Haryana

Karnal

CC/555/2023

Vijay Kumar - Complainant(s)

Versus

Care Health Insurance Limited - Opp.Party(s)

Sham Sunder Pruthi

05 Nov 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.555 of 2023

                                                        Date of instt.04.10.2023

                                                        Date of Decision: 05.11.2024

 

Vijay Kumar son of Shri Nand Lal, resident of house no.1759, Sector-7, Urban Estate, Karnal.

                                                                        …….Complainant.

                                              Versus

 

1. Care Health Insurance Limited, 5^th floor, 19 Chawla House, Nehru Place, New Delhi-110019, through its Manager.
2. M/s Care Health Insurance Ltd. formerly known as M/s Religare Health Insurance, Corporate office: Vipul Tech Square, Tower-C, 3^rd floor, Golf Course Road, Sector-43, Gurgaon-122009 through its Manager.

…..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:  Shri S.S. Pruthi, counsel for the complainant.

                    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 alongwith his wife is a health policy holder of OPs since 06.09.2017, which has been continuously renewed from time to time. The existing policy no.18037485 with insured card ID no.79511116 at the time of treatment is valid w.e.f. 06.09.2021 to 05.09.2022 under plan name Group Care 360 (PNB-Platinum). Under the said policy, the complainant is provided health insurance cover of Rs.7,00,000/- which include Cataract Surgery. During the currency of policy, he has diagnosed with BE IMSC L&R i.e. Cataract of Left Eye by doctors of Foresight Eye Clinic, Super Specialty Eye Hospital, Malviya Nagar, New Delhi and as such was admitted for OSMICS with IOL implantation, on 08.08.2022. The hospital authority requested the OPs for Pre-authorization of cashless hospitalization for expected cost of Rs.45,000/- which was sent to the OPs for approval of competent Authority. The OPs sanctioned Rs.40,000/- vide authorization letter dated 08.08.2022 under claim no.AL80774273 for cashless hospitalization. After approval of the OPs, the complainant was operated under Day Care on 08.08.2022 by implanting Monofocal Lens Alcon SN6OWF IQ (India) as pre-approved by OPs, in his left eye and then was discharged at night on the same day. Hospital authorities informed the complainant that they have received a sum of Rs.17,000/- only on 25.10.2022 as against initially approved amount of Rs.40,000/- from the OPs and insisted upon the complainant to pay differential amount of Rs.23,000/-. The complainant requested many times to OPs through emails and telephonically to settle the claim and pay the balance amount of Rs.23,000/- as per Cashless Authorization letter issued for the approved amount of Rs.40,000/-. But OPs did not pay any heed to the request of complainant. Then complainant sent a legal notice dated 11.07.2023 but it also did not yield any result. 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 direct to the OPs to pay Rs.23000/-with interest @ 18% per annum from 06.01.2023 i.e. the date of payment till realization, to pay Rs.30,000/- as compensation for mental pain, agony and harassment and to pay Rs.25,000/- as 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 the present complaint is pre-mature in nature. The complainant has only filed for cashless facility request and has not filed any reimbursement claim. Therefore, company cannot ascertain its liability in this matter. The OPs issued a Group Health Insurance Policy to the Group policyholder i.e. Punjab National Bank, vide Group Policy no.17499225 namely “Punjab National Bank Group Care 360 (PNB-Platinum)” thereby covering its customers complainant Mr. Vijay Kumar, complainant’s spouse Mrs. Vimal Pruthi, vide certificate of insurance no.18037485 with effect from 06.09.2020 to 05.09.2021 for a sum insured upto Rs.7,00,000/- subject to policy terms and conditions. The policy was further renewed from 06.09.2021 to 05.09.2022. The policy was further renewed from 06.09.2022 to 05.09.2023. A cashless request no.80774273 was received from M/s Foresight Eye Clinic on behalf of complainant for his hospitalization on Foresight Eye Clinic on 08.08.2022. As per the pre-authorization form, the complainant was provisionally diagnosed with IMSCLR. The OPs upon perusing the documents processed the claim of Rs.45000/- in accordance with policy terms and conditions. Accordingly, the claim for an amount of Rs.17000/- was approved and paid on 25.10.2022. The same was intimated to the complainant, vide settlement letter dated 27.10.2022 and as sum of Rs.28000/- were deducted. Reason for Deduction are as under:-

Head/Particulars	Clause/Remarks	Amount
Hospital Discount		5000/-
Tariff difference	As per the MOU between the hospital and the company, the company is entitled to pay Rs.22000/- in respect to treatment of contract (inclusive of IOL cost). However, as per the bill dated 08.08.2022, it is mentioned that the complainant availed the package charges of Rs.45000/-.

 

It is further pleaded that OPs company received a legal notice dated 11.07.2023 which was duly replied and wherein OPs company requested the complainant to file for reimbursement for the deducted amount alongwith documents. However, the complainant failed to provide the documents to process the claim in accordance to policy terms and conditions. There is no deficiency in service and unfair trade practice on the part of the OPs. 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 valid from 06.09.2021 to 05.09.2022 Ex.C1, copy of insurance policy valid from 06.09.2022 to 05.09.2023 Ex.C2, copy of discharge summary dated 08.08.2022 Ex.C3, copy of Lens Implant Card Ex.C4, copy of Pre-authorization form Ex.C5, copy of OPD slip dated 02.08.2022 Ex.C6, copy of cashless authorization letter dated 08.08.2022 Ex.C7, copy of claim approval letter dated 22.10.2022 Ex.C8, copy of receipt dated 06.01.2023 Ex.C9, copy of legal notice Ex.C10, postal receipt Ex.C11, reply of legal notice Ex.C12, letter dated 07.08.2023 issued by OPs Ex.C13, courier receipt Ex.C14, acknowledgement Ex.C15, email to OP Ex.C16 and closed the evidence on 05.03.2024 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Parth Arora Ex.OP1/A, copy of policy certificate Ex.OP1, copy of claim authorization form Ex.OP2, copy of policy terms and conditions Ex.OP3, copy of claim settlement letter dated 27.10.2022 Ex.OP4, copy of legal notice Ex.OP5, copy of reply to legal notice Ex.OP6 and closed the evidence on21.05.2024 by suffering separate statement.

6.             We have heard the learned counsel for the parties and perused the case file carefully and 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 complainant alongwith his wife purchased a health insurance policy from the OPs. During the subsistence of the insurance policy, complainant was diagnosed with BE IMSC L&R i.e. Cataract of Left Eye in Super specialty Eye Hospital, New Delhi and spent an amount of Rs.40,000/- on his treatment. The pre-authorization request of complainant was approved. OPs paid only Rs.17,000/- and deducted the amount of Rs.23,000/- on the basis false and frivolous ground. Thus, there is deficiency in service and unfair trade practice on the part of the OPs 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 the a cashless request was received from M/s Foresight Eye Clinic on behalf of complainant for his hospitalization on 08.08.2022. As per terms and conditions of the insurance policy, an amount of Rs.17000/- was approved and paid on 25.10.2022 and as sum of Rs.28000/- were deducted. He further argued that the present complaint is premature as the OPs requested the complainant to file the claim for reimbursement for the deducted amount alongwith documents but complainant did not file any claim and also failed to provide the documents to process the claim and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, complainant alongwith his wife availed Health Insurance Policy plan name Group Care 360 (PNB-Platinum) from the OPs. It is also admitted that during the subsistence of the insurance policy the complainant has taken treatment for Cataract of Left Eye in Super specialty Eye Hospital, New Delhi and spent an amount of Rs.40,000/- on his treatment. It is also admitted that an amount of Rs.17,000/- has already paid to the insured.

11.           Complainant has spent an amount of Rs.40,000/- on his treatment but OPs paid only Rs.17,000/- and made the deduction of Rs.23,000/- without any cogent reason. OPs have alleged that the deduction made by them as per terms and conditions of the insurance policy. OPs also alleged that till date no claim has been submitted by the complainant for reimbursement. On the other hand, complainant has alleged that he submitted the claim with the OPs for reimbursement of the remaining amount of Rs.23,000/-. The onus to prove his version was relied upon the complainant. To prove his version, complainant has placed on file application Ex.C13 dated 07.08.2023 alongwith courier receipt Ex.C14 and Trackin Courier Pvt. Ltd. Delivery Run Sheet Ex.C15. It is evident from the application Ex.C13 dated 07.08.2013, complainant applied for reimbursement of the claim. It is also evident from the Delivery Run Sheet Ex.C15, OPs have received the claim application on 09.08.2023. Hence, it has been proved on record, complainant has applied for reimbursement of the remaining claim amount of Rs.23,000/-. OPs have also failed to prove on record as to why such huge deduction made in the cashless claim. Thus, the plea taken by the OPs, has no force.

12.           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”.

13.           Keeping in view, the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, the act of the OPs, while deducting the amount of Rs.23000/- amounts to deficiency in services and unfair trade practice, which is otherwise proved genuine one. Hence, the complainant is entitled for remaining amount of Rs.23000/- alongwith interest, compensation for mental pain, agony and harassment and litigation expenses etc.

14.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.23000/- (Rs. twenty three thousand only) to the complainant alongwith interest @ 9% per annum from the date of filing the complaint i.e. 04.10.2023 till its realization. We further direct the OPs to pay Rs.20,000/- 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 receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated: 05.11.2024   

                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Neeru Agarwal)         (Sarvjeet Kaur)

                   Member                          Member