District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 112/2022.
Date of Institution:28.02.2022.
Date of Order: 07.02.2023.
Jas Ram resident of House No. 162/8, Village Ankhir, Tehsil & District Faridabad.
…….Complainant……..
Versus
1. M/s. Care Health Insurance Company Limited, Branch Office –Ist floor, Plot No. 37BP, WG Tower, Neelam Bata Road, NIT, Faridabad – 121001 through its Manager.
2. M/s. Care Health Insurance Company Limited Corporate Office – Unit No. 604-607, 6th floor, Tower-C, Unitech cyber Park. Sector-39, Gurugram, Haryana – 122001 through its Manager.
3. M/s. Care Health Insurance Company Limited Registered office -5th floor, 19 Chawla House, Nehru Place, New Delhi – 110 019 through its Director/principal Officer.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Bhagender Bhadana, counsel for the complainant.
Sh. N.K.Garg, counsel for opposite parties.
ORDER:
The facts in brief of the complaint are that the complainant and his wife Smt. Rajesh were the policy holders of the opposite parties under the Plan Group Care 360 (Through Scheme III for Sarva Haryana Gramin Bank), Group Policy No. 18498780 bearing certificate of insurance No. 35310035 valid w.e.f 26.10.2021 to midnight of 25.10.2022 for the mediclaim floater benefit value of Rs.5,00,000/-. The complainant had already paid the amount of yearly premium of Rs.7,172/- to the opposite parties. On 12.01.2022 the complainant became sick due problem/complaint of blood in vomitus since one day associated with breathing difficulty restlessness. Hence the complainant was admitted in Asian Hospital, Badkhal Flyover Road, Sector-21A, Faridabad on 12.01.2022 for the treatment of the said disease. The complainant remained admitted as indoor patient in the said hospital and the complainant was discharge don 15.01.2022 from the said hospital. The Medical Officer of Asian Hospital, Badkhal Flyover road, sEctor-21A, Faridabad sent the intimation to the opposite parties through TPA regarding admission, tests and treatment of the complainant in above said hospital and fulfil all procedure. However, the doctors of the said hospital raised the bill dated 15.01.2022 for Rs.83,098/- to the complainant. The doctors of the said hospital applied for cashless at the time of hospitalization of the complainant’s from Asian Hospital Badkhal Flyover Road, Sector-21A, Faridabad but instead of paying the amount of Rs.83,098/- to the complainant the opposite parties sent the false and frivolous denial letter dated 14.01.2022 to the Asian Hospital, Faridabad thereby the opposite parties had rejected the claim of the complainant on the false and frivolous ground that “permanent exclusion: condition caused by suicide or
substance abuse/intoxication. Non disclosure of material facts/pre existing ailments at the time of proposal – history of alcoholism’ “Non-disclosure of material fact/pre-existing ailment at the time of proposal” & permanent exclusion condition caused by suicide or substance abuse/intoxication and having no documentary proof with the company in this regard. In this regard it was submitted that no previous history for admission of the complainant in any hospital except the clinical advise, prior to taking the policy from the bank and disclosed all the relevant facts to the authorized representative of opposite party at the time of proposal of this policy. All the tests reports of the complainant were OKEY at the time of admission of the complainant on 18.11.2021 but at that time the claim bill amount Rs.18,229/0 of the complainant was rejected without any specific reason and justification and the opposite parties did not issued any letter to the complainant till date but in the second time when the complainant was admitted in Asian Hospital on 29.11.2021 and remained there upto 01.12.2021 the mediclaim reimbursement of Rs.35,060/- was admitted as cashless and paid by the opposite parties. The opposite parties were avoiding to reimburse the complainant for the treatment amount of Rs.83,098/- to the complainant on one pretext or the other on the false, vague and baseless grounds. The complainant sent legal notice dated 04.09.2020 to the opposite parties but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay an amount of mediclaim expenses of Rs.101327/- alongwith interest @ 24% p.a. from the date of discharge of the complainant till upto jointly or severally.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 5500 /-as litigation expenses.
2. Opposite parties put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that the complainant had issued a Group Insurance Policy bearing No. 18498780 vide certificate of insurance No. 35310035 w.e.f. 26.10.2021 to 25.10.2022. The complainant alongwith his spouse were covered under the policy for a sum insured of Rs.5,00,000/- subject to the terms and conditions.
Cashless Request (Claim No. 80647897)
Cashless request was received from Asian Institute of medical Sciences, Faridabad on behalf of the complainant for his hospitalization on 12.01.2022 with provisional diagnoses of acute lever disease and hematemesis. In order to check the veracity of the claim, the opposite party company triggered a claim investigation, who on the basis of the documents submitted supplied investigation report alongwith the claim form. It was observed that as per the patient’s statement himself: He had been taking 1-2 bottle of alcohol in single time since 40 years.. The ailment of the complainant had a direct co-relation with the habit of alcohol intake. Therefore, cashless claim of the complainant was ejected by the opposite party company vide letter dated 14.10.2022 as per terms & conditions of the policy.
2nd cashless request (80616776)
The another cashless request was received from Asian Institute of medical Sciences, Faridabad on behalf of the complainant for his hospitalization on 18.11.2021 with provisional diagnoses of lower respiratory tract infection and fever. Post Scrutinizing the documents sent by the complainant with the
cashless request, the opposite party company rejected the claim vide claim denial letter dated 18.11.2021 and made the following observations:
We have revived his request and hereby inform him that the cashless hospitalization cannot be approved as per the terms & conditions of the policy staed below:
30 days waiting period.
30 days waiting period.
The said rejection of claim was in accordance to the exclusion mentioned in the policy terms & conditions. The waiting period mentioned in clause 5.1(1)(a) of the policy terms & conditions was reproduced herein below:
Expenses related to the treatment of any illness within any 30 days from the first policy commencement date shall be excluded except claims arising due to an accident provide the same were covered.
Free look period
The complainant had the opportunity of returning the policy with terms & conditions of the policy if not acceptable to the insured. However, no such option was exercised by the insured post policy assurance. The relevant clause pertaining to free look period herein for the kind perusal of the forum.
3rd Cashless request (92029058)
The another cashless request was received from Asian Institute of medical sciences, Faridabad on behalf of the complainant for his hospitalization on 29.11.2021 with provisional diagnosis of cough with shortness of breath since 2
days associated with ghabrahat, vomiting and weakness and the same was duly approved by the opposite party company.
Opposite parties denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties– M/s. Care Health Insurance company Limited & Others with the prayer to: a) pay an amount of mediclaim expenses of Rs.101327/- alongwith interest @ 24% p.a. from the date of discharge of the complainant till upto jointly or severally. b) pay Rs. 50,000/- as compensation for causing mental agony and harassment . c) pay Rs. 5500 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Jas Ram, Ex.C-1 - insurance policy, Ex.C-2 – Premium acknowledgement, Ex.C-3 - Bill dated 15.01.2022, Ex.C-4 – Discharge summary, Ex.C-5 ^ – Deposit receipts, Ex.C-7 - denial letter dated 14.01.2022, Ex.C-8 – bill dated 18.11.2021, Ex.C-9 – discharge summary, Ex.C-10 – bill dated 01.12.2021, Ex.C-11 – discharge summary, Ex.C-12 – legal notice, Ex.C-13 to 15 – postal receipts,, Ex.C-16 - envelop, Ex.C-17 & 18 - track consignments.
On the other hand counsel for the opposite parties strongly agitated
and opposed. As per the evidence of the opposite parties Ex.R-1 – policy terms & conditions, Ex.R-2 – pre authorization form, Ex.R-3 - denial letter dated 14.01.2022, Ex.R-4 – Audio Video Recording, Ex.R-5 – Certificate u/s 65-B of Indian evidence Act, Ex.R-6 – pre-Authorization Form, Ex.R-7 – denial letter dated 18.11.2021, Ex.R-8 – Cashless Authorization letter dated 01.12.2021.
6. In this case, the complainant was admitted in the Asian Hospital in 3 times. Firstly he was admitted in the Asian hospital from 12.01.2022 to 15.01.2022. The claim of the complainant was denied by the opposite party vide Ex.R-7 on the ground of 30 days waiting period. Second claim was filed by the complainant which was paid by the complainant to opposite party for the period from 18.11.2021 to 18.11.2021. Thirdly, the claim of the complainant was repudiated on the ground of non disclosure of material facts. During the course of arguments, counsel for the complainant argued at length and stated at Bar that as per the discharge summary the claim of the complainant was for the same disease. As per discharge summary, no doubt the patient was admitted in the hospital in three times. First claim of the complainant was repudiated by the insurance company on the valid ground and second claim was paid by the complainant. Third claim of the complainant was repudiated by the opposite party on the ground of non disclosure of the material facts when the disease is the same.
7. Moreover, when the date of birth of the insured is 01.Jan. 1957 then the Insurance Company was at liberty to get the complainant medically examined prior to issuance of the policy in question. Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing the policy in question whether a person is fit to be insured or not. It was the duty of the opposite party to get the complainant immediately examined before issuing the policy as per IRDA guidelines.
8. The ground of rejection of claim does not stand to the test of scrutiny because opposite party has not placed on record any credible evidence to prove that the complainant had pre existing disease which was not disclosed by him at the time of obtaining said policy.
9. Therefore, not releasing claim of the complainant amounts to deficiency in service on the part of opposite party.
10. Resultantly, the complaint is allowed. Opposite parties, jointly & severally are directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a from the date of filing of complaint till its realization. The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties free of costs and file be consigned to record room.
Announced on: 07.02.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
