STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA, PANCHKULA   

                                                First Appeal No.297 of 2020

                                                Date of Institution: 09.07.2020

                                                Date of Decision: 15.07.2020

Religare Health Insurance Company Limited, Vipul Tech Square Tower C, 3^rd Floor, Sector 43, Golf Course Road, Gurugram-122009.

…..Appellant-Opposite Party

VERSUS

Manish Kumar son of Roop Chand, resident of Raj Nagar, Kaithal Road, Jind.

..…Respondent-Complainant

CORAM:    Hon’ble Mr. Justice T.P.S. Mann, President.

                   Shri Harnam Singh Thakur, Judicial Member

Present:-    Shri Paras Money Goyal, counsel for the appellant.

                                                O R D E R

T.P.S. MANN, J.  

          Delay in filing of the appeal is condoned for the reasons specified in the application.

2.      Religare Health Insurance Company Limited, Vipul Tech Square Tower C, 3^rd Floor, Sector 43, Golf Course Road, Gurugram-122009-opposite party has challenged the order dated 15.01.2020 passed by learned District Consumer Disputes Redressal Forum, Jind whereby complaint preferred by Manish Kumar-complainant under Section 12 of the Consumer Protection Act, 1986 was allowed and the opposite party directed to pay a sum of Rs.1,45,000/- to the complainant which was spent by him on his treatment alongwith simple interest @ 9% per annum from the date of filing of the complaint i.e. 25.07.2019 till its realization; Rs.20,000/- as compensation on account of mental agony and physical harassment; and; Rs.7,000/- as litigation expenses.  The order was to be complied within 45 days from the date of the order and in case of default, the opposite party was liable to pay simple interest @ 12% per annum on the aforesaid amount for the period of default.

3.      According to the complainant, he had purchased health insurance policy No.13008557 from the opposite party by paying a premium of Rs.16,221/- w.e.f. 16.09.2018 covering him, his wife Manisha and two children Nidhi and Rudra upto Rs.5,00,000/-.  At the time of insurance, the complainant was hale and hearty and not suffering from any ailment.  On 18.03.2019, the complainant suffered chest pain and was immediately taken for treatment to Noble Heart and Super Specialty Hospital, Rohtak.  He was discharged by the treating doctor on 19.03.2019.  He had spent a sum of Rs.22,150/- on his treatment.  He submitted claim for payment of treatment bill but the opposite party refused to the said amount.  The complainant again felt chest pain on 10.04.2019 and the family members took him to the aforementioned hospital.  The doctors suggested that it was a case of heart problem and accordingly a stent was inserted on 12.04.2019.  The complainant had incurred a sum of Rs.1,45,000/- on his treatment but the opposite party repudiated the claim.  The complainant submitted the requisite documents on 20.05.2019 but the opposite party avoided the claim and ultimately refused to pay the sum, which amounted to deficiency in service on the part of the opposite party.  Hence, the complaint. 

4.      Upon notice, the opposite party appeared and filed reply raising preliminary objections that the complaint was not maintainable being false and frivolous; the complainant had no cause of action and locus standi to file the complaint and the learned District Forum had no jurisdiction to entertain and try the complaint.  On merits, it was stated that on receipt of the cashless claim, the opposite party conducted investigated to check the veracity of the claim and accordingly, vide letter dated 18.03.2019, a query was sent to the hospital asking for various documents i.e. OPD papers with first consultation.  On receipt of reply from the hospital, the opposite party came to the conclusion that the complainant was consuming tobacco (smoking), which was excluded under the terms and conditions of the policy and accordingly, the claim of the insured vide letter dated 19.03.2019 was rejected with the observation that cashless denied under permanent exclusion for smoking and its related complication.  Pleading that there was no deficiency in service on the part of the opposite party, dismissal of the complaint was sought.

5.      The complainant placed on record his affidavit Annexure CW1/A alongwith documents (Annexures C-1 to C-28).  On the other hand, the opposite party tendered in evidence affidavit (Annexure OPW1/A) of Tejinder Singh, Manager (Legal) alongwith documents Annexures OP1/1 to OP1/10.

6.      After hearing learned counsel for the parties and perusing the record, learned District Consumer Forum allowed the complaint and granted the necessary relief to the complainant, as mentioned above. 

7.      Learned counsel for the appellant has submitted that on receipt of the cashless claim of the complainant, an investigation was conducted by the opposite party to conduct the veracity of the claim by putting a query to the complainant vide letter dated 18.03.2019 and asking for old OPD papers with first consultation.  On receipt of the reply from the complainant, the opposite party concluded that the complainant used to consume tobacco (smoking), which was excluded under the terms and conditions of the policy.  Accordingly, the claim set up by the complainant was rejected.  As such, there was no deficiency in service on the part of the opposite party. 

8.      After hearing learned counsel for the appellant and on going through the impugned order, the State Commission finds that it remains undisputed that during the treatment of the complainant, an amount of Rs.1,45,000/- was spent by the complainant and in that regard, bills (Annexures C-12, C-20, C-21 and C-22) were placed on the file.  However, the said amount was not released by the opposite party.  The opposite party repudiated the claim of the complainant on the ground that the complainant was in the habit of smoking and resultantly suffered its complications, which was excluded under the policy.  However, there is no proof on the record to establish that the complainant was a smoker.  As such, the opposite party was not justified in repudiating the claim of the complainant as regards amount of Rs.1,45,000/- spent by the complainant on his treatment. 

9.      In view of above, it cannot be said that there is any force in the present appeal.  The appeal is devoid of any merit and therefore dismissed. 

10.    The statutory amount of Rs.25,000/- deposited by the appellant while filing the appeal be disbursed in favour of the complainant against proper receipt and identification in accordance with rules, subject to appeal/revision, if any.

U.K