoarthritis and Osteoporosis, Gout, Rheumatism, Spinal disorders (unless caused by accident), joint replacement surgery (unless caused by accident), Arthroscopic knee surgeries/ACL reconstruction/Meniscal and Ligament Repair". From the above statement/admission of the insurance company it is apparent that the said claim is admissible in case of accident which has not been denied at any stage by the opposite party. It is clear that claim lodged by the wife of the complainant Ex.C1 is admissible
10. In view of the above said discussion by considering the circumstances and facts of the case it is clear that claim lodged by Mrs.Sukhdeep Kaur wife of the complainant Ex.C1 is admissible as the injury was sustained having slipped from motor cycle which is an accident and hence the present complaint is partly allowed and opposite party is hereby directed to pay Rs.65,300/- the amount paid by complainant with 7% interest from the date of filing of complaint till its realization including Rs.5,000/- as litigation expenses. Compliance of order be made within 30 days from the receipt of certified copy of the order.
11. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
12. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (R.S.Sukhija)
JUNE 23, 2022. Member.
YP.
