DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.141/2022
Mrs. Renu Bhardwaj
W/o Sh. Satish Bhardwaj
R/o H.No.593/A Chirag Delhi
New Delhi, Pin Code -110017
….Complainant
Versus
Cholamandalam Ms General Insurance Company Limited
Through its Authorized Representative
Registered Office At: 2nd Floor, “DARE HOUSE”, 2, N.S.C.
Bose Road, Chennai, Tamil Nadu, Pin Code-600001.
Office also at:
Plot No.39, 2nd Floor, Samyak Tower, Pusa Rd,
Near to Metro Pillar Number 120, Karol Bagh,
New Delhi, Delhi-110005
….Opposite Party
Date of Institution : 24.05.2022
Date of Order : 07.10.2024
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Present: Adv. Vishal Bhardwaj along with AR of complainant.
Adv. Kamaldeep for OP.
ORDER
Member: Ms. Kiran Kaushal
1. Facts of the case as pleaded by the complainant are that the complainant had taken a Family Floater cashless Mediclaim Insurance Policy issued by Cholamandalam MS General Insurance Co. Ltd., hereinafter referred to as OP.
2. It is stated that during the currency period of the policy complainant felt abdominal pain and consulted a doctor on 19.10.2020. Pursuant to the consultation and check up, complainant was advised to undergo a surgery for the removal of uterus. It is stated that a claim was raised and pre-authorisation approval of Rs.40,000/- was approved by OP on 19.10.2020.
3. Prior to the surgery complainant was asked to get Covid RTPCR Test and certain other tests done. Report of the said test came out to be positive. When the complainant apprised the doctor about the positive Covid RTPCR the doctor told the complainant that the surgery could be conducted after the complainant recuperates from Covid. Complainant’s husband informed representative of OP regarding the positive Covid RTPCR test report who advised him to seek cancellation of the pre-authorized approval of Rs.40,000/- and if admitted for Covid then the complainant has to seek fresh approval. Pursuant to the said advice complainant’s husband sought cancellation of the already approved cashless. Thereafter, the complainant was home quarantined and was advised to wait for another month after the quarantined period. Complainant’s husband enquired about the tentative expenditure of surgery and was told that complainant would have to pay Rs.3,22,800/- for the surgery.
4. It is next stated that complainant’s husband informed OP about the complainant’s admission at the hospital on 04.12.2020 and sought insurance mediclaim approval from OP. It is stated that the hospital sent required documents for approval of mediclaim cashless insurance policy to OP but no reply was received despite repeated reminders.
5. Since no reply was forthcoming from OP, complainant underwent the advised surgery and was discharged after paying the hospital bills. It is stated that despite having a cashless insurance coverage complainant had to go through lot of hardships, immense loss and injury was caused to the complainant in terms of physical, financial and psychological well being.
6. Complainant alleges deficiency in service and unfair trade practice in view of the non-compliance and non-adherence of I as per Regulation – 27 (i) of Chapter IV Administration of health insurance policies under IRDAI (Health Insurance Amendment) Regulations, 2019 dated 19.11.2019 which states as under:-
‘An insurer shall settle or reject claim, as may be the case, within 30 days of the receipt of the last necessary document’.
7. Complainant on 19.12.2020, physically handed over all the original documents to OP. Nearly after 83 days of due submissions of the documents to OP, a health claim query letter dated 13.03.2021 was sent to the complainant. OP sent another health claim query on March 2021. Reply to both the letters was provided by the complainant. To complainant’s dismay despite the complainant mailing OP on 24.05.2021 that hard copy of all original documents had already been submitted at the Karol Bagh Office, OP kept sending reminders/letters to the complainant to furnish the original documents. The said conduct of asking for documents again and again illustrate that OP is engaged in unfair trade practices. 7. It is further stated that complainant kept following up with OP for reimbursement of the claim but to no avail.
8. Alleging deficiency in service and unfair trade practice complainant prays for direction to OP to pay Rs.97,184/- towards mediclaim expenses incurred by the complainant; Rs.10,00,000/- towards mental agony and harassment; Rs.1,50,000/- towards litigation cost total amounting to Rs.12,47,184/- with interest @ 18% per annum.
9. Written statement is filed on behalf of OP stating interalia that claim of the complainant is rejected as complainant had failed to provide the required documents for adjudication of the claim. It is stated that OP had repeatedly requested the complainant for certain documents which were not provided by the complainant. Complainant by not providing the documents is trying to conceal the ailment and also concealing the facts. Hence the claim was rightly rejected for non-supply of documents stated in letter dated 13.03.2021 , 20.04.2021, 05.05.2021 and 15.06.2021 which is annexed as annexure-A. In light of the facts, it is stated that the complaint be dismissed being premature with exemplary costs being false, frivolous and vexatious in nature.
10. Rejoinder, is filed on behalf of the complainant stating that the complainant had already submitted all the original documents with the Karol Bagh Office of OP, therefore it was neither possible nor it could be expected to resubmit the original documents again. It is stated that all the bills, investigation reports, discharge summary and all other documents were duly submitted OP on 19.12.2020. Despite original documents duly submitted with OP and having replied to all the letters/mails OP has arbitrarily rejected/repudiated the genuine claim of the complainant.
11. Evidence by way of affidavit on behalf of the both the parties and written submission on behalf of the complainant are filed. Submissions made by the parties are heard. Material placed on record is perused.
12. On perusal of the documents placed before us it is seen that complainant had taken a Group Health Insurance, Family Floater Policy from OP in the name of Shri Satish Bhardwaj. Wife and daughter of Shri Bhardwaj were also insured under this policy. During the subsistence of the policy wife of Shri Bhardwaj i.e. the complainant was admitted for abdominal pain in the hospital. Since it was Covid period complainant was advised to take Covid test which came out to be positive. Post her recuperation from Covid, surgery was performed to remove the uterus of the complainant for which she remained admitted in the hospital from 04.12.2020 to 07.12.2020.
13. It is complainant’s case that despite having the facility of cashless claim , complainant was deprived of the same . Nonetheless, complainant after surgery was discharged on the payment made by her husband. It is next seen that OP raised Health Claim Queries with the complainant on 13.03.2021, 29.03.2021 and sent reminders pertaining to the same to the complainant. On perusal it is noted that most of the Health Claim Queries related to providing the requisite documents.
14. Complainant’s claim that the original documents were handed over physically in the Karol Bagh office of OP is found to be true. Annexure C-12 with the complaint is a letter dated 19.12.2020 which is stamped by New Delhi branch office of OP. The said letter is addressed to OP which shows that about 15 documents were provided by the complainant which included inter alia original prescriptions, original receipts of the doctors from which the complainant had taken the treatment. It is noticed that original bills along with the investigation reports were also enclosed with the said letter. Complainant ,time and again informed OP regarding the submission of original documents in their Karol Bagh Branch.
15. Complainant’s claim was finally repudiated vide letter dated 15.06.2021. Repudiation letter is appended at Page 7 of the written statement which states that the claim is not admissible for the reasons stated as under:-
‘We have not received Query response/deficiency documents requested from the insured in spite of several reminders, hence the claim is closed. The following are the details of the deficient documents request: 1. Kindly submit treatment doctor certificate when the patient first complained and sought medical attention with regards to Abnormal uterine bleeding along with consultation papers. [Treating doctor certification not enclosed only self declaration provided] Please furnish details of onset, progress and duration of the ailment and treatment taken by the patient till date for further processing of the claim. 2. Kindly provide all previous conservative treatment records prior to surgery. Kindly submit treating doctor certificate regarding if any comorbidities like diabetes and hypertension certified by treating doctor.’
16. This Commission is of the considered view that having received the documents in their Karol Bagh office OP cannot repudiate the claim on the ground that OP had not received the query response/deficient documents. OP is found to be deficient in service as despite receiving the documents OP has wrongfully repudiated the claim of the complainant.
17. In light of the discussion above OP is directed to pay compensation of Rs.2,00,000/- towards mental agony and harassment within three months from the date of order failing which OP shall pay the above stated amount with interest @6% per annum till realisation.
Parties be provided copy of the judgment as per rules. File be consigned to the record room. Order be uploaded on the website.
