Haryana

Karnal

CC/421/2022

Ankit Kamra - Complainant(s)

Versus

M/s Care Health Insurance Limited - Opp.Party(s)

Deepak Arya

23 Oct 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 421 of 2022

                                                        Date of instt.25.07.2022

                                                        Date of Decision:23.10.2024

 

Ankit Kamra son of Shri Vijay Kamra, resident of house no.602, Gali no.2-A, R.K. Puram, Karnal, Haryana.

                                               …….Complainant.

                                              Versus

 

1. M/s Care Health Insurance Ltd. (Formerly known as Religare Health Insurance Co. Ltd.), office at SCO no.354, Mugal Canal, Karnal-132001, through its Branch Manager/Authorised Signatory (M) 92546-47500.
2. M/s Care Health Insurance Ltd. (Formerly known as Religare Health Insurance Co. Ltd.), office at 5^th floor, 19 Chawla House, Nehru Place, New Delhi-110019, through its authorized officer/authorized signatory.

 

                                                                    …..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

      Ms. Neeru Agarwal…….Member

      Ms. Sarvjeet Kaur…..Member

 

 Argued by: Shri Deepak Arya, counsel for the complainant.

                    Shri Ashwani Kumar Popli, counsel for the OPs.

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant had purchased a Health Insurance Policy Plan namely “Care Advantage” Ad on Care Shield, vide policy no.31842636 valid from 26.06.2021 to 25.06.2022 after paying premium of Rs.9149/- under portability scheme. At the time of taking said policy, complainant disclosed to the OPs about pre-existing disease i.e. Hidradentitis Suppurativa and Respiratory allergy which is duly mentioned in the present policy of the complainant. When the aforesaid policy was ported/migrated in the company of OPs, at that time OPs and his agent assured the complainant to settle each and every claim which will be incurred on the medical treatment of the aforesaid disease upto Rs.25,00,000/- and a sum insured of Rs.25,00,000/- would be given to the complainant. The cashless and reimbursement both facilities are available in the aforesaid insurance policy on medical treatment etc. During the subsistence of the insurance policy, complainant had taken the treatment for the abovesaid disease and claim was settled and disbursed by the OPs in favour of complainant. Thereafter, for further treatment of said disease a pre-authorization/preapproval was sanctioned by the OPs and an approval letter was sent to Medanta The Medicity, Sector-38, Gurgaon, vide cashless authorization letter dated 10.05.2022. Wherein the OPs sanctioned total claim amount Rs.9,00,000/- as pre-approval Rs.5,00,000/- against claim no.AL:80714177 for surgical treatment admission date 10.05.2022 and discharge dated 19.05.2022. After sanctioning of pre-approval the complainant was admitted in said hospital for his treatment but on 17.05.2022 the pre-authorization claim of complainant was denied/repudiated by the OPs on the ground that “Restricted Sum Insured Exhausted. Initially stands null and void.” whereas more than 12 lakhs balance was available in said insurance policy. Complainant paid Rs.5,80,013/- to said hospital from his own pocket and requested the OPs through emails as well as telephonically for reimbursement of said treatment claim amount, but OPs did not bother to send reply of the aforesaid email of the complainant. It is further alleged that some other claims of the complainant were also rejected by the OPs on the false and frivolous ground. The detail of pending claim towards the OPs are as under:-

Sr. No.	Claim no.	Amount
1.	Claim no.AL: 80714177 (for Reimbursement claim no.92381625	Rs.5,80,013/-
2.	Claim no.92120156	Rs.8000/-
3.	Claim no.92315296	Rs.55,373/-
4.	Claim no.92296599	Rs.1,47,500/-
	Total Amount	Rs.7,90,886/-

 

Apart from above mentioned amount, a post operative treatment of the complainant is still going on. It is further alleged that two separate letters were sent by the OPs to complainant through emails mentioning that total claim amount settled is  Rs.12,74,705/- in first letter and Rs.12,63,200/- in second letter and balance sum insured has been shown Rs.12,25,295/- in first letter and Rs.12,36,800/- in second letter, till policy year end. Complainant requested the OPs several times for settlement of the claim and its disbursement/reimbursement but all the times, OPs have not given any satisfactory response to the complainant and intentionally and deliberately adopted delayed tactic. Due to this act and conduct of OPs, complainant has to suffer mental pain, agony and harassment. Then complainant sent a legal notice dated 27.06.2022 to the Ops but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence, complainant filed the present complaint seeking direction to the OPs to make/reimburse the claim amount of Rs.7,90,000/-+Rs.15,000/- post treatment alongwith interest, to pay the insurance claim regarding all bills of post treatment, which will be submitted by the complainant, to pay compensation amounting to Rs.1,00,000/- on account of causing mental pain, agony and harassment and to pay Rs.22,000/- as litigation expenses.

 2.            On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that OPs issued a health insurance policy bearing policy no.31842636, valid from 26.06.2021 to 25.06.2022, for the sum insured of Rs.25,00,000/- to complainant. The policy was renewed 25.06.2023. The policy was ported from Cigna TTK Pro-health insurance wherein the date of first enrolment was 26.06.2015. It is further pleaded that the pre-existing disease of Hindradentitis Suppurative and Respiratory Allergy was disclosed at the time of porting the policy and accordingly the port benefit for the same was provided by the company to the complainant. The OPs had already paid Rs.12,74,705/- for the expenses incurred by complainant for the treatment of pre-existing disease and its related complication i.e. Hindradentitis Suppurative and Respiratory Allergy, during the tenure of policy period from 26.06.2021 to 25.06.2022. It is further pleaded that as per clause 4.1(a)(i)(a) and (b) fresh exclusion shall apply to the extent of sum insured increased in the case of enhancement of sum insured. The sum insured of the complainant at the time of portability was Rs.5,50,000/- and No Claim Bonus was Rs.1,10,000/-. Hence, the total sum insured was Rs.6,60,000/- and the complainant had been provided port benefit for the pre-existing disease of Hindradentitis Suppurative and Respiratory Allergy upto Rs.6,60,000/- and fresh exclusion was applied for the remaining sum insured. The relevant clause is reproduced herein through which the OP process the claim:

Exclusions

4.1 Standard Exclusion

(a) Waiting Periods:

(i) Pre-existing Diseases-code-Exclu01

a.     Expenses related to the treatment of a pre-existing disease (PED)and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer.

b.     In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.

Insurance policy is issued subject to policy terms and conditions and not on an arbitrary basis. It is further pleaded that company had also sent a recovery letter dated 30.08.2022 thereby directing the complainant to pay the company, an amount of Rs.6,14,705/- (Rs.1274705-6,60,000). However, the company has not received any amount yet. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy Ex.C1, copy of cashless authorization letter dated 10.05.2022 Ex.C2, copy of claim form dated 23.05.2022 Ex.C3, copy of outdoor patient summary dated 10.05.2022 Ex.C4, copies of medical bills Ex.C5, copy of receipt dated 18.05.2022 Ex.C6, copy of tax invoice Ex.C7, copy of claim denial letters dated 17.05.2022, 21.05.2022 and 22.01.2022 Ex.C8 to Ex.C10, copy of letter dated 27.12.2022 Ex.C11, copy of tax invoice dated 27.12.2021 Ex.C12, copy of letter dated 05.10.2022 Ex.C13, copy of letter dated 05.09.2022 Ex.C14, copy of claim form dated 15.05.2022 Ex.C15, copy of letter dated 14.04.2022 Ex.C16, copy of doctor slip dated 14.04.2022 Ex.C17, copy of laboratory test report form dated 14.04.2022 Ex.C18, copy of invoice dated 15.04.2022 and 14.04.2022 Ex.C19 and Ex.C20, copy of cash receipt dated 15.04.2022 Ex.C21, copy of claim denial letters dated 19.04.2022, 26.04.2022, 04.04.2022 Ex.C22 to Ex.C24, copies of emails Ex.C25 to C29, copy of legal notice dated 27.06.2022 Ex.C30, postal receipts Ex.C31, copy of renewal policy period from 26.06.2022 to 25.06.2023 Ex.C32 and closed the evidence on 02.02.2023 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Ravi Boolchandani Ex.OP1/A, copy of letter dated 06.07.2021 Ex.OP1, copy of terms and conditions of the policy Ex.OP2, copy of insurance policy Ex.OP3, copy of discharge summary of Medanta-The Medicity Gurgaon Hospital Ex.OP4, copy of letter dated 30.08.2021 Ex.OP5, copy of claim form Ex.OP6, copy of letter dated 15.11.2021 Ex.OP7, copy of claim form Ex.OP8, copy of letter dated 15.11.2021 Ex.OP9, copy of claim form Ex.OP10, copy of letter dated 15.11.2021 Ex.OP11, copy of certificate issued by Dr. Arshdeep Consultant Dermatologist dated 09.11.2021 Ex.OP12, copy of letter dated 25.11.2021 Ex.OP13, copy of certificate issued by Dr. Arshdeep Consultant Dermatologist dated 13.12.2021 Ex.OP14, copy of letter dated 23.12.2021 Ex.OP15, copy of certificate issued by Dr. Arshdeep Consultant Dermatologist dated 10.01.2022 Ex.OP16, copy of letter dated 15.02.2022 Ex.OP17, copy of discharge summary  of Medanta Hospital for the period from 02.03.2022 to 12.03.2022 Ex.OP18, copy of letter dated 26.03.2022 Ex.OP19, copy of certificate issued by Dr. Arshdeep Consultant Dermatologist dated 28.02.2022 Ex.OP20, copy of letter dated 17.04.2022 Ex.OP21, copy of discharge summary for the period from 15.05.2022 to 20.05.2022 Ex.OP22, copy of claim denial letter dated 31.05.2022 Ex.OP23, copy of certificate issued by Dr. Arshdeep Consultant Dermatologist dated 14.04.2022 Ex.OP24, copy of claim denial letter dated 19.04.2022 Ex.OP25, copy of certificate issued by Dr. Arshdeep Consultant Dermatologist dated 04.04.2022 Ex.OP26, copy of claim denial letter dated 26.04.2022 Ex.OP27, copy of certificate issued by Dr. Arshdeep Consultant Dermatologist dated 27.12.2022 Ex.OP28, copy of claim denial letter dated 22.01.2022 Ex.OP29, copy of reply of legal notice Ex.OP30, copy of recovery letter dated 30.08.2022 Ex.OP3, copy of civil appeal no.1557 of 2004 Ex.OP4 and closed the evidence on 18.05.2022 by suffering separate statement.

6.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for the complainant, while reiterating the contents of complaint, has vehemently argued that complainant purchased a Health Insurance Policy from the OPs for the sum insured of Rs.25,00,000/- under the portability scheme. At the time of taking said policy, complainant disclosed about pre-existing disease to the OPs.  During the subsistence of the insurance policy, complainant had taken the treatment and claim was settled and disbursed by the OPs in favour of complainant. For further treatment of the pre-authorization was sanctioned by the OPs and sent an approval letter dated 10.05.2022  to Medanta The Medicity, Sector-38, Gurgaon and sanctioned the claim amount Rs.9,00,000/- After sanctioning of pre-approval the complainant was admitted in said hospital for his treatment but on 17.05.2022 the pre-authorization claim of complainant was denied by the OPs. Complainant paid Rs.5,80,013/- to said hospital from his own pocket and requested the OPs for reimbursement of said amount, but OPs did not bother to pay the same. Some other claims of the complainant have also been rejected by the OPs on the false and frivolous ground. Complainant requested the OPs several times for reimbursement of the claim amount but OPs did not pay the same and rejected the claim of complainant on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that that OPs issued a health insurance policy for the sum insured of Rs.25,00,000/- to complainant. The pre-existing disease of Hidradentitis Suppurative and Respiratory Allergy was disclosed at the time of porting the policy and accordingly the port benefit for the same was provided to the complainant. The OPs had inadvertently paid Rs.12,74,705/- instead of Rs.6,60,0000/-  to the complainant. Thus, OPs have already initiated the recovery proceeding against the complainant and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant has availed Health Insurance Policy Plan namely “Care Advantage” Ad on Care Shield from the OPs. It is also admitted that the policy was ported from Cigna TTK Pro-health insurance to OPs. It is also admitted that at the time of porting of the policy complainant has disclosed about pre-existing disease i.e. Hidradentitis Suppurativa and Respiratory allergy to the OPs. It is also admitted that during the subsistence of the insurance policy the complainant has taken treatment from Medanta The Medicity, Sector-38, Gurgaon and spent an amount of Rs.7,90,886/-

11.           The claim of the complainant has been denied by the OPs, vide letters Ex.C22 and Ex.C23 dated 19.04.2022 and 26.04.2022 on the ground, which are reproduced as under:-

“The claim is not payable as per policy terms and conditions listed below:-

. Claim repudiated: For sum insured for pre-existing disease is limited to previous sum insured.

.       Sub Limit Exhausted.”

12.           The claim of the complainant has been repudiated on the abovesaid grounds. Complainant has alleged that at the time of taking the policy, complainant disclosed to the OPs about pre-existing disease which is also mentioned in the policy. The sum assured under the policy was Rs.25,00,000/-. OPs have alleged that they had already paid Rs.12,74,705/- for the treatment of pre-existing disease. The sum insured of the complainant at the time of portability was Rs.5,50,000/- and No Claim Bonus was Rs.1,10,000/-. Hence, the total sum insured was Rs.6,60,000/- and the complainant had been provided port benefit for the pre-existing disease of Hindradentitis Suppurative and Respiratory Allergy upto Rs.6,60,000/- and fresh exclusion was applied for the remaining sum insured. The company had also sent a recovery letter dated 30.08.2022 thereby directing the complainant to pay the company, an amount of Rs.6,14,705/- (Rs.1274705-6,60,000) but OPs had not received the said amount.

13.           Since, the recovery proceeding qua the excess amount has already initiated against the complainant by the OPs. The question whether the OPs have paid excess amount to the complainant and the complainant is still entitled for remaining amount as alleged by the OPs, cannot be decided in summary proceeding and for that elaborate and detail evidence is required. Hence, the best platform to decide the matter in dispute is the Civil Court where elaborate and detailed testimony can be produced by the parties. In this regard, we have placed reliance upon the observations made in case titled as Love Motels Pvt. Ltd. Vs. Union Territory of Chandigarh 2007 (4) CPJ Page 305 (NC) wherein it has been observed by the Hon’ble National Commission that complicated issues involved, not adjudicable summarily-Dismissed with liberty to seek remedy in Civil Court. Further, in case titled as M/s The Bills through its Proprietor Versus PNB reported in 1998 (1) CPC page 150, decided by Consumer Disputes Redressal Commission, Union Territory, Chandigarh it has been held that complicated issues being involved, the matter needs to be decided Civil Court-Complaint stands dismissed.

14.          Keeping in view the ratio of law laid down the aforesaid judgments, facts and circumstances of the case, we disposed off the present complaint with the liberty to complainant to approach the Court/Civil Court of competent jurisdiction, if so desired. In view of the law laid down Hon’ble Supreme Court in Laxmi Engineering Works Versus PSG Industries Institute (1995) 3 SCC 583 the complainant would be at liberty to get the benefit of provisions of Section 14(2) of the Limitation Act, to exclude the period spent in prosecuting the present complaint before this Commission while computing the period of limitation prescribed for filing such complaint. No order as to cost. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated:23.10.2024

         President,

      District Consumer Disputes                           

      Redressal Commission, Karnal.

 

                   ( Neeru Agarwal)            (Sarvjeet Kaur)

                           Member                        Member