BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 206 of 2021
Date of Institution : 06.09.2021
Date of Decision : 30.07.2024
Joginder Singh (aged about 53 years) son of Sh. Fateh Singh, resident of House No. E-12, University Campus, CDLU Sirsa (Haryana) 125055.
……Complainant.
Versus.
1. Cholamandalam MS General Insurance Company Limited, Registered Office: 2nd Floor, ‘Dare House’ 2. N.S.C. Bose Road, Chennai- 600001 through its Managing Director/ Chief General Manager/ Authorized Signatory.
2. Cholamandalam MS General Insurance Company Limited, Branch Office: Dabwali Road, Sirsa through its Branch Manager/ Authorized Signatory.
3. Cholamandalam MS General Insurance Company Limited, Regional Office : SCO- 2463-64, Ist Floor Sector-22C, Chandigarh, through its Regional Manager/ Authorized Signatory.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA………MEMBER
Present: Sh. Raghav Arora, Advocate for the complainant.
Sh. H.S. Raghav, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that he is a heart patient and he undergone bypass heart surgery and in order to secure himself from the burden of any health issue of complainant or his family, the complainant purchased one group health insurance policy from ops bearing policy No. 2842/00165605/ 0004/ 000/00 w.e.f. 14.12.2018 to 13.12.2019 for sum assured of Rs.5,00,000/- with pre-ailment/ pre existing disease (Bypass heart surgery). The total premium of Rs.11,012/- was paid by the complainant to the ops and complainant, his wife Smt. Surekha and two children Parteek and Harshita were covered under the said policy. That said policy was cashless policy and at the time of purchasing the said policy, it was assured by ops that some of the hospitals are duly empanelled with the ops and on account of hospitalization of any of insured persons in the empanelled hospital, all the expenses will be borne by the ops itself. It is further averred that thereafter said policy was renewed by the ops w.e.f. 14.12.2019 to 13.12.2020 after conducting all the tests and checkups required for renewal of the policy. That during the aforesaid both years i.e. 14.12.2018 to 13.12.2020, the complainant did not avail any medical claim under the said policy and thereafter said policy was again renewed by ops w.e.f. 14.12.2020 to 13.12.2021 after conducting all the tests and checkups required for renewal of the policy. It is further averred that complainant suddenly fell seriously ill and on 15.02.2021 he was admitted in Medanta – The Medicity Hospital, Sector -38, Gurugram and on the same day TPA desk of the hospital informed the ops by email about the admission of complainant but no response was given by ops up to 17.01.2021. The complainant underwent angiography and angioplasty on 16.02.2021 in the said hospital. That after waiting for a three days when no response was received from the ops’ side then the hospital submitted the bill to the ops’ company on 18.02.2021. It is further averred that thereafter instead of making the payment of bill raised by the hospital, the ops made several excuses on one pretext or the other and complainant was shocked and surprised after knowing the excuse of the ops that ops misled the hospital and complainant by saying that policy has expired. In fact, the policy was renewed regularly in continuation period since 14.12.2018 to 13.12.2021 every year and thus the said policy is well within the period of its existence w.e.f. 14.12.2020 to 13.12.2021. That when the complainant contacted again and again to the office of ops at Sirsa, Chandigarh and Chennai, then ops admitted that policy number mentioned on the certificate is wrong. It is further averred that under the same policy number, the complainant claimed reimbursement and same was given to the hospital for their necessary action. That it was the great blunder mistake committed by the ops by mentioning the wrong policy number on the policy renewed on 14.12.2020 in the continuation of policy dated 14.12.2018 and then dated 14.12.2019 and that was the only reason the complainant could not get the financial assistance at the time of his treatment and discharge from the hospital and due to negligent act of the ops the complainant had to deposit the bill amount of Rs.2,11,258/- from his own pocket which was borrowed by him from his friends. That complainant underwent mental trauma and mental agony and act and conduct of ops amounts to gross negligence, deficiency in service and they have caused unnecessary harassment to him. The complainant also got served a legal notice to the ops on 12.03.2021 but to no effect. It is further averred that ops have not properly gone through the medical record of complainant and even relied upon their wrong record prepared by their officials while committing negligence and they have intentionally rejected the claim of complainant just to usurp the amount of claim and they did not pay any heed to the requests of complainant. Hence, this complaint.
3. On notice, ops appeared and filed written statement taking certain preliminary objections regarding maintainability, cause of action and complaint does not qualify the ingredients of a valid complaint as envisaged in Section 2 (c) of Consumer Protection Act, 1986 as amended up to date, as such complaint is liable to be dismissed on this ground alone and that complainant has created a false story in his complaint to mislead this Commission by concocting and distorting the facts and circumstances of present case. It is further submitted that complaint is not maintainable and is liable to be dismissed as there is no deficiency in service on the part of ops in terminating the claim of complainant as same was intimated to him vide denial letter dated 19.03.2021 on the ground that a denial of cashless access is not to be considered in any way as a denial of treatment. The insured can send a request for reimbursement within 30 days of discharge. It has been clearly mentioned in a judgment of case titled Ravneet Singh Bagga Versus KLM Royal Dutch Airles that where there is a dispute between parties and where the service provider has after considering all the material with them and the relevant facts has acted in a particular manner, then such acts will not amount to deficiency in service.
4. On merits, it is submitted that claim in question is pre mature as same has not been applied in proper form as per demand vide letter dated 19.03.2021 alongwith all necessary documents, hence the present complaint is liable to be dismissed on this score alone as in absence of documents, answering ops are unable to rightly dispose of the claim. The complainant never supplied the required documents and concealed the true and material facts and insurance company issued letter for providing all the relevant documents but after several demands complainant never supplied required documents. It is further submitted that as per terms and conditions of the policy every consumer who has purchased the policy is bound to disclose the true facts in proposal form but there are some terms and conditions alongwith the policy to which complainant/ policy holder must follow strictly and in case of violation then it is clear violation of the terms and conditions of the health policy and in that case the claim shall be rejected by the insurance company. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
5. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C17.
6. On the other hand, ops have tendered affidavit of Sh. Sujeet Kumar Sahu, Deputy Manager Legal as Ex.R1 and documents Annexures R1 to Ex.R7.
7. We have heard learned counsel for the parties and have gone through the case file.
8. From the group health insurance policy Ex.C1, it is evident that complainant had purchased health insurance policy from ops for the sum insured amount of Rs.5,00,000/- for the period 14.12.2018 to 13.12.2019 and under the said policy, complainant himself, his wife Smt. Surekha and children Parteek and Harshita were insured. The complainant was also insured for pre existing disease as his bypass surgery was done as is evident from Ex.C1. The said policy was also got renewed by complainant from ops for the period 14.12.2019 to 13.12.2020, then from 14.12.2020 to 13.12.2021 as is evident from Ex.C2 and Ex.C3. It is also proved on record that during the said insurance policy effective from 14.12.2020 to 13.12.2021, complainant was admitted in Medanta The Medicity Hospital, Gurgaon on 15.02.2021 where his coronary angiography and coronary angioplasty was done on 16.02.2021 as is evident from discharge summary Ex.C16. From the bill of hospital Ex.C8, it is evident that hospital charged amount of Rs.2,11,258/- from the complainant for the said treatment. The claim of complainant has not been paid and said amount has not been reimbursed by ops on the ground of non submission of required documents but however it is impossible and not believable that a insured person who is having health insurance policy and has spent such a huge amount on his treatment will not submit the required documents and as such the ops have not paid the claim amount to complainant on just lame and simple excuses. Moreover the ops have not explained that which documents were not supplied by complainant. The treatment record as well as bills have also been placed on file by complainant. So the denial of claim of complainant is wrong and illegal as same is based on just lame excuses. Non payment of claim amount to the hospital on the grounds of wrong policy number or expiry of policy, if any are also lame excuses because it is proved on record from Ex.C3 that policy was in existence at the time of treatment of complainant. So non payment of genuine claim amount by ops to the complainant clearly amounts to deficiency in service and unfair trade practice on the part of ops due to which complainant has suffered unnecessary harassment and mental agony who was already under mental trauma and despite the fact that policy was cashless, the ops have not approved cashless claim to the hospital. As such complainant is entitled to claim amount of Rs.2,11,258/- spent by him on his treatment in the above said hospital besides compensation for harassment.
9. In view of our above discussion, we allow the present complaint and direct the opposite parties to make payment of claim amount of Rs.2,11,258/- to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 06.09.2021 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.10,000/- as compensation for harassment and Rs.5000/- as litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 30.07.2024. District Consumer Disputes
Redressal Commission, Sirsa.
