District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 489/2022.
Date of Institution:08.09.2022.
Date of Order:14.07.2023.
Shri Lakhmi Chand son of Shri Hari Singh resident of Bamni Khera, Sarai Distt. Palwal Adhar No. 9739 2052 6376.
…….Complainant……..
Versus
1. Care health Insurance Limited, Unit NO. 604-607, 6th floor, Tower-c, Unitech Cyber Park, Sector-39, Gurugram-122001.
2. Care Health Insurance Near LIC office, Plot No. 37 BP, Neelam Bata Road, Faridabad.
…Opposite parties
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. P.K.Tyagi, 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 taken the family medicare health policy bearing No. 16256574 and the complainant had paid the premium amount pertaining to the above said policy to the opposite party without any delay. During the mediclaim policy the complainant was admitted in Metro Heart Institute with Multispecialty Hospital,
Sector-16A, Faridabad on dated 21.6.2022 and was discharged on 24.6.2022 and the hospital had raised the bill amount of Rs.1,45,257/- and at that time his client intimated to the representative of the opposite party through telephonically call and the representative of the opposite party assured his client that his claim file NO. 92471412-00 would be definitely approved, but no fruitful result came out and the said amount had paid by his aforesaid client from her own pocket and later on his client had sent all related documents regarding the treatment of his aforesaid client for getting the imbursement of the mediclaim amount but no fruitful result came out.. The complainant sent legal notice dated 22.07.2022 to the opposite party through registered post but all in vain. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) make the mediclaim amount of Rs.1,45,257/- approximately and the policy No. 16256574 alongwith interest @ 18% p.a. to the complainant which had been beard complaint from his own pocket during the insurance mediclaim policy.
b) pay Rs. 1,00,000/- 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 Laxmi Chand had taken a Health Insurance Policy namely “Care” bearing No. 16256574 from 30.11.2021 to 29.11.2022 covering the complainant and his spouse for a sum insured of Rs.3,00,000/- subject to policy terms & conditions. A Cashless request (AL NO. 807741530) was received form Metro Heart Institute with Multispecialty Hospital, Faridabad for the hospitalization of the complainant from 21.6.2022 for the complaint of chest pain
and ghabrahat. Upon receipt of the cashless request, query dated 22.6.2022 was raised and the hospital was asked to provide certain documents/information. The hospital replied to the aforesaid quarry. Upon receipt of the query, an internal investigation was also triggered to check the veracity of the request and during his investigation, the complainant had admitted that he was a smoker since 20/25 years and he had a habit of drinking alcohol 100 ml. a day. It was pertinent to mention that the same was not disclosed at the time of taking the policy. It was further pertinent to mention that smoking and alcohol consumption were one of the primary causes of heart disease. Therefore, the cashless request was rejected on the basis of chronic alcoholism vide denial deter dated 23.6.2022. The post denial of cashless request, the complainant filed a reimbursement claim (CL No. 92471412) for the same hospitalization i.e. Metro Heart with speciality hospital, Faridabad from 21.6.2022 to 23.06.2022 and as per the discharge summary, he was diagnosed with Acute Inferior Wall MI, CAD (Ignificient single vessel), primary PTCA with drug coated stenting to RCA, LVEF 45% and UTI . During verification of the cashless request came to the fore-front that the complainant was a chronic alcoholic and smoker, therefore, the claim was rejected on the basis of non-disclosure of chronic alcoholism and habit of smoking vide denial letter dated 12.07.2022. 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 Co. Ltd. with the prayer to: a) make the mediclaim amount of Rs.1,45,257/- approximately and the policy No. 16256574
alongwith interest @ 18% p.a. to the complainant which had been beard complaint from his own pocket during the insurance mediclaim policy. b) pay Rs. 1,00,000/- 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 complainant, Ex.C-1 – insurance policy,, Ex.C-2 – health card,, Ex.C-3 – premium acknowledgement,, Ex.C-4 – final break up, Ex.C-5 – Discharge summary, Ex.C-6 – Claim Denial letter, Ex.C-7 – legal notice, Ex. C-8 – postal receipt, Ex.C-9 – Receipt,, Ex.C-10 – Cash/Credit Memo.
On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties Ex.CW-1/A – affidavit of Sahil Chauhan, Manager-Legal, duly authorized representative of opposite party company, Care Health Insurance Ltd., 3rd floor, Tower C, Vipul Tech Square,Sector-43, Gold Course Road, Gurugram, Ex.R-1 - policy,, Ex.R-2 – Pre-Authorisation Form, Ex.R-3 – Deficiency letter,, Ex.R-4 – denial letter, Ex.R-5 – discharge summary, Ex.R-6 – claim form, Ex.R-7 – claim denial letter, Ex.R-8 – proposal form,Ex.R-9 – legal notice.
6. In this case, the complaint was filed by the complainant with the prayer to make the mediclaim amount of Rs.1,45,257/- approximately and the policy No. 16256574 alongwith interest @ 18% p.a. to the complainant which had been beard complaint from his own pocket during the insurance mediclaim policy.
In this case, the complainant had taken the family medicare health policy bearing No. 16256574 and the complainant had paid the premium amount pertaining to the above said policy to the opposite party without any delay. The complainant admitted in Metro Heart Institute with Multispecialty Hospital, Sector-16A, Faridabad on dated 21.6.2022 and was discharged on 24.6.2022 and
the hospital had raised the bill amount of Rs.1,45,257/-. Opposite parties repudiated the claim of the complainant vide letter dated 23.06.2022 on the ground that the cashless hospitalization cannot be approved as per the terms and conditions of the policy stated below:
- Non disclosure of material facts.pre-existing ailments at the time of proposal (chronic alcoholic).
- Non disclosure.
7. During the course of argument Shri Mukesh Tomar, counsel for the complainant has made a statement that” I am ready to receive the amount of Rs.1,10,000/- from the opposite party, as the claim of the complainant.”
On the other hand, counsel for the opposite parties has stated at Bar that the bills are on higher side.
8. After going through the evidence led by the parties as well as the statement of the counsel for the complainant , the Commission is of the opinion that when the insured is above 65 years then the Insurance Company was at liberty to get the complainant medically examined prior to issuance of the policy in question. Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing the policy in question whether a person is fit to be insured or not. It was the duty of the opposite party to get the complainant immediately examined before issuing the policy as per IRDA guidelines. Therefore, not releasing claim of the complainant amounts to deficiency in service on the part of opposite party.
9. Resultantly, the complaint is allowed. Opposite parties are directed to
Rs.1,10,000/- to the complainant within 30 days from the date of receipt of the copy of order The opposite parties are also directed to pay Rs.2200/- as
compensation on account of mental tension, agony and harassment and Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties free of costs and file be consigned to record room.
Announced on: 14.07.2023 (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.
