District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.505/2022.
Date of Institution:16.09.2022.
Date of Order: 26.02.2024.
Dev Dutt S/o Shri Chaju Ram R/o Village Shahpur Kalan, Ballabgarh, District Faridabad – 121004 (Haryana) Aged 61 years. Aadhar No. 8612 8261 0613.
…….Complainant……..
Versus
1. Care Health Insurance Limited, (Formerly known as Religare Health Insurance Company Limited) Head Office at Unit NO. 604, 6th floor, Tower-C, Unitech Cyber Park, Sector-39. Gurgram-122001 (Haryana) through its Principal Officer/Managing Director.
Branch office at CHIL, Vipul Tech Square, Tower-C, 3rd floor, Golf Course Road, Gurugram – 122009(Haryana).
2. Sarvodaya Hospital and Research Centre, Sector-8, Faridabad through its Principal Officer/Authorised Person.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Kamlesh Sharma , counsel for the complainant.
Sh. N.K.Garg , counsel for opposite party No.1.
Sh. Yogender Singh, counsel for opposite party No.2
ORDER:
The facts in brief of the complaint are that the complainant had obtained mediclaim policy bearing policy No. 37246998, plan name 360 (Scheme III for SHCB), Single Premium Floater, ID No. 99815309 issued on 04.01.2022 valid form 09.12.2021 to 08.12.2023 from the opposite party against which the complainant had paid the premium of Rs.13,268/- including the GST in the said premium amount to the opposite party. The said mediclaim policy had issued the opposite party to the complainant with regard to provide the cashless facility for treatment without charging from the complainant and directly dealing with insurance company against sum insured amount of Rs.5,00,000/-. Suddenly the complainant was started to problem in shortness of breath with ghabrahat and thus the complainant admitted in the emergency department of opposite party No.2 – Sarvodaya Hospital and Research Centre, sector-8,Faridabad onn06.07.2022 at about 08:36p.m. under IP No. IP264833 and wherein the doctors of said hospital provided the treatment to the complainant and discharged the complainant from the said hospital on 12.07.2022 at stable condition. Opposite party No.2 had issued the net bill of Rs.3,45,479.91 vide summary bill of supply dated 12.07.2022 after giving the discount of Rs.15,479.91 the complainant had paid an amount of Rs.3,30,000/- to the opposite party No.2. The opposite party No.2 sent all the document sot the opposite parpty No.1 through email and other modes to pay and reimburse the amount of Rs.3,30,000/- to the complainant which had already been paid by the complainant to opposite party No.2 qua the treatment charges but the
opposite party No.1 vide its denial letter dated 12.07.2022 with the observations that the cashless hospitalization could not be approved as per the terms and conditions of the policy. The complainant had been contacting the opposite parties time and again through telephone and through his written requests and letters vide which the complainant had been requesting the opposite parties to pay and reimburse an amount of Rs.3,30,000/- to the opposite party No.2 and other allied expenses. After submission of all relevant documents opposite parties had been deliberately avoiding the complainant’s legitimate demands towards the aforesaid amount. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) release an amount of Rs.3,30,000/- alongwith interest @ 24% p.a. qua the bill amount of treatment to the opposite parties No.2.
b) reimburse an amount of Rs.3,30,000/- which had been paid by the complainant to the opposite party No.2 qua the net bill amount of treatment.
c) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
d) pay Rs.21,000/- as litigation expenses.
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the opposite party company issued a Group policy bearing NO. 18498780 to policy holdr “Sarv Haryana Gramin Bank” under which a health insurance policy bearing COI No. 37246998 under the plan namely “Group Care 360 (Scheme III for SHGB)” was issued to the complainant Mr. Dev. Dutt. The said policy was issued for the period w.e.f.9.12.2021 till 08.12.2023 for providing policy coverage to the complainant and his spouse for a sum insured of
Rs.5,00,000/- subject to policy terms & conditions. The complainant approached the opposite party company with a cashless facility request claim NO. AL-80751765-00 from Sarvodaya Hospital & Research Centre, Faridabad on 06.07.2022 for complaints of shortness of breath and ghabrahat and was stated to have been provisionally diagnosed with LRTI with respiratory failure with suspected acute LVF with ACS. The opposite party company on receipt of the said cashless request sent a deficiency letter dated 7.7.2022 seeking following information/documents:
(i) to provide (i) Exact duration and past hospital of present ailment with first consultation paper and all past treatment records;
Any heart disease PED?
(ii) Pre-hospitalization OPD treatment records;
The hospital replied to the above quarry stating that the complainant insured did not have any past history of heart disease. Another query was also raised to the treating hospital vide deficiency letter dated 08.07.2022 and 09.07.22 seeking following information/documents:
To provide
(i) Documents required details of personal habits;
(ii) Exact duration and past history of present ailments with first consultation paper and all past treatment records. COPD.
(iii) Pre-hospitalization OPD treatment record and all past OPD records of COPD.
Another query was also raised to the treating hospital vide deficiency letter dated
09.07.2022 with consultation paper for COPD prior to 2.6.2022 (mandatory).
The cashless claim was initially approved for a sum of Rs.30,000/- and the same was intimated to the hospital vide cashless authorization letter dated 10.07.2022. However, the said approval and final settlement was always conditional and stand null & void in case of any misrepresentation/concealment of fact or any kind of discrepancy found in medical documents or information provided. Thereafter, an enhancement of cashless claim was requested by the treating hospital vide letter dated 11.7.2022 wherein it was informed that the insured had underwent CAG+PTCA (Angioplasty) surgery. After perusal of the documents received alongwith a pre-authorization cashless request form and addl. Documents procured during the investigation, the opposite party company came up forefront with the following findings:
As per the preliminary discharge summary provided the insured was mentioned with final diagnoses of type-II respiratory failure, LRTI. Acute LVF, with CAD-SVD with post PTCA +stent 2, LCX, AK1 and LEF-25%. It was pertinent to mention that any treatment relating to heart disease/heart failure was not covered until the expiry of 12 months/one year as had been stated in the policy itself. The policy certificate was mentioned below:
List of conditions with specific wait period
Conditions with wait period of 12 months
- Pancreatitis
- End stage liver disease
- Cerebrovascular accident
- Renal failure/end stage renal disease
- Cardiomyopathies
- Myocardial infarction
- Heat failure
- Arrhythmia/Heart blocks
- All types of cancer
In view of the above findings, the opposite party company repudiated the cashless request vide denial letter dated 11.07.2022 on the following grounds:
One year waiting period for heart disease and related complications. Initial stands full & void. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Opposite party No. 2 put in appearance through counsel and filed written statement wherein Opposite party No.2 refuted claim of the complainant and submitted that the answering opposite party had performed it part of duty diligently and had sent the request for cashless hospitalization/treatment of the patient alongwith the estimate expenses summary and other required documents to Insurance company/TPA on 06.07.2022 when the complainant was admitted with the answering opposite party. The insurance company, upon the intimation/request of the answering opposite party denied the said request for cashless treatment under the mediclaim policy vide its denial letter dated 12.07.2022 giving reasons that “The cashless hospitalization cannot be approved as per the terms and conditions of the policy”. The complainant got discharged from the answering opposite party on 12.07.2022, the answering opposite party provided him with all the services even after his discharge and provided all necessary clarifications etc.
for the approval of his cashless claim. If opposite party No.1 had denied his mediclaim inspite of having all the information and clarification received from the answering opposite party then the answering opposite party can’t be held liable to pay anything to the complainant. The answering opposite party had provided the best of the medical services to the complainant and he got discharged on dated 12.07.2022 from the answering opposite party hospital, the comlainant’s condition improved clinically during the hospital stay, and he was stable before being discharged and as far as the responsibility to reimburse the expenses of the treatment under the mediclaim policy was the concern of the opposite party No.1 and the answering opposite party had also provided all the necessary support in this regard which he could provide to the complainant. Opposite party No. 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties–Care Health Insurance Limited. with the prayer to: a) release an amount of Rs.3,30,000/- alongwith interest @ 24% p.a. qua the bill amount of treatment to the opposite parties No.2. b)reimburse an amount of Rs.3,30,000/- which had been paid by the complainant to the opposite party No.2 qua the net bill amount of treatment. c) pay Rs.1,00,000/- as compensation for causing mental agony and harassment . d) pay Rs.21,000/- as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW-1/A – affidavit of Dev Dutt, Ex.C-1 – policy,, Ex.C-2 – emergency
certificate, Ex.C-3 – discharge summary, , Ex.C-4 – summary bill of supply,, Ex.C-5 – Sales summary,, Ex.C-6 – essentiality certificate,, Ex.C-7 receipt, Ex.C-8 – OPD sheet,, Ex.C-9 – denial letter.
On the other hand counsel for the opposite party No.1 strongly agitated and opposed. As per the evidence of the opposite party No.1 Ex.RW1/A – affidavit of Deepak Mishra of Care health Insurance Ltd, Ex.R-1 – insurance policy alongwith terms and conditions, Ex.r-2 – Cashless Hospitalization for medical insurance policy,, Ex.R-3 & 4 – deficiency letters, Ex.R-5 – Cashless Authorization letter dated 10.07.2022, Ex.R-6 – cashless request,Ex.R-7 – denial letter.
As per the evidence of opposite party No.2 Ex.DW2/A – affidavit of Saurabh Gehlaut, Authorized representative of Sarvodaya Hospital & Research centre. YMCA road, sector-8, Faridabad,, Ex.D-2/A – denial letter, Ex.D-2/B – discharge summary,, Ex.D-2/C – letter dated 04.01.2022, Ex.D-2/D – Taxable income-cum-bill of supply.
7. In this case, the complaint was filed by the complainant with the prayer release an amount of Rs.3,30,000/- alongwith interest @ 24% p.a. qua the bill amount of treatment to the opposite parties No.2..
8. As per Ex.C-1, the complainant obtained medicalim policy bearing policy No. 37246998, plan name 360 (Scheme III for SHCB), Single Premium Floater, ID No. 99815309 issued on 04.01.2022 valid form 09.12.2021 to 08.12.2023 from the opposite party As per discharge summary vide Ex.C-3 ,the complainant admitted in Sarvodaya Hospital from 06.07.2022 to 12.07.2022 for the diagnosis of Type 2 Respiratory Failure LRTI ACUTE LVF CAD – ACS CAG-SVD POST PTCA + STENT TO LCX AKI LVEF-25%. Waiting period of this disease is 12 months vide denial letter dated 11.07.2022. As per the insurance policy the details are as under:
Benefit
S.No | Particulars | Basis of offer (On Annual Basis. |
1. | Sum insured | Rs.5,00,000/- |
2. | In patient care | Up to sl. |
3. | Day care treatment | Upto sum insured, 170 procedures |
4. | Pre hospitalization medical expenses | 15 days |
5. | Pot hospitalization medical expenses | 30 days |
6. | Domestic road ambulance | Upto Rs.1000 per hospitalization |
7. | Alternative treatments (IPD basis) | Upto Rs.25,000/- for Ayurveda, Unani, Siddha and Homeopath treatment |
8. | Health Check up | Complimentary Health checkup for Prime Member and Spouse Once at 3 years provided there are no claims reported during block |
9. | Wait period | 30 days Yes (Except Accidental injuries) |
10. | Named ailments | 1 year (see Annexure D) (see Annexure E) |
11, | Pre existing disease | 3 years |
12. | Room rent | 1% of Sl per day |
13. | ICU charges | 2% of Sl. Per day |
Annexure D
List of conditions with specific wait period conditions with wait period of 12 month.
- Pancreatitis
- End Stage Liver Disease
- Carebroascular accident
- Renal failure/End Stage Penal Disease.
- Crodomyopathies
- Myocardial Infraction
- Heart Failure
- Heart Block
- All types of cancer
Admission of the complainant is less than 12 months which is mentioned in the above exclusion clause.
9. Keeping in view of the above submissions, the Commission is of the opinion that no deficiency in service on the part of the opposite parties have been proved. Resultantly, the complaint is dismissed. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 26.02.2024 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
