Haryana

Karnal

CC/263/2023

Shishan Ram - Complainant(s)

Versus

Care Health Insurance Limited - Opp.Party(s)

G.K. Mittal

30 Sep 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.263 of 2023

                                                        Date of instt.03.05.2023

                                                        Date of Decision: 30.09.2024

 

Shishan Ram aged about 41 years son of Shri Rajbir, resident of village Koer, Tehsil Nilokheri, District Karnal. Aadhar card no.4422 1846 6410.

                                                                        …….Complainant.

                                              Versus

 

Care Health Insurance Ltd. (Formerly known as Religare Health Insurance Company Ltd.) Registered office at 5^th Place, 19 Chawla House, Nehru Place, New Delhi-110019, through its Manager.

 

                                                                        …..Opposite Party.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

              Ms. Neeru Agarwal…….Member

      Ms. Sarvjeet Kaur…..Member

 

 Argued by: Shri G.K. Mittal, counsel for the complainant.

                    Shri Ashwani Kumar Popli, counsel for the OP.

 

                     (Jaswant Singh, President)

ORDER:   

                

                  The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that the complainant had purchased a cashless medical health policy from the OP, vide policy no.17449218 valid from 06.06.2020 to 05.06.2021. Thereafter, complainant got renewed the said policy and said policy is valid from 06.06.2021 to 05.06.2022. In the said policy complainant (himself), his wife Smt. Poonam Devi and dependent son Kunwar Partap Singh are covered. In the month of September 2021, the complainant fell ill and due to his illness, he was admitted in Sanjiv Bansal Cygnus Hospital, Railway Road, Karnal and remained under treatment as indoor patient till 24.09.2021 but due to non-improvement of the complainant’s condition, the family members of the complainant got discharge him from the hospital to take him to higher institution/PGI Chandigarh. On 24.09.2021, the complainant reached to PGI Chandigarh, but the complainant was not admitted in the hospital and hence the family members of complainant again admitted to the complainant in Sanjiv Bansal Cygnus Hospital, Karnal due to his chronic liver disease with Jaundice, Ascitis, Coagulopathy Sepsis and again the complainant remained admitted in the said hospital from 24.09.2021 to 04.10.2021 and the complainant had spent a huge amount for his treatment. After discharge from the hospital, complainant submitted the documents i.e. remaining hospital bill and medicine bills amounting to Rs.1,11,870/- to OP for reimbursement of medical expenses under abovesaid policy. But OP has not passed the claim of the complainant and orally replied the complainant that due to consuming liquor he had fell ill. As per the terms and conditions of the policy, OP has to pay 60 days medicines expenses after discharging from the hospital. After discharge from the hospital, complainant submitted the medical bills with the OP for reimbursement but OP not passed the claim of the complainant. OP has received all the original documents and medicines bills from the complainant. Thereafter, complainant approached the OP several times and requested to reimburse the claim amount but OP did not pay any heed to the request of complainant and lingered the matter on one pretext or the other and lastly denied the claim of complainant on the false and frivolous ground. In this way, there is deficiency in service and unfair trade practice on the part of the OP. Hence, the present complaint.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; locus standi; jurisdiction and concealment of true and material facts. On merits, it is pleaded that OP issued a health insurance policy under plan namely “Care Floater” by the OP bearing policy no.17449218 w.e.f. 06.06.2020 till 05.06.2021 providing policy coverage to himself alongwith his spouse and a son for sum insured of Rs.500000/- subject to policy terms and conditions. The said policy was further renewed on annual basis w.e.f. 06.06.2021 till 05.06.2022. OP received a reimbursement claim no.CL-91981468-00-01 for complainant’s hospitalization at Sanjiv Bansal Cygnus Hospital, Karnal from 24.09.2021 till 04.10.2021. As per the discharge summary, the insured was finally diagnosed with HSV Positive, ACLF (Acute on Chronic Liver Failure) with Jaundice/Ascites/Coagulopathy Sepsis. The said claim form was received with the company on 10.11.2021. On perusal of medical documents received with claim form, made following observations:

i.      As per ICPs verified on 25.11.2021, under insured’s Relative declaration, the insured has a Drinking habit and currently he is suffering from Liver Failure due to Alcohol consumption but insured clearly denied for any Drinking habit.

ii.     However, the treating doctor in his statement mentions that etiology of present ailment is HCV.

        The insured and the treating doctor are trying to manipulate the medical records by hiding insured’s history of alcohol consumption. The OP in view of the above findings observed any treatment in relation to substance abuse or intoxication is permanently excluded from the policy terms and conditions. Accordingly, the reimbursement claim of the complainant was rejected and the same was intimated to the complainant, vide Denial letter dated 30.11.2021 on the following grounds:-

1. Permanent Exclusion
2. Permanent exclusion: condition caused by suicide or substance abuse/intoxication.

Policy Terms and Conditions:

The relevant clause pertaining to Permanent Exclusion is reproduced herein below:

4.2 Permanent Exclusions:

Any claim in respect of any insured person for, arising out of or directly or indirectly due to any of the following shall not be admissible, unless expressly stated to the contrary elsewhere in the policy terms and conditions.

23)       Act of self-destruction or self-inflicted injury, attempted suicide, or suicide while sane or insane or illness or injury attributable to consumption, use misuse, or abuse of intoxicating drugs, alcohol or hallucinogens.

It is further pleaded that the complainant has not supplied all the documents required for deciding the claim in hand and as such, the present complaint being premature is liable to be dismissed. 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.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy Ex.C1, copy of medical bills Ex.C2, copy of claim denial letter dated 30.11.2021 Ex.C3, copy of claim denial letter dated 03.12.2021 Ex.C4, copy of cashless authorization letter dated 24.09.2021 Ex.C5, copy of Lama Summary Ex.C6 and closed the evidence on 02.02.2024 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Parth Arora, Manager Ex.OP1/A, copy of policy certificate Ex.OP1, copy of policy claim form Ex.OP2, copy of discharge summary Ex.OP3, copy of claim form Ex.OP4, copy of customer feed back form Ex.OP5, copy of claim denial letter dated 30.11.2021 Ex.OP6, copy of terms and conditions of the policy Ex.OP7, copy of list of day care surgeries Ex.OP8, copy of list of expenses generally excluded (non medical) in hospital indemnity policy Ex.OP9, list of hospitals where claim will not be admitted Ex.OP10, list of hospitals where co-payment of 20% is not applicable under optional cover Smart Select Ex.OP11, copy of service request form Ex.OP12 and closed the evidence on 20.05.2024 by suffering separate statement.

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

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that the complainant purchased a cashless health policy from the OP  under the sum insured of Rs.5,00,000/-. During the subsistence of the insurance policy, complainant fell ill and got admitted in Sanjiv Bansal Cygnus Hospital, Karnal and spent an amount of Rs.1,11,870/- on his treatment. Complainant submitted the claim for reimbursement of abovesaid amount, but OP denied the claim of complainant on the false and frivolous ground. Thus, there is deficiency in service and unfair trade practice on the part of the OP and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that OP received the mediclaim of complainant regarding hospitalization in Sanjiv Bansal Cygnus Hospital, Karnal and on scrutiny of the documents, it was observed that insured was a drinking habits and was suffering from Liver Failure due to Alcohol consumption. The treatment in relation to substance abuse or intoxication is permanently excluded from the policy terms and conditions. Thus, the reimbursement claim of the complainant was rightly denied by the OP and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, complainant availed Health Insurance Policy Plan namely “Care Floater” from the OP. It is also admitted that during the subsistence of the insurance policy, complainant remained admitted in Sanjiv Bansal Cygnus Hospital Karnal.

11.           The claim of the complainant has been denied by the OP, vide denial letter Ex.C3/OP6 dated 30.11.2021 on the following grounds, which are reproduced as under:-

“We have reviewed the claim file by you pertaining to health insurance policy and herby inform you that the claim is not payable as per policy terms and conditions listed below:

.       Permanent exclusion.

.       Permanent exclusion: condition caused by suicide or substance abuse/intoxication.

12.           The claim of the complainant has been denied by the OP on the abovesaid ground. OP has alleged that complainant was a habitual of intoxication. The onus to prove its case was relied upon the OP but OP has miserably failed to prove the same by leading any cogent and convincing evidence. The case of the OP is based upon discharge summary Ex.OP3, on perusal of said discharge summary, it is no where mentioned that complainant was habitual of intoxication. There is nothing on the file to prove that the complainant was habitual of intoxication. Thus, the repudiation of the claim is based only on the basis of presumption and assumption, which is not admissible in the eyes of law.

13.           Furthermore, now a days 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”.

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

 15.          The complainant has claimed an amount of Rs.1,11,870/- on account of his treatment and in this regard, he has placed on file medical bills Ex.C2 (23 bills) and the said medical bills neither denied nor rebutted by the OP. Hence, the complainant is entitled for the said amount of alongwith interest, compensation for mental pain, agony harassment and litigation expenses etc.

16.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.1,11,870/- (Rs. one lakh eleven thousand eight hundred seventy only)  to the complainant alongwith interest @ 9% per annum from the date of denial of the claim i.e. 30.11.2021 till its realization. We further direct the OP to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs. 11,000/- 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: 30.09.2024

                                                               

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Neeru Agarwal)         (Sarvjeet Kaur)

                   Member                          Member