DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

                            Complaint Case No: CC/7/2024

                                                           Date of Institution: 23.01.2024

                            Date of Decision: 18.09.2024

Subash Chander aged about 67 son of Bachan Dev resident of Street No. 6, Near Government High School, School Road, Tapa Mandi, Teshil Tapa, District Barnala.    

ﾅComplainant

                                                   Versus

1. Care Health Insurance Limited, Regd Office, 5th Floor, 19 Chawla house, Nehru Place, New Delhi-110019 through its Manager/Authorized Signatory.   

2. Punjab Gramin Bank, Branch Pakho Kalan, Tapa, District Barnala, through its Manager.    

                                                                                       ﾅOpposite Parties

Complaint Under Section 35 of the Consumer Protection Act, 2019.

Present: Sh. Gagandeep Garg Adv counsel for complainant.

              Sh. Dhiraj Kumar Adv counsel for opposite party No. 1.

    Opposite party No. 2 exparte. 

Quorum.-

1. Sh. Ashish Kumar Grover: President

2. Sh. Navdeep Kumar Garg : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Care Health Insurance Limited, Regd Office, 5th Floor, 19 Chawla house, Nehru Place, New Delhi-110019 through its Manager/Authorized Signatory & others (in short the opposite parties). 

2. The facts leading to the present complaint are that the complainant is lay man having not very much knowledge of the technicalities of the banks and insurance Companies. It is alleged that the op no. l is the Head office being insurance Company and op no.2 is Bank branch of Punjab Gramin Bank and op no.1 is doing business of insurance and providing services of insurance to the customers and the op no.2 is doing the business of banking and op no.2 has a tie up with the op no. 1 to do the insurance of the account holders with the op no.2 and op no. 1 has also sister concern. It is further alleged that complainant has also saving account bearing no.87720100012718 with Op no.2. It is alleged that in the month of May 2022 complainant went for one transaction with the op no.2 and where agent of the op no. 1 talked about the various types of health policies issued by the ops and also told the benefits of the one policy Group Care 360 Policy, thereafter complainant agreed to purchased said policy for himself. It is further alleged that in the next year again complainant renewed the said Group Care 360 Policy from op no.1 and 2 for himself for the period of 28.05.2023 to 27.05.2024 after paying the amount of Rs. 8386 /- for the said policy. Thereafter, ops examined medically to the complainant and also done other necessary checkup and after doing all the medical checkup and complainant found physically fit op no. 1 and op no.2 issued policy bearing No. 18348790 in the name of complainant and as per policy terms complainant was insured Up to the amount of Rs. 5,00,000/- lacs for the period of policy one year or the any type of ailment, disease or bodily problem for the above said period and it was cashless policy. It is further alleged that complainant in the month of September 2023 suffered from problem of ACUTE PANCREATITIS and thereafter complainant admitted to the Chandigarh Clinic and Nursing Home Neuro and Gastro Centre Bathinda and where he remained admitted form 03.09.2023 to 06.09.2023 and on 06.09.2023 the complainant was discharge from said Hospital and total expenditure of Rs. 23,173/- approximately was charged by said hospital despite the fact that policy was cashless and complainant has to pay all the payment in cash to hospital. It is alleged that thereafter immediately complainant approached to the op no.1 for submission of the claim documents and op no.1 in view to grab the claim of complainant returned to complainant 3-4 times to complete the unjust formalities to get the claim amount, and thereafter on 13 Oct 2023 after completion of all required documents op no.1 accepted all the original documents and kept it with itself and generated claim no.93629003-00 of the claim and assured that claim will be paid very soon to complainant. It is further alleged that complainant has already submitted all the treatment history, medical bills, discharge summary and other relevant documents in original with opposite parties but the opposite parties did not pay single money of medical treatment claim of the said policy. As such, the act and conduct of the opposite parties comes within the definition of the unfair trade practice as well as deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.-

i. The opposite parties may be directed to pay the genuine claim of the remaining amount of complainant i.e. Rs. 23,173/- alongwith interest @ 18% per annum from the date of deposit of documents till realization.

ii. To pay Rs. 50,000/- towards mental tension and harassment. 

iii. Further, to pay Rs. 15,000/- as litigation expenses. 

3. Upon notice of this complaint, the opposite party No. 1 appeared and filed written version by taking preliminary objections interalia on the grounds that the complaint is not maintainable. The present complaint has been filed with malafide intention and has not come with clean hands. The complaint is false, frivolous and vexatious in nature. The complainant has tried to challenge the veracity of decision of the opposite party to repudiate the claim. This Commission has no jurisdiction to entertain the present complaint etc. 

4. On merits, it is admitted that the opposite party company issued group health Insurance policy to the group policyholder i.e. Punjab Gramin Bank vide Group Policy No. 18348790 namely "Group Care 360ﾰ (Scheme 1 for PGB)" thereby covering its customer Mr. Subash Chander vide Certificate of Insurance No. 43234226 from 28-05-2022 till 27-05-2023 for a sum insured up to Rs. 5,00,000/- subject to policy terms and conditions. The said policy was further renewed till 27-05-2024. It is further alleged that the Policy Certificate along with Policy Terms and Conditions was delivered electronically to the Complainant no dispute was raised during the free look period as prescribed under policy terms and conditions. It is further alleged that believing the information and details provided by the Proposer including the medical history to be true and correct in all respect and going due credence to the under writing norms of replying opposite party Company, a Policy issued. It is further alleged that a reimbursement claim was filed for the hospitalization of the complainant at Chandigarh Clinic & Nursing Home Neuro & Gastro Centre from 03-09-2023 till 06-09-2023 as he was diagnosed with Acute pancreatitis, benign prostate hypertrophy, acute kidney injury. Upon receipt of the claim a query dated 28-10-2023 was raised and the complainant was asked to provide: 1. TREATING DOCTOR'S CERTIFICATE FOR ETIOLOGY OF PRESENT AILMENT. 2. 1ST CONSULTATION PAPER IMMEDIATELY AFTER INCIDENT. Upon the receipt of the claim an investigation was also triggered to check the veracity of the claim. Therefore the opponent sent a claim denial letter dated 09-11-2023, stating that the claim has been rejected on the grounds of: WAITING PERIOD APPLICABLE, 5.1.1(b).vi.3 2 YEAR WAITING PERIOD TREATMENT FOR BENIGN PROSTRATE HYPERTROPHY, 5.1.1(b).vi.10 2 YEAR WAITING PERIOD TREATMENT OF INTERNAL TUMORS, SKIN TUMORS, CYSTS, NODULES, POLYPS INCLUDING BREAST LUMPS (EACH OF ANY KIND) UNLESS MALIGNANT. It is further alleged that as per CLAUSE 5: EXCLUSIONS, Standard Exclusions (b) Specific Wait Period for named ailments; Expenses related to the treatment of the listed Conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with the Company. This exclusion shall not be applicable for claims arising due to an accident. It is further alleged that in case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase. Further, if any of the specified disease/procedure falls under the waiting period specified for pre-Existing diseases, then the longer of the two waiting periods shall apply. It is further alleged that the waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion. If the insured person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage. It is further alleged that the complainant violated the terms and conditions of the policy. All other allegations of the complaint are denied and prayed for the dismissal of complaint. 

5. The opposite party No. 2 was proceeded against exparte vide order dated 15.3.2024 due to non appearance. 

6. The complainant filed rejoinder to the written version of opposite party No. 1 vide which denied the averments as mentioned in the version. 

7. The complainant tendered into evidence affidavit of complainant as Ex.C-1, copy of policy as Ex.C-2, copy of discharge summary Ex.C-3, copy of medical lab bills and test report as Ex,C-4 to Ex.C-38, copy of payment receipt Ex.C-39 to Ex.C-45, copy of claim submission form as Ex.C-46 to Ex.C-47, copy of reminder Ex.C-48 to Ex.C-49, copy of denial claim as Ex.C-50, copy of aadhar card as Ex.C-51 and closed the evidence.

8. The opposite party No. 1 tendered into evidence affidavit of Sh. Prabhjyot Singh Authorized Signatory as Ex.OP1/1, copy of policy as Ex.OP1/2 (5 pages), copy of claim form as ExOP1/3 (4 Pages), copy of deficiency letter as Ex.OP1/4, copy of denial letter as Ex.OP1/5, copy of terms and conditions as Ex.OP1/6 (43 Pages) and closed the evidence.

9. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments filed by the complainant. 

10. It is admitted case of the opposite party No. 1 that the opposite party company issued group health Insurance policy to the group policyholder i.e. Punjab Gramin Bank vide Group Policy No. 18348790 namely "Group Care 360ﾰ (Scheme 1 for PGB)" thereby covering its customer Mr. Subash Chander vide Certificate of Insurance No. 43234226 from 28.05.2022 till 27.05.2023 for a sum insured up to Rs. 5,00,000/- (as per insurance policy Ex.C-2 & Ex.O.P1/2). 

11. Ld. Counsel for the complainant argued that in the month of September 2023 suffered from problem of ACUTE PANCREATITIS and thereafter complainant admitted to the Chandigarh Clinic and Nursing Home Neuro and Gastro Centre Bathinda and where he remained admitted form 03.09.2023 to 06.09.2023 (as per Ex.C-3) and on 06.09.2023 the complainant was discharge from said Hospital and total expenditure of Rs. 23,173/- approximately was charged by said hospital despite the fact that policy was cashless and complainant has to pay all the payment in cash to hospital. It is further argued that thereafter immediately complainant approached to the opposite party No. 1 for submission of the claim documents and but the opposite party No. 1 in order to grab the claim of complainant returned to complainant 3-4 times to complete the unjust formalities to get the claim amount and thereafter on 13 Oct 2023 after completion of all required documents the opposite party No. 1 accepted all the original documents and kept it with itself and generated claim No.93629003-00 of the claim and assured that claim will be paid very soon to complainant. It is further argued that despite the fact that the complainant has already submitted all the treatment history, medical bills, discharge summary and other relevant documents in original with Insurance Company but they did not pay single money of medical treatment claim of the said policy.

12. On the other hand, Ld. Counsel for the opposite party No. 1 argued that believing the information and details provided by the Proposer including the medical history to be true and correct in all respect and going due credence to the under writing norms the opposite party company issued the above said policy. It is further argued that a reimbursement claim was filed for the hospitalization of the complainant at Chandigarh Clinic & Nursing Home Neuro & Gastro Centre from 03.09.2023 till 06.09.2023 as he was diagnosed with Acute pancreatitis, benign prostate hypertrophy, acute kidney injury and upon receipt of the claim a query dated 28.10.2023 Ex.O.P1/4 was raised and the complainant was asked to provide as mentioned therein. It is further argued that upon the receipt of the claim an investigation was also triggered to check the veracity of the claim, therefore the opposite party sent a claim denial letter dated 09.11.2023 Ex.O.P1/5 stating that the claim has been rejected on the grounds as mentioned therein. 

13. We have carefully gone through the facts and evidence produced by both the parties. We have gone through the denial letter dated 9.11.2023 of opposite party Ex.O.P1/5 vide which the opposite party rejected the claim of the complainant on the ground that "WAITING PERIOD APPLICABLE, 5.1.1(b).vi.3 2 YEAR WAITING PERIOD TREATMENT FOR BENIGN PROSTRATE HYPERTROPHY, 5.1.1(b).vi.10 2 YEAR WAITING PERIOD TREATMENT OF INTERNAL TUMORS, SKIN TUMORS, CYSTS, NODULES, POLYPS INCLUDING BREAST LUMPS (EACH OF ANY KIND) UNLESS MALIGNANT". On the other hand, Ld. Counsel for the complainant argued that the complainant has taken the treatment in the above said hospital of ACUTE PANCREATITIS. The complainant to prove this fact has placed on record copy of certificate of doctor of Chandigarh Clinic & Nursing Home Neuro & Gastro Centre Ex.C-9 vide which it is mentioned that "This is to inform that Mr. Subhash Chand has admitted in our hospital on 3.9.2023 and was diagnosed with DIOPATHIC Acute Pancreat, The Etiology of Pancreatitis is Idiopathic". So, from the above said certificate Ex.C-9 of doctor who treated the complainant it established that the complainant was diagnosed with Diopathic Acute Pancreatitis and not taken the above said treatment as alleged by the opposite party in its denial letter Ex.O.P1/5.  

14. Further, the Ld. Counsel for the complainant argued that the terms and conditions were not supplied to the complainant alongwith policy, therefore the same are not part of contract. We have carefully gone through the policy placed on record by the complainant Ex.C-2 which is of one page and the terms and conditions are not the part of the policy in question. On the other hand, the opposite party No. 1 has failed to place on record any postal receipt or any document to prove that they have supplied the terms and conditions of the policy to the insured/complainant alongwith policy in question. Therefore, the terms and conditions on which the opposite party No. 1 has relied upon are not part of the contract. The Hon'ble Supreme Court of India titled Modern Insulators Limited Versus Oriental Insurance Company Limited reported in 2000(1) CPC-596 in which Hon'ble Supreme Court held that "As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclose to the appellant, respondent cannot claim the benefit of the said exclusion clause." The Hon'ble Supreme Court of India (2019) 6 SCC 212 in case titled Bharat Watch Company Through its Partner Vs National Insurance Company Limited held that "Conditions of exclusion under policy document not handed over to insured by insurer and in absence of insured being made aware of terms of exclusion, held, it is not open to insurer to rely upon exclusionary clauses". Ld. Counsel for the complainant also relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that 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. 

15. From the above discussion, it is proved that the claim of the complainant/insured was declined by the opposite party No. 1 on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite party No. 1. 

16. The complainant to prove his claim has placed on record copies of receipts and pharmacy bills as Ex.C-33 to Ex.C-38 and Ex.C-43 which shows that Rs. 21,602/- has been spent on the treatment of the complainant in the above said hospital. However, the complainant in the present complaint has claimed Rs. 23,173/-.

17. In view of the above discussion, the present complaint is partly allowed against the opposite party No. 1 and the opposite party No. 1 is directed to pay an amount of Rs. 21,602/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite party No. 1 is further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

18th Day of September, 2024

 

      (Ashish Kumar Grover)

                                               President

         

                (Navdeep Kumar Garg)

       Member