Haryana

Karnal

CC/136/2023

Rajesh - Complainant(s)

Versus

Care Health Insurance Limited - Opp.Party(s)

J.P. Singh

18 Dec 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.136 of 2023

                                                        Date of instt 27.02.2023

                                                        Date of Decision: 18.12.2024

 

Rajesh aged 35 years son of Shri Krishan Chand, resident of VPO Kailana, Tehsil Gannaur, District Sonepat now residing at House no.370, Chopra Enclave, opposite Dyal Singh College, Karnal. Aadhar card no.8193 4867 8062. Mobile no.9466589992.

 

                                                                        …….Complainant.

                                              Versus

 

  1. Care Health Insurance Limited, Correspondence office:- Vipul Tech Square Tower C, 3rd floor Sector 43, Golf Course Road, Gurgaon 122009 through its Claims Manager.
  2. Care Health Insurance Limited, registered office:- 5th floor, 19 Chawla House, Nehru Place, New Delhi-110019 through its Chairperson/Director.
  3. Care Health Insurance Limited, SCO 354, Mugal Canal, Ground floor, Karnal, Haryana 132001.

 

                                                                   …..Opposite Parties

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.

              Ms. Neeru Agarwal…..Member  

      Ms. Sarvjeet Kaur…..Member

 

Argued by:  Complainant in person.

                    Shri Ashwani Kumar Popli, counsel for the OPs.

                   

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant purchased a Care Health Insurance Policy, bearing Group Policy no.18498780 and certificate of insurance no.31276851 dated 27.03.2022, valid upto 26.03.2023 for sum insured of Rs.2,00,000/- single premium floater from the OPs and the premium of the said policy was given through Sarva Haryana Gramin Bank to the OPs on behalf of the complainant which was duly received by OPs/authorized agent and paid a premium of Rs.3437/- which was duly received by the OPs and authorized person. The said policy was in continuously in validation from 27.03.2022 to 26.03.2023. As per policy, the complainant and his family members were covered in emergency admission for any disease as per policy terms. On 25.10.2022, the complainant got admitted in Ajmani General and Maternity Hospital opposite Civil Hospital, Karnal for his emergency and serious treatment i.e. fever, Dengue, Cough, Thromboctopenia/Thrombocytes etc. in other words, there was an emergency for treatment and admission in the abovesaid hospital to save the life of the complainant. The complainant admitted on 25.10.2022 and discharge on 29.10.2022 from the abovesaid hospital. The doctor concerned of the abovesaid hospital issued a medical certificate regarding the acute illness and emergency admission for the same. The complainant has spent an amount of Rs.15,328/- on his treatment excluding diet money and other charges etc. The intimation was sent to the OPs. Complainant lodged a claim no.92723537-00 on 13.11.2022 with the OPs but OPs rejected the claim of the complainant on the false and frivolous ground. Then complainant sent a legal notice dated 02.02.2023 to the OPs but it also did not yield any result. Due to this act and conduct of OPs, complainant has suffered mental pain, agony and harassment. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence complainant filed the present complaint seeking direction to the OPs to pay Rs.1,00,000/- as compensation on account of expenses incurred on his medical treatment, medicines, diet money, charges of doctors etc. and for mentally, physically, financially losses and litigation expenses.

 2.            On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that complainant covered under Group Health Insurance Policy namely “Group Care 3600 (Scheme III for SHGB), vide policy no.31276851 cover the complainant and his family w.e.f.27.03.2021 to 26.03.2022 for a sum insured of Rs.2,00,000/-, subject to policy terms and conditions. Policy was renewed further on annual basis till 26.03.2023. A reimbursement claim no.92723537 was received from the complainant for his hospitalization at Ajmani General & Maternity Hospital, Karnal from 25.10.2022 to 29.10.2022 for diagnosis of Dengue Fever. Upon receipt of the claim, OP triggered an investigation to check the veracity of the claim. On investigation the following points came to light:-

  1. That it is submitted that Ajmani General & Maternity Hospital, Karnal has been blacklisted by the OPs company w.e.f. 09.01.2022 and put under the category of “Non-preferred Hospitals” for the reason that previously many fraud claims have been received from Ajmani General & Maternity Hospital using fraudulent documents and therefore, it is a suspicious hospital. The hospital is prone to mal-practice and various claims have been rejected recently.
  2. That it is further submitted that as per the below screenshot of the website of the OPs, the said hospital is mentioned under the list of non-preferred hospitals.

                In the light of the facts mentioned above, it is pertinent to mention that the OPs company has rightly been rejected the claim of the complainant on the ground of Treatment Taken from Non-preferred hospital, vide letter dated 13.11.2022. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Complainant has tendered into evidence his affidavit Ex.CW1/A, copy of insurance policy Ex.C1, copy  of Claim Denial letter dated 13.11.2022 Ex.C2, copy of emergency certificate Ex.C3, copy of discharge summary Ex.C4, copy of Doctor initial Assessment Ex.C5, copies of medication charts dated 25.10.2022, 26.10.2022, 27.10.2022, 28.10.2022, 29.10.2022 Ex.C6 to Ex.C10, monitoring chart Ex.C11, copy of serology Ex.C12, copy of x-ray report Ex.C13, copy of OPD receipt Ex.C14 to Ex.C16, copies of receipts against bills dated 29.10.2022 and 26.10.2022 Ex.C17 and Ex.C18, copies of lab book slips Ex.C19 to Ex.C26, copy of bill receipt Ex.C27, copy of OPD service receipt Ex.C28, copies of Bala Jee Medical Store bills Ex.C29 to Ex.C34, copy of complete blood bill count Ex.C35 and Ex.C36, copy of urine examination and platelet count Ex.C37, copy of platelet count Ex.C38, copy of serum creatinine and platelet count Ex.C39, platelet count Ex.C40, SGPT & Platelet count Ex.C41, platelet count Ex.C42, serum creatinine and platelet count Ex.C43 and closed the evidence on 08.04.2024 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Deepak Mishra, Manager-Legal Ex.OP1/A, copy of policy certificate Ex.OP1, copy of claim form dated 25.10.2022 to 29.10.2022 Ex.OP2, copy of discharge summary Ex.OP3, copy of claim denial letter dated 13.11.2022 Ex.OP4, copy of legal notice dated 01.02.2023 Ex.OP5, copy of reply to legal notice dated 28.02.2023 Ex.OP6 and closed the evidence on 30.07.2024 by suffering separate statement.

6.             We have heard the complainant and learned counsel for the OPs and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Complainant, while reiterating the contents of the complaint, has submitted that he purchased a Health Insurance Policy from the OPs. The sum insured under the policy is Rs.2,00,000/-. On 25.10.2022, during the subsistence of the policy, he was admitted in Ajmani General & Maternity Hospital, Karnal and has spent an amount of Rs.15328/- on his treatment. After discharge from the hospital, he lodged the claim with the OPs and submitted all the required documents for reimbursement of the said amount but OPs did not pay the claim and rejected the same on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that on receipt of claim for the hospitalization  of complainant at Ajmani General & Maternity Hospital, Karnal from 25.10.2022 to 29.10.2022 for diagnosis of Dengue Fever. Investigation was conducted and found that Ajmani General & Maternity Hospital, Karnal has been blacklisted by the OPs company w.e.f. 09.01.2022 and put under the category of “Non-preferred Hospitals.”  Thus, the OPs have rightly been rejected the claim of the complainant and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant purchased a Care health Insurance Policy from the OPs. The amount covered under the policy is Rs.2,00,000/-. It is also admitted that during the subsistence of insurance policy complainant has taken treatment from Ajmani General & Maternity Hospital, Karnal.

11.           The claim of the complainant has been repudiated by the OPs, vide letter Ex.C2/Ex.OP4 dated 13.11.2022 on the ground which is reproduced as under:-

“ We have reviewed the claim file by you pertaining to Health Insurance Policy and hereby inform your that the claim is not payable as per policy terms and conditions listed below:

.       Claim rejected treatment taken from Non-Preferred Hospital.

.       Treatment Taken in Excluded Providers (as per Annexure v) except in case of emergency hospitalization.

12.           The claim of the complainant has been repudiated by the OPs on the abovesaid ground. The OPs have alleged that complainant has taken the treatment from Ajmani General & Maternity Hospital, Karnal. The said hospital has been blacklisted by the OPs company on 09.01.2022 and put under the category of “Non-preferred Hospitals.”  The complainant has purchased the policy in question on 27.03.2022, and at that time, OP did not disclose that the abovesaid hospital was not on the panel of the OP. If the said hospital had de-paneled on 09.01.2022, it was the duty of the OPs to inform to all their customers, so that they can got the knowledge of the same. It is not the case of the OPs that in this regard, they had informed to their customers including complainant. Further, OP has not placed on file copy of letter dated 09.01.2022, vide which the said hospital has been blacklisted.  Hence, the plea taken by the OPs is only on the basis of presumption and assumption, which is not admissible in the eyes of law.

13.           Furthermore, nowadays it has become a trend of insurance companies, they issue the policies by giving false assurances and when insured amount is claimed, they make such type of excuses. Thus, the denial of the claim of complainant is arbitrary and unjustified. In this regard, we place reliance on the judgment of Hon’ble Punjab and Haryana High Court titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, wherein the Hon’ble Punjab and Haryana High Court 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. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

                Keeping in view that the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, the act of the OPs while repudiating the claim of complainant amounts to deficiency in services and unfair trade practice, which is otherwise proved genuine one.

14.           The complainant has spent an amount of Rs.15,328/- on his treatment and in this regard he has submitted the bills Ex.C17 to Ex.C29, the said amount neither denied nor rebutted by the OPs.  Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental pain, agony harassment and litigation expenses etc.

15.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.15328/- (Rs. fifteen thousand three hundred twenty eight only) alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 13.11.2022 till its realization to the complainant. We further direct the OPs to pay Rs.10,000/- to the complainant on account of mental agony and harassment and Rs.5500/- towards the litigation expenses. This order shall be complied within 45 days from the date of receipt of copy of the order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated: 18.12.2024    

                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

                    (Neeru Agarwal)      (Sarvjeet Kaur)

                       Member                      Member           

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