| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C.No. 126 of 27-7-2021 Decided on : 06-07-2023 Rajiv Goyal aged about 53 years, son of Sh. Krishan Kumar, R/o 191 C, Model Town, Phase -1 Bathinda. ........Complainant Versus Care Health Insurance Ltd. (formerly Religare Health Insurance Co. Ltd.), Unit No. 604, 605, 606 and 607, 6th Floor, Tower C, Unitech Cyber Park, GURGAON 122001, through its Divisional Manager/Managing Director. .......Opposite party Complaint under Section 35 of the Consumer Protection Act, 2019 QUORUM Sh. Lalit Mohan Dogra, President Sh. Shivdev Singh, Member Present : For the complainant : Sh. Rajiv Goyal, Advocate. For opposite party : Sh. Varun Gupta, Advocate. ORDER Lalit Mohan Dogra, President The complainant Rajiv Goyal (here-in-after referred to as complainant) has filed this complaint U/s 35 of Consumer Protection Act, 2019 (here-in after referred to as 'Act') before this Commission against Care Health Insurance Ltd (here-in-after referred to as opposite party). Briefly stated, the case of the complainant is that he being member of Ola Money, enrolled himself alongwith his family consisting of his wife and two children, under the Group Health Insurance Scheme vide policy No. 17310352 effective from 10.4.2020 to 09.04.2021 and paid the premium to the tune of Rs.4602/-, for a sum insured of Rs.5.00 Lacs with the opposite party. However, no terms & conditions of the policy was supplied to the complainant by the opposite party nor any specific condition/exclusion clause was conveyed to the complainant. In this way, the complainant and his aforesaid family members were insured with the opposite party vide the aforesaid policy. It is alleged that at the time of enrollment with the opposite party, opposite party assured the complainant that in case of any health disorder or any minor or major operation, opposite party shall indemnify the insured, his aforesaid family members for the total expenses incurred thereon by the insured upto Rs.5.00 Lacs. It is alleged that on 23.03.2021, Kiran Goyal, wife of the complainant suddenly started suffering from vomiting and abdomen pain and accordingly, she was taken to Dr. Parminder Bansal, M.D., Care Hospital, Power House Road, Bathinda and after getting the necessary tests done from Satyam Lab and also after got conducting the Ultrasound from Satyam Scan Centre, Bathinda, he advised for treatment of the wife of the complainant as indoor patient and accordingly, patient was got admitted with Dr. Parminder Bansal of Prime Care Hospital, Bathinda, where she was treated as indoor patient and ultimately, she was discharged on 25.3.2021 and in this way, wife of the complainant remained admitted for three days in the aforesaid hospital and , an amount of about Rs.15,000/- was spent by the complainant on the treatment of his wife. It is further alleged that as per health insurance, the complainant lodged the claim of Rs.15,000/- with the opposite party under the bonafide impression that the aforesaid genuine and lawful claim shall be reimbursed by the opposite party, but to the utter surprise of the complainant, the opposite party has repudiated the aforesaid lawful and genuine claim of the complainant vide letter dated 31.3.2021 on flimsy grounds to the effect that `Admission not justified: Could have been managed on OPD basis'. Thereafter, the complainant made several correspondence with the opposite party through various mails, but the opposite party did not reconsider the claim of the complainant. The complainant alleged that ultimately, the complainant got served a registered legal notice dated 30.4.2011 upon the opposite party thereby calling upon the opposite party to make the payment of claim of Rs.5000/ per day, as per terms & conditions of the Certificate of Insurance, alongwith interest @ 18% p.a. on account of delayed payment, but the opposite party gave deaf ears and did not make the payment of claim amount nor responded the legal notice. It is also alleged that the aforesaid ground for rejection of the claim of the complainant is false and frivolous. Due to the above said adament attitude of the opposite party, the complainant has suffered mental tension & agony, physical, social harassment and as such the complainant claims Rs. 50,000/- as damages. On this backdrop of facts, the complainant has prayed for directions to make the payment of Rs.15,000/- as aforesaid, to the complainant, alongwith interest on the delayed payment from the date of due till its realization and Rs.50,000/- as compensation on account of mental tension,agony, physical and social harassment and Rs.5000/- as litigation expenses. Upon notice, opposite party appeared through counsel and contested the complaint by filing written written reply raising legal objections that the claim of the complainant does not fall within the purview of the insurance as granted by the replying opposite party and falls within permanent exclusion of the policy, so the present complaint is not maintainable. The complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead the Commission. The present complaint is not maintainable in the present form as the complaint involves disputed question of facts which cannot be determined in summary jurisdiction. The present complaint filed by the complainant with the mala-fide intention and has not come before this Commission with clean hand. That prima facie no cause has arisen in favour of the Complainant to file the present Complaint. That intricate questions of law and facts are involved in the matter in issue and parties should have to lead evidence by examining the witnesses. The complaint is false, frivolous and vexatious in nature and that the complainant is estopped from filing the present complaint by his own acts, conduct, omissions and acquiescence. It has been pleaded that the opposite party issued Group Policy to Zipcash Card Services Private Limited bearing No.14459772 (Product: Group Care (Ola Money) thereby covering the Complainant Mr. Rajiv Goyal vide Certificate of Insurance No. 17310352 with effect from 10-04-2020 till 09- 04-2021 for a sum insured of Rs. 5,00,000/- subject to the Policy Terms and Conditions. Further, no assurance was given beyond the terms and conditions of the Policy. The replying Opposite Party Company further submits that the Policy kit containing all relevant documents was duly delivered to him, thereby giving an opportunity to the insured to verify and examine the benefits, terms and conditions of the Policy taken by him. It is pertinent to mention here that the deceased assured never approached the replying opposite party Company stating that any information given in the Policy Schedule was incorrect. It has been pleaded that the opposite party had reimbursement claim vide claim No.91641680-00. The Complainant approached the opposite party with a Reimbursement Claim with respect to his spouse's hospitalization from 23-03-2021 till 25-03-2021 at Prime Care Hospital, Bathinda. The insured was hospitalized with a diagnosis of Acute gastroenteritis along with UTI. On perusal of the documents, the opposite party came to know that she was in a stable condition and could have been managed on OPD basis. Hence, the admission was not justified. Accordingly, the opposite party rejected the claim of the Complainant vide claim Denial letter dated 31.3.2021 with the following observation : • ADMISSION NOT JUSTIFIED: COULD HAVE BEEN MANAGED ON OPD BASIS • ADMISSION NOT JUST'IF'IED Insured could have been managed on OPD basis and the Admission was for evaluation and investigation purpose only. Policy Terms & Conditions: The Relevant clause is reproduced herein through which the opposite party processed the claim: 3.2 Permanent Exclusions i) Any condition or treatment as specified in Annexure-C Annexure C Entry 71.- Hospitalization for evaluation / diagnostic purpose On merits, opposite party has reiterated its version as pleaded in legal objections and detailed above. After controverting all other averments of the complainant, the opposite party prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his affidavit dated 16.7.2021 (Ex. C-1) and documents (Ex.C-2 to Ex.C-33). In order to rebut the evidence of complainant, the opposite party has tendered into evidence affidavit of Ravi Boolchandani dated 2.2.2021 (Ex. OP-1/1) and documents (Ex. OP-1/2 to Ex.OP-1/6). The learned counsel for the complainant has argued that complainant alongwith his family members are insured with the opposite party. On 23-3-2021, wife of the complainant suddenly fell sick and thereafter she remained admitted with Dr Parminder Bansal, Prime Care Hospital, Bathinda upto 25-3-2021 and an amount of Rs. 15,000/- was spent by complainant on her treatment. On claim being lodged, the opposite party rejected the claim vide repudiation letter Ex. C-24 dated 31-3-2021. The reason mentioned in the repudiation letter was admission not justified : to have been managed on OPD basis. On the other hand, learned counsel for the opposite party has argued that as per terms and conditions of the policy special exclusion clause 3.2, claim of the complainant was rightly repudiated as admission was not justified and insured could have been managed as OPD basis and the admission was for evaluation and investigation purposes only. We have heard learned counsel for the parties and gone through the file carefully. It is admitted fact that complainant and his family members were insured with the opposite party upto the sum assured of Rs. 5.00 Lacs vide policy of insurance Ex. C-3. It is further admitted fact that the wife of the complainant remained admitted at Prime Care Hospital and spent Rs. 15,000/- on the treatment of his wife as per bill attached with the complaint. The only question before this Commission is whether repudiation of claim by the opposite party is justified or not. This Commission is of the view that to treat a patient as a indoor or outdoor patient, is the discretion of treating doctor and doctor is only person to decide as to what type of treatment is required to be administered to the patient. Accordingly, patient/wife of the complainant remained admitted in the hospital as per advice of the doctor. The act of the opposite party in repudiating the genuine claim of the complainant is unjustified and amounts to deficiency in service on the part of the opposite party. Resultantly, this complaint is partly allowed and opposite party is directed to pay Rs. 15,000/- to the complainant alongwith interest @9% p.a. from the date of filing of this complaint till realization. The complainant is also held entitled to Rs. 2,000/- as compensation for mental tension and harassment and litigation expenses. The compliance of this order be made by the opposite party within 45 days from the date of receipt of copy of this order. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room. Announced:- 06-07-2023 - (Lalit Mohan Dogra)
President (Shivdev Singh) Member
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