District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.560/2021.
Date of Institution: 27.10.2021.
Date of Order: 23.11.2022.
Mr. Amit Sajwan S/o Shri Balwant Singh R/o House NO. FCA 1197/D SGM Nagar, NIT, Faridabad – 121001.
…….Complainant……..
Versus
M/s. Care Health insurance Limited Formally known as Religare Health Insurance company Ltd., Regd. Office 5th floor, 19 Chawla House, Nehru Place, New Dlehi – 110 019.
…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. Suresh Sharma, counsel for the complainant.
Sh. N.K.Garg, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant was the policy holder of the opposite party company bearing policy No. 16859063 was issued in favour of the complainant on 10.02.2020 providing a coverage to complainant and his spouse Mrs. Preeti Rawat for upto Rs.5,00,000/- for the period from 11.02.2020 to 10.02.2021 and further renewed on 10.02.22021 to 10.02.2022 On 22.11.2020 complainant was having a fevr with chest pain with difficulty in breathing with cough. During that time Covid was in it high peak and it was spreading with high speed. On 22.11.2020 complainant went to M/s. Kedar Hospital for the treatment and dr. Amit Jain advised him to get done his Covid-19 Test. Covid test was conducted on the same day and report was positive of complainant and complainant was declared suffering from Covid-19. The complainant was very well traded by the hospital. It was alleged that when no hospital was ready to give beds to covid patient Kedar hospital had saved the life of the complainant by treating complainant in a very good manner. Several tests was done by the hospital and difficulty in the health of complainant was cured. The complainant was again tested for Covid-19 on 28.11.2020 and esulted into not detected and complainant was discharged form hospital on 29.11.2020. The detailed information regarding the admission in the hospital as well as details regarding the covid-19 already sent to the opposite arty and the opposite party admitted about the receipt of the said documents and a bill for a sum of Rs.2,39,788/- wee also sent to the opposite parties to enable them to entertain and made the payment of the bill under mediclaim policy referred to above to the complainant. As per the terms and conditions of the mediclaim policy, if any policy holder (patient) becomes sick or injured and remains under the treatment for 24 hours in a minimum 15 wedded hospital, the total treatment expenses incurred by the patient should be reimbursed to the policy holder within the stipulated period of 30 days after the receipt of the requisite papers and documents of the hospital form the policy holder at the end of the opposite parties. In respect of the above, the complainant was sorry to inform the opposite parties that they had even acknowledged the receipt of the papers and documents of the hospital which fulfills the condition of the policy of the insurance company i.e. the opposite party as this hospital was of more than 50 bedded hospital with all requisite equipments and instruments of the recognized hospital. Instead of reimbursing the claim of the complainant opposite party No.2 treated the claim of the complainant as No Claim with the remarks Untrue statement were made or there had been a misrepresentation vide their letter in which he remarked that the claim was not payable. When opposite party turned himself from his obligation to pay the complainant in his hard times then the bill of Rs.2,39,788/- was paid by the complainant himself from the savings to the hospital. The aforesaid act of opposite party 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 Rs.2,39,788/- with interest @ 24% p.a.since date of due till the date of realization of the amount in full to the complainant jointly & severally.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 50,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the complainant had taken a Health Insurance policy bearing NO. 16859063 covering the complainant namely Amit Sajwan, his spouse Preeti Rawat w.e.f. 11.2.2020 to 10.02.2021 for a sum insured of Rs.5,00,000/- subject to policy terms & conditions governing the policy. The said policy was further renewed for the period from 11.2.2021 to 10.02.2022. The policy issuance and its subsequent renewal were subject to policy terms & conditions governing the policy. The complainant approached the opposite party company with a reimbursement claim for his hospitalization at Kedar Hospital Multi Speciality, Faridabad form 22.11.2020 to 29.11.2020 as per discharge of Kedar Multi Specialty, Faridabad. The complainant was diagnosed with Covid-19 positive, UTI Leucocytosis, Hypovitaminosis D, Hypothyroidism and transminitis with fatty liver. The opposite party company on receipt of the claim sent query letters dated 6.1.2021, 10.02.2021 and further reminder letters dated 9.1.2021, 12.1.2021 to the complainant for following documents/informations:
i) address proof of proposer/nominee as mentioned in policy, Mr. Amit Sajwan S/o Balwant Singh f.c.a. 1197/d SGM Nagar, Faridabad -121001 Haryana.
ii) Recent passport size photograph of proposer/nominee Mr. Amit Sajwa
iii) Pre hospitalization OPD treatment record.
iv) Investigation report supporting diagnosis. Covid positive test report.
v) Original cash paid receipt against final bill.
vi) Complete indoor case papers with admission notes, history sheet, doctor’s notes, nursing notes and vital chart.
Upon perusal of the submitted document and as per the findings of the claim investigation, following observations were made:
i) as per the treating doctor’s statement of Krishna Nursing Home and Cosmoasthetic Centre dated 22.1.2021, the complainant was not treated under his supervision.
ii) the complainant disclosed in his questionnaire form which was duly filled and signed that he was not having any complaint sof vomiting and nausea during his entire hospitalization but as per Nurses Medication Chart of M/s. Kedar Hospital dated 29.11.2020 , EMSET injection (emset injection was an antiemetic medicine commonly used to control nausea and vomiting due to certain medical conditions like stomach upset) was given to the complainant during his entire hospitalization.
iii) the complainant have concealed and given a contradictory version about his illness before hospitalization and also failed to provide any proof about sickness before hospitalization.
iv) in the claim for the complainant had left material column knowingly and intentionally to conceal the true factum of illness and treatment.
Therefore, on the basis of above findings the claim was rejected vide letter dated 23.02.2021 on the basis of the claim being a fraudulent claim. Opposite party 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 party– M/s. Care health Insurance Limited with the prayer to: a) pay an amount of Rs.2,39,788/- with interest @ 24% p.a. since date of due till the date of realization of the amount in full to the complainant jointly & severally. b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 50,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/1 – affidavit of complainant, Ex.CW1/A (colly) –policy, Ex.CW1/B - Molecular diagnostics,, Ex.CW1/C(colly) – in patient bill,
On the other hand counsel for the opposite party strongly agitated and
opposed. As per the evidence of the opposite party Ex.RW-1/A – affidavit of Sahil Chauhan, Manager Legal having its office at Vipul Tech Square, Tower C, 3rd floor, Golf Course road, Sector-43, Gurugram of M/s. Care health Insurance Ltd. Ex.R-1 – policy, Ex.R-2 – Discharge summary, Ex.R-3 to 6 – query letter, Ex.R-7 - Statement of Krishna Nursing Home and cosmoasthetic Centre dated 22.1.2021, Ex.R-8 – questionnaire form, Ex.R-9 – Nurses Medication Chart, Ex.R-10 – claim denial letter dated 23.02.2021
6. In this case, the complainant had taken a Health Insurance policy bearing NO. 16859063 covering the complainant namely Amit Sajwan, his spouse Preeti Rawat w.e.f. 11.2.2020 to 10.02.2021 for a sum insured of Rs.5,00,000/-. The said policy was further renewed for the period from 11.2.2021 to 10.02.2022. The complainant approached the opposite party company with a reimbursement claim for his hospitalization at Kedar Hospital Multi Speciality, Faridabad form 22.11.2020 to 29.11.2020 as per discharge of Kedar Multi Specialty, Faridabad. The complainant was diagnosed with Covid-19 positive, UTI Leucocytosis, Hypovitaminosis D, Hypothyroidism and transminitis with fatty liver. The opposite party sent query letters dated 6.1.2021, 10.02.2021 and further reminder letters dated 9.1.2021, 12.1.2021 vide Ex. R-3 to R-6 to the complainant in which they demand the required documents. As per treating doctor’s statement of Krishna Nursing Home and Cosmoasthetic Centre dated 22.1.2021 vide Ex.R-7, the complainant was not treated under his supervision. Opposite party has repudiated the claim of the complainant on 23.02.2021 on the basis of the claim being a fraudulent claim vide Ex. R-10.
7. After going through the evidence led by parties, the Commission is of the opinion that the complaint is allowed. Opposite party is 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 along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite party is 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 concerned free of costs and file be consigned to record room.
Announced on: 23.11.2022 (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.
