District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.581/2021.
Date of Institution: 10.11.2021.
Date of Order: 20.09.2022.
Kamal Narang S/o Shri H.C. Narang, age 44 years R/o flat No. 1101, Tower D1, Puri Pranayam Apartments, Sector-82, Kheri Kalan, Faridabad.
…….Complainant……..
Versus
Care health Insurance Limited, registered office at 5th floor, 19 Chawla House, Nehru Place, New Delhi and Branch office at SCO NO. 102-103, 2nd floor, Dwarka Complex, Sector-16, near ICICI Bank, Faridabad through its Managing Director/Manager.
…Opposite party……
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. Arun Dua, counsel for the complainant.
Sh. P.L.Garg, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant purchased an insurance policy “Care Advantage” from the opposite party bearing No. 18180562 for sum insured of Rs.100,00,000/- valid for the period from 10.10.2020 to 09.10.2021 and paid annual premium of Rs.47,507/-. To the opposite party. The complainant was admitted to Indraprastha Apollo Hospital, New Delhi on 08.12.2020 and was operated for avascular necrosis of both hips on 09.12.2020. The complainant was thereafter discharged from the hospital on 10.12.2020 and was advised physiotherapy by Dr. Yatinder Kharbanda, Senior Consultant, Orthopaedics (Joint Replacement and Arthroscopic Surgery) Indraprastha Apollo Hospital, New Delhi for three months. The complainant intimated the opposite party regarding his illness, hospitalization and operation and the opposite party acknowledged the receipt of the same and registered the claim of the complainant vide claim No. 91516873-00 against policy bearing No. 18180562. The opposite party thereafter settled the claim of the complainant and transferred a sum of Rs.972,922/- to the account of Indraprastha Apollo Hospital, New Delhi against claimed amount of Rs.11,06,992/-. The complainant thereafter underwent physiotherapy sessions at Health – Link Physiotherapy Clinic, Sector-16, Faridabad and submitted claims with the opposite party regarding pre approved and post hospitalization expenses. The opposite party, however approved a sum of Rs.12,095/- against claim No. 91516873-01 and further approved a sum of Rs.17,584/- against claim No. 91516873-02 and further approved a sum of Rs.70,751/- against claim No. 91516873-03. The complainant thereafter submitted claim with the opposite party for Rs.70,000/- for the expenses incurred on physiotherapy session form 6/1/2021 to 09.02.2021. The opposite party, however, out of the blue, repudiated the claim of the complainant vide claim denial letter dated 3.3.2021 as under:
:”We have received the claim filed by you pertaining to Health Insurance Policy 18180562 and hereby inform you that the claim was not payable as per policy terms and conditions listed below”
Claim repudiated maximum physiotherapy charges paid in 91516873-01 benefit not covered in policy”
The opposite party had malafidely and wrongly repudiated the claim of the complainant qua post hospitalization expenses of Rs.70,000/- incurred on physiotherapy.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) accept the claim of the complainant and release policy benefits of Rs.70,000/- i.e the expenses incurred on post hospitalization physiotherapy sessions for the period from 6/1/2021 to 9.2.2021 in favour of the complainant under policy NO. 18180562.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-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. 18180562 in favour of the complainant Kamal Narang, his spouse namely Parul Narang and in the name of his daughter and his son we.f 10.10.2020 to 9.10.2021 for a sum insured of Rs.1,00,00,000/-. The complainant filed a re-imbursement claim with opposite party company alongwith pre and post hospitalization expenses. The claim was approved/settled by the opposite party company for an amount of Rs.9,72,922/- to the account of Indraprastha Apollo Hospital, New Delhi as per the policy terms and conditions as mentioned in para No.7 of the complaint of the complainant vide claim approval and settlement letter dated 1.1.2021. The complainant thereafter underwent physiotherapy sessions at Health-Link Physiotherapy clinic, Sector-16, Faridabad and submitted claim with the opposite party company regarding pre and post physiotherapy expenses. The opposite party company, however, approved a sum of Rs.17,584/- against claim NO. 91516873-02 and further approved a sum of Rs.70,751/- against claim No. 91516873-03 also approved and paid a sum of Rs.12,095/-. The complainant submitted bills for an amount of Rs.70,000/- as post hospitalization expenses for physiotherapy done from 6.1.2021 till 9.2.2021. The claim was processed as per policy terms and conditions under reasonable and customary charges Therefore, the claim was rejected vide denial letter dated 3.3.2021 on the basis of maximum and reasonable physiothereapy charges duly paid on above basis in 91516873-01. The said denial letter which was reproduced as under:
We have reviewed the claim filed by you pertaining to health insurance policy (18180562) and hereby inform you that the claim was not payable as per policy terms and conditions listed below:
Claim repudiated maximum physiotherapy charges paid in 91516873-01.Benefit not covered in policy. 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 parties– Care Health Insurance Co. Ltd. with the prayer to: a) accept the claim of the complainant and release policy benefits of Rs.70,000/- i.e the expenses incurred on post hospitalization physiotherapy sessions for the period from 6/1/2021 to 9.2.2021 in favour of the complainant under policy NO. 18180562. b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .c) pay Rs. 11,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Kamal Narang, Ex.C-1 – insurance policy valid for the period 10.10.2020 to 09.10.2021, Ex.C-2 – insurance policy valid from 10.10.2021 to 09.10.2024, Ex.C-3 – Discharge summary, Ex.C-4 - letter dated Ist January,2021 regarding claim approval & settlement Letter, Ex.C-5 – receipt dated 15.01.2021, Ex.C-6 – claim denial letter dated 03.03.2021.
On the other hand counsel for the opposite party strongly agitated and
opposed. As per the evidence of the opposite party Ex.RW-1 – affidavit of Sahil Chauhan, Manager-legal at Care Health Insurance Ltd. Ex.R-1 – policy with terms
& conditions,, Ex.R-2 – Claim approval & settlement letter,, Ex.R-3 – claim denial letter.
6. After going through the evidence led by the parties, the Commission is of the opinion that the complainant filed a re-imbursement claim with deponent company alongwith pre and post hospitalization expenses. The claim was approved/settled by the deponent company for an amount of Rs.9,72,922/- to the account of Indraprastha Apollo Hospital, New Delhi as per the policy terms & conditions as mentioned in para No.7 of the complaint of the complainant vide claim approval and settlement letter dated 0101.2021 vide Ex.R2. The complainant thereafter underwent physiotherapy sessions at Health- Link Physiotherapy clinic, Sector-16, Faridabad and submitted claim with the deponent company regarding pre and post physiotherapy expenses. The deponent company, however, approved a sum of Rs.17,584/- against claim No. 91516873-02 and further approved a sum of Rs.70,751/- against claim No. 91516873-03 and also approved and paid a sum of Rs.12,095/-. It is evident from the policy certificate vide Ex.C1 in which it has been mentioned in page No.2 of the policy:
Schedule of Benefit
1. | Hospitalization Medical Expenses and post hospitalization expenses. | Pre-hospitalization for 30 days & post hospitalization of 60 days. Maximum up to Sl |
Keeping in view of the above, the complaint is allowed. Opposite party is directed to release policy benefits of Rs.70,000/- i.e. the expenses incurred on post hospitalization physiotherapy sessions for the period from 6.1.2021 to 9.2.2021 in favour of the complainant under policy No. 18180562. 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. Compliance of this order be made within 30 days from the date of receipt of copy of order. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 20.09.2022 (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
