DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

 

Complaint Case No : CC/37/2022

Date of Institution   : 28.01.2022

Date of Decision    : 24.05.2024

Ashok Kumar Jindal, aged about 66 years, son of Banarsi Dass Jindal resident of # B-X/154, Ahata Narain Singh, Barnala, Tehsil and District Barnala, Punjab (Mobile No. 94632-18380).           

                          …Complainant Versus

1. Care Health Insurance Limited, Formerly known as Religare Health Insurance Company Limited, Corporation Office Unit No. 604-607, 6th  Floor, Tower C, Unitech Cyber Park, Sector 39, Gurugram-122001, Haryana, through Branch Manager;

2. Punjab National Bank, Main Branch, Barnala, through its Branch Manager.  

                             …Opposite Parties

Complaint Under Section 35 of Consumer Protection Act, 2019.

Present: Sh. Dhiraj Kumar counsel for complainant.

Sh. Rajiv Goyal counsel for opposite party No. 1.

Sh. Pankaj Singla counsel for opposite party No. 2.

Quorum:-

1. Sh. Jot Naranjan Singh Gill : President

2.Smt. Urmila Kumari : Member

3.Sh. Navdeep Kumar Garg : Member

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT

1. The present complaint has been filed under Section 35 of the Consumer Protection Act 2019, (amended upto date) against Care Health Insurance Limited and others (hereinafter referred as opposite party No. 1 & 2).  

2. The facts leading to the present complaint are that the complainant obtained a group Mediclaim policy for the year 2021-2022 valid from 28.7.2021 to 27.7.2022 of opposite party No. 1 through opposite party No. 2 in this regard the opposite party No. 1 issued policy bearing No. 17499225 to the complainant for sum of Rs. 5,00,000/- and the complainant got insured himself and his wife through the above said policy. It is further alleged that the complainant fall down and feels pain and swelling bilateral knee with difficulty in walking and was admitted in Paras Hospital, Panchkula on 21.9.2021 where his B/L total knee replacement done on 22.9.2021 and discharged on 28.9.2021 and in this regard concerned hospital applied for claim of Rs. 3,44,832/-, out of which Rs. 2,00,000/- was approved/paid as cashless by the opposite parties to the said hospital. However, said hospital had not applied for taxi/ambulance charges, which were paid by the complainant and Rs. 1,81,359/- was due against the opposite parties and the complainant applied for claim of Rs. 1,81,359/- alongwith claim form, original bills, copy of policy, original discharge summary, treatment record, copy of cancelled cheque, copy of PAN card, copy of Aadhar Card etc. before the opposite parties, which was wrongly denied by the opposite parties vide letter dated 1.12.2021 with reason SUB Limit Capping/SUB Limit Exhausted. It is further alleged that on 3.1.2022 the complainant sent a legal notice to the opposite parties to make the payment of Rs. 1,81,359/- within 7 days from the receipt but the opposite parties have failed to make the payment and also failed to give reply of the same. The above said act and conduct of the opposite parties  amounts to deficiency in service and negligence on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.- 

i)To make the payment of Rs. 1,81,359/-;  

ii)To pay Rs. 30,000/- as compensation of humiliation and harassment of the complainant and 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 answering opposite party after evaluates the claim under the policy have already paid entire amount as per policy terms and conditions to the complainant. The present complaint has been filed with mala-fide intention and complainant has not come with clean hands. No cause of action has been arisen. The complaint is false, frivolous and vexatious in nature. This Commission has no jurisdiction to entertain the present complaint etc. As such, there is no deficiency in service on its part. On merits, it is submitted that the replying opposite party issued a group health insurance policy bearing No. 17499225 to the group of policyholder i.e. Punjab National Bank thereby covering its account holders i.e. the complainant and his spouse with effect from 28.7.2021 to 27.7.2022 for a sum insured of Rs. 5,00,000/- to each insured subject to policy terms and conditions vide certificate of insurance number 32263277. The policy was ported wherein the date of first enrollment was 28.7.2017 and the copy schedule bearing relevant details of the policy alongwith policy bond having terms and conditions were duly sent and delivered to the proposer. It is further submitted that treatment of fracture/dislocation/knee surgery are only payable upto Rs. 1,00,000/- and the policy certificate was also mailed to the email id of the complainant at lifeknown598@gmail.com on 20.7.2021. It is further submitted that the complainant approached the opposite party and filed a claim through the treating hospital (Paras Hospital) for hospitalization of the insured and the complainant also claimed pre and post hospitalization expenses. As per the discharge summary she was hospitalized at Paras Hospital w.e.f. 21.9.2021 till 28.9.2021 and was diagnosed with Bilateral osteoarthritis knee. She was operated for bilateral total knee replacement and on this the replying opposite party was approved an amount of Rs. 2,00,000/- and the same was paid vide NEFT No. 111026655944 on 2.11.2021. Since there was capping of Rs. 1,00,000/- on knee replacement and since both the knees were replaced in the current claim, hence, Rs. 2,00,000/- was allowed and the claim was processed accordingly. The complainant is claiming Ambulance charges, however, the same was not payable as per Clause 5(3) (1) read with Annexure 2 List 1 Entry 67. Moreover, the company had already paid Rs. 2,00,000/- as per policy terms and conditions. The replying opposite party rejected the claims for pre and post hospitalization expenses vide letter dated 1.12.2021 and 5.12.2021. The complainant also sent a legal notice dated 3.1.2022 in which incorrect policy number was mentioned, hence the opposite party replied vide letter dated 19.1.2022 thereby specifying the need for correct policy number. All other allegations of the complainant are denied and prayed for the dismissal of complaint with costs. 

4. The opposite party No. 2 also filed written version by taking legal objections on the grounds that the opposite party No. 2 is not doing the business of insurance nor under law it can carry the business of insurance. Complainant has got no locus-standi to file the present complaint. The present complaint is frivolous, vexatious and liable to be dismissed. This Commission has no jurisdiction to entertain and adjudicate upon the dispute involved in the complaint. The present complaint is barred by limitation etc. On merits, it is admitted to the extent that the complainant is having one saving account bearing No. 44000104246940 with answering opposite party. The complainant has paid the premium amount through answering opposite party and premium amount is charged by opposite party No. 1 and insurance policy is issued by opposite party No. 1, rest averments of this Para doesn't relate with the answering opposite party. All other allegations are denied by the opposite party and prayed for the dismissal of complaint with costs. 

5. Ld. Counsel for complainant has filed rejoinder against the written version of opposite party No. 1 vide which the complainant denied the averments mentioned in the written version of opposite party No. 1.  Ld. Counsel for the complainant has suffered the statement dated 27.4.2022 that I do not want to file any rejoinder against the version of opposite party No. 2.   

6. To prove the case the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy Ex.C-2 (containing 3 pages), copy of claim form Ex.C-3 (containing 3 pages), copies of bills and receipts Ex.C-4 to Ex.C-13, copy of cashless authorization letter Ex.C-14 (containing 4 pages), copies of Taxi Charges receipts Ex.C-15 to C-18, copy of discharge summary Ex.C-19 (containing 2 pages), copies of Emails Ex.C-20 & Ex.C-21, copy of claim denial letter Ex.C-22, copy of legal notice Ex.C-23, postal receipts Ex.C-24 & Ex.C-25 and closed the evidence. 

7. To rebut the case the opposite party No. 1 tendered into evidence copy of policy letter dated 19.7.2021 Ex.O.P1/1 (containing 3 pages), copy of proposal form Ex.O.P1/2, copy of terms and conditions Ex.O.P1/3 (containing 91 pages), copy of cashless authorization letter dated 18.9.2021 Ex.O.P1/4 (containing 2 pages), copy of cashless authorization letter dated 28.9.2021 Ex.O.P1/5 (containing 2 pages), copy of claim form Ex.O.P1/6 (containing 3 pages), copy of patient bill Ex.O.P1/7, copy of discharge summary Ex.O.P1/8 (containing 10 pages), copies of claim denial letters Ex.O.P1/9 and Ex.O.P1/10, copy of claim approval and settlement letter as Ex.O.P1/11 (containing 2 pages), copy of cashless form Ex.O.P1/12 (containing 11 pages), copy of legal notice Ex.O.P1/13 (containing 2 pages), copy of reply to legal notice Ex.O.P1/14 and closed the evidence. 

8. The opposite party No. 2 tendered into evidence affidavit of Arjun Vinayak Ex.O.P2/1, copy of statement of account Ex.O.P2/2 (containing 2 pages), copy of General Power of Attorney Ex.O.P2/3 (containing 10 pages) and closed the evidence. 

9. We have heard the learned counsel for the parties and have gone through the record on file. Written arguments filed by complainant and opposite party No. 1.

10. Ld. Counsel for the complainant argued that the complainant obtained a group Mediclaim policy for the year 2021-2022 valid from 28.7.2021 to 27.7.2022 of opposite party No. 1 through opposite party No. 2 in this regard the opposite party No. 1 issued policy bearing No. 17499225 to the complainant for sum of Rs. 5,00,000/- and the complainant got insured himself and his wife through the above said policy(Ex.C-2). It is further argued that the complainant fall down and feels pain and swelling bilateral knee with difficulty in walking and was admitted in Paras Hospital, Panchkula on 21.9.2021 where his B/L total knee replacement done on 22.9.2021 and discharged on 28.9.2021 (Ex.C-19) and in this regard concerned hospital applied for claim of Rs. 3,44,832/-, out of which Rs. 2,00,000/- was approved/paid as cashless by the opposite parties to the said hospital, however said hospital had not applied for taxi/ambulance charges, which were paid by the complainant and Rs. 1,81,359/- was due against the opposite parties and the complainant applied for claim of Rs. 1,81,359/- alongwith claim form, original bills, copy of policy, original discharge summary, treatment record, copy of cancelled cheque, copy of PAN card, copy of Aadhar Card etc. before the opposite parties, which was wrongly denied by the opposite parties vide letter dated 1.12.2021 (Ex.C-22) with reason SUB Limit Capping/SUB Limit Exhausted. It is further argued that on 3.1.2022 (Ex.C-23) the complainant sent a legal notice to the opposite parties to make the payment of Rs. 1,81,359/- within 7 days from the receipt but the opposite parties have failed to make the payment and also failed to give reply of the same.

11. Ld. Counsel for the opposite party No. 1 argued that the opposite party No. 1 issued a group health insurance policy bearing No. 17499225 to the group of policyholder i.e. Punjab National Bank thereby covering its account holders i.e. the complainant and his spouse with effect from 28.7.2021 to 27.7.2022 for a sum insured of Rs. 5,00,000/- to each insured subject to policy terms and conditions vide certificate of insurance number 32263277 (Ex.O.P1/1) and the policy was ported wherein the date of first enrollment was 28.7.2017 and the copy schedule bearing relevant details of the policy alongwith policy bond having terms and conditions were duly sent and delivered to the proposer. It is further argued that treatment of fracture/dislocation/knee surgery are only payable upto Rs. 1,00,000/- and the policy certificate was also mailed to the email id of the complainant at lifeknown598@gmail.com on 20.7.2021. It is further argued that the complainant approached the opposite party and filed a claim through the treating hospital (Paras Hospital) for hospitalization of the insured and the complainant also claimed pre and post hospitalization expenses and as per the discharge summary, he was hospitalized at Paras Hospital w.e.f. 21.9.2021 till 28.9.2021 and was diagnosed with Bilateral osteoarthritis knee (Ex.O.P1/8). It is also argued that she was operated for bilateral total knee replacement and on this the replying opposite party was approved an amount of Rs. 2,00,000/- and the same was paid vide NEFT No. 111026655944 on 2.11.2021 (Ex.O.P1/11), since there was capping of Rs. 1,00,000/- on knee replacement and since both the knees were replaced in the current claim, hence, Rs. 2,00,000/- was allowed and the claim was processed accordingly. It is argued that the complainant is claiming Ambulance charges, however, the same was not payable as per Clause 5(3) (1) read with Annexure 2 List 1 Entry 67 and the company had already paid Rs. 2,00,000/- as per policy terms and conditions and the opposite party No. 1 rejected the claims for pre and post hospitalization expenses vide letter dated 1.12.2021 and 5.12.2021 (Ex.O.P1/9 & Ex.O.P1/10). 

12. Ld. Counsel for the opposite party No. 2 argued that the opposite party No. 2 is not doing the business of insurance nor under law it can carry the business of insurance. It is also argued that the complainant is having one saving account bearing No. 44000104246940 with answering opposite party and the complainant has paid the premium amount through opposite party No. 2 and premium amount is charged by opposite party No. 1 and insurance policy is issued by opposite party No. 1. It is also argued that there is no deficiency in service on the part of opposite party No. 2.

13. It is admitted fact that the opposite party No. 1 issued a group health insurance policy bearing No. 17499225 to the group of policyholder i.e. Punjab National Bank thereby covering its account holders i.e. the complainant and his spouse with effect from 28.7.2021 to 27.7.2022 for a sum insured of Rs. 5,00,000/- to each insured. It is also admitted fact that the complainant fall down and feels pain and swelling bilateral knee with difficulty in walking and was admitted in Paras Hospital, Panchkula on 21.9.2021 where his B/L total knee replacement done on 22.9.2021 and discharged on 28.9.2021. 

14. In the present case the allegation of the complainant is that  on the above said treatment the concerned hospital applied for claim of Rs. 3,44,832/-, out of which Rs. 2,00,000/- was approved/paid as cashless by the opposite party No. 1 to the said hospital, however said hospital had not applied for taxi/ambulance charges, which were paid by the complainant and Rs. 1,81,359/- was due against the opposite party No. 1 and the complainant applied for claim of Rs. 1,81,359/- alongwith claim form, original bills, copy of policy, original discharge summary, treatment record, copy of cancelled cheque, copy of PAN card, copy of Aadhar Card etc., before the opposite party No. 1, which was wrongly denied by the opposite party No. 1 vide letter dated 1.12.2021 and 5.12.2021 with reason SUB Limit Capping-Treatment of Fracture/Dislocation/Knee Surgery/SUB Limit Exhausted. We have perused the copy of insurance policy Ex.C-2 placed on record by the complainant vide which at Page No. 2 it is mentioned that the complainant Ashok Kumar Jindal and his wife Chitranjan Jindal are insured for the amount of Rs. 5,00,000/-.  It is further mentioned in the column of Benefits at Sr. No. 3 Pre-hospitalization Medical expenses 30 days and at Sr. No. 4 Post-hospitalization Medical expenses 60 days and at Sr. No. 5 Domestic Road Ambulance upto Rs. 2,000 per hospitalization. So, from the above said benefits as mentioned in Ex.C-2 it is cleared that the complainant and his spouse are entitled for Pre-hospitalization Medical expenses and Post-hospitalization Medical expenses. Further, we have perused the copies of bills placed on record by the complainant Ex.C-4, Ex.C-5, Ex.C-9, Ex.C-11, Ex.C-12 and Ex.C-13 which comes to the tune of Rs. 1,54,703/- (i.e Rs. 1100+5799+144688+130+1569+1417= Rs. 1,54703/-). However, the complainant in his complainant has alleged that the total claim amount was Rs. 3,44,832/- out of which Rs. 2,00,000/- was paid as cashless by the opposite party No. 1 to the hospital, but the said hospital had not applied for taxi/ambulance charges, which were paid by the complainant and Rs. 1,81,359/- was due against the opposite party No. 1 and in this regard the complainant has placed on record copies of receipts Ex.C-15 to Ex.C-18 on account of taxi charges from Barnala to Paras Hospital, Panchkula for an amount of Rs. 3,500/- each which comes to the tune of Rs. 14,000/-. But in the above said receipts no taxi number and no taxi registration number was mentioned and even no name of the taxi owner or driver was mentioned to prove the fact that who issued the above said receipts to the complainant, so the above said receipts are not admissible.

15. During arguments, Ld. Counsel for the complainant has produced the original policy for the perusal of this Commission and after perusal of the original policy this Commission has come to the conclusion that the policy placed on record by the complainant Ex.C-2 and policy document Ex.O.P1/1 placed on record by the opposite party No. 1 does not match with each other and the column Sub Limit Capping at the  bottom of Page No. 2 of Ex.O.P1/1 is totally different because the same does not show in the policy document placed on record by the complainant Ex.C-2. So, we are of the view that opposite party No. 1 has placed on record the different page of the policy document which is not a reliable piece of evidence.

16. Ld. Counsel for complainant placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. 

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 the remaining/balance amount of Rs. 1,54,703/- (as per above said bills) alongwith interest @ 7% per annum to the complainant from the date of filing the present complaint till realization. The opposite party No. 1 is further directed to pay Rs. 15,000/- on account of consolidated amount of compensation as well as litigation expenses to the complainant.  

17. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order.

18. Copy of this order be supplied to the parties free of costs as per rules. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

       24th Day of May, 2024

 

            (Jot Naranjan Singh Gill)

            President

 

(Urmila Kumari)

Member

 

(Navdeep Kumar Garg)

Member