District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 624/2022.
Date of Institution: 23.11.2022.
Date of Order:22.08.2023.
Jeet Pal Singh resident of flat No.F-112-A, Near Sai Vatika, Sector-63, Ballabgarh, District Faridabad.
…….Complainant……..
Versus
1. Care Health Insurance Limited, Formerly known as Religare Health Insurance Co. Ltd., Unit No.604, 6th floor, Tower NO.C, Unitech Cyber Park, Sector-39, Gurugram through its authorized person.
2. Care Health Insurance Limited, Formerly known as Religare Health Insurance Co. Ltd., 5th floor, 19 Chawla House Nehru Place, New Delhi – 110 019 through its authorized person.
…Opposite parties
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
PRESENT: Sh. Deepak Sharma , counsel for the complainant.
Sh. N.K.Garg , counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant had already taken the Care Health Insurance Policy with his family namely Anju,Mr. Saurabh and Deepak vide policy No. 30536477 dated 07.03.201 to 6.3.2023 sum insured amount of Rs.5,00,000/- from the opposite parties and the complainant had paid the premium amount to the opposite parties i.e. Rs.47,013/-. During the mediclaim policy, the wife of the complainant namely Anju was suffering from AFI with age with severe Dehydration and in this regard the wife of the complainant was admitted in Sunshine Hospital, Sector-64, Unchagaon Ballabgarh, Faridabad on 30.05.2022 at about 2:16 a.m. and was discharged on 4.6.2022 at 2.00p.m. and the said hospital raised the bill amount of Rs.25,696/- which was paid by the complainant in cash from his own pocket. Later on the complainant had sent all related documents regarding the treatment of complainant as well as bill for getting the imbursement of the mediclaim amount but the opposite parties lingering the matter on one pretext to the another and the opposite parties intentionally and knowingly issue the letter on dated 15.08.2022 and rejected the claim of the complainant The complainant sent a legal notice dated 10.10.2022 to the opposite parties but all in vain. 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) make the mediclaim amount of Rs.25,696/- in respect of the policy bearing No. 30536477 dated 07.03.2021 to 6.3.2023 alongiwth interest @ 18% p.a. to the complainant which was paid by the complainant form his his own pocket.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 22,000 /-as litigation expenses.
2. Opposite parties Nos.1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties Nos. 1 & 2 refuted claim of the complainant and submitted that the complainant Jeet Pal Singh was issued a Health Insurance Policy namely “CARE” cover type floater bearing No. 30536477 w.e.f. 7.3.2011 till 6.3.2002 by the opposite party company covering the complainant, his spouse namely Anju and his two sons namely Sourabh and Deepak for a sum insured of Rs.5,00,000/- subject to policy terms & conditions.
Claim No.1 (Re-imbursement claim (92374581-00)
The complainant approached the opposite party company with a reimbursement with respect to treatment of his son namely Saurabh undergone at ACE Multispeciality Hospital, Faridabad wherein he was admitted from 29.04.2022 till 2.5.2022 and was diagnosed with Enteric fever. The opposite party company on receipt of the claim sent a deficiency letter dated 21.05.2022, 28.05.2022, 16.6.2022, 2308.2022 and 30.6.2022 to provide the following documents necessary for proper and legally process of the claim:
i) Complete indoor case papers with admission notes, history sheet, doctor’s notes, nursing notes and vital chart;
ii) Detailed original final bill, pathologist registration certificate, treating doctor registration certificate.
The opposite party raised several reminders, despite that opposite party company did not get any response from the insured, hence same was got rejected vide letter dated 27.08.2022 with the following observations:
Claim No.2 Second re-imbursement claim NO. 92468188-00
Thereafter the complainant filed a second re-imbursement claim for the hospitalization of his wife namely Anju at Sunshine Hospital from 30.05.2022 till 01.6.2022 and was diagnosed with AFI with age with Sever Dehydration. Upon receipt of the claim an investigation was triggered to check the veracity of the claim. It was found that:
No doctor Paritosh stamp to validate ICP.
No Dr. Paritosh Signature even on DS.
Dr. Paritosh itself signature not matching on records.
Upon receipt of the claim multiple quarry was raised vide letter dated 09.07.202, 16.7.2022 and 23.7.2022 and was asked to provide the information. Despite the multiple quarry letters, the answering opposite party did not get any response from the insured hence the claim was rejected vide letter dated 15.08.2022 on the basis of Policy condition for Claim No.2
Clause 7.1 “Disclosure to information norm”
“if any untrue or incorrect statements are made on there had been a misrepresentation, mis-description or non-disclosure of any material particulars or any material information having been withheld or if a claim was fraudulently made or any fraudulent means or devises were used by the policy holder or the insured person or anyone acting on his/their behalf, the company shall had no liability to make payment or any claims and the premium paid should be forfeited ab initio to the company.”
Opposite parties Nos.1 & 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties–Care Health Insurance Company Ltd. with the prayer to: a) make the mediclaim amount of Rs.25,696/- in respect of the policy bearing No. 30536477 dated 07.03.2021 to 6.3.2023 alongwith interest @ 18% p.a. to the complainant which was paid by the complainant form his own pocket. b)pay Rs. 50,000/- as compensation for causing mental agony and harassment . c) pay Rs. 22,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Jeet Pal Singh, Ex.C-1 –policy, Ex.C-2 – Discharge on request,, Ex.C-3 – Final bill, Ex.C-4 & 5 – Cash memo/Estimate, Ex.C-6 – claim denial letter dated 15.08.2022, Ex.C-7 – legal notice, Ex.C-8 & 9 – postal receipts.
On the other hand, counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties Ex.RW1/A – affidavit of Garvit Saini of Care Health Insurance Ltd., Ex.R-1 – policy, Ex.R-2 – Discharge summary,, Ex.C-3 (colly) – deficiency letter dated 21.05.2020, Ex.R-4 – claim denial letter dated 27.08.2022, Ex.R-5 – History sheet, Ex.R-6 – Discharge on request, Ex.R-7 (colly) – deficiency letter dated 09.07.2022, Ex.R-8 – claim denial letter dated 15.08.2022.
6. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days from the date of receipt of the
copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite parties are also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alongwith Rs.2200/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. File be consigned to the record room.
Announced on: 22.08.2023 (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.
