District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 330/2022.
Date of Institution:9/22.06.2022.
Date of Order: 03.05.2023.
Shiv Singh S/o Shri Mangal Singh R/o H.No.864/14, 30 Foot Road, Parwatia Colony, Near Aggarwal Light House, Near Sector-22, Faridabad.
…….Complainant……..
Versus
1. M/s. Care Health Insurance Ltd., (Formerly known as M/s. Religare health Insurance) Corporate office: Unit NO. 604-607, 6th floor, Tower-C, Unitech Cyber Park, Sector-39, Gurugram – 122001 through its Managing Director/Director/Authorised Signatory.
2. M/s. Care Health Insurance Ltd., (Formerly known as M/s. Religare health Insurance) Ist floor, Plot NO. 37BP, WG Tower, Neelam Bata Road, NIT Faridabad – 121001 through its Branch Manager.
…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. N.P.Singh, counsel for the complainant.
Sh. P.L.Garg, counsel for opposite parties.
ORDER:
The facts in brief of the complaint are that the complainant alongwith his wife Shanti Devi were regular mediclaim policy holder of the opposite parties of their Group Care 360 o (PNB Platinum) policy, through Punjab, National Bank vide policy/certificate No. 17499225/31634306 valid from 7.6.2021 to 6.6.2022 for sum assured of Rs.5,00,000/-. During the period of insurance policy on 15.4.2022 complainant was suddenly sick and went to Metro Heart Institute with Multispecialty, Sector-16A, Faridabad with complaint of increased frequency of urine, feeling incomplete emptying of bladder where the doctors of the said hospital medically examined and advised him to admit in hospital. The doctor of the said hospital had made request to the opposite parties for pre-authorization, but the opposite parties had approved only Rs.25,000/- vide letter dated 16.04.2022. The opposite parties had illegally denied the claim vide letter dated 17.4.2022 because sub limit exhausted and after denial the hospital authorities demanded the money form complainant and at the time of discharge they had charged the amount of Rs.1,02,155/- from the complainant and then the complainant discharged on 17.4.2022/-. The complainant had lodged claim of Rs.77,155/- with the opposite parties which was duly received by the opposite parties with a request to disburse the claimed amount. The complainant sent legal notice dated 12.5.2022 to the opposite party through registered post but all in vain. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) pay the claimed amount of Rs.77,155/- alongwith interest @ 18% p.a. from the date of due till actual payment.
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 opposite party company had issued a group policy No. 17499225 to policy holder “Punjab National bank” under which a health insurance policy under the plan namely “Group Care 360 (PNB Platinum)” bearing certificate of insurance No. 31634306 was issued to the complainant - Mr. Shiv Singh. The said policy was issued for the period w.e.f. 7.6.2021 till 6.6.2022 for providing policy coverage to the complainant and his spouse for a sum insured of Rs.5,00,000/- subject to policy terms & conditions.
Cashless claim No. 80699524-00 and 92336217-00
a. a cashless request was received from the hospital on behalf of the complainant/insured as he was told to be admitted in Metro Heart Institute, Faridabad on 15.4.2022 for complaints of frequency of urine and was provisionally diagnosed with severally obstruction.
b. Upon receipt of cashless request, the opposite party company gave sanction as per terms of policy for an amount of Rs.25,000/- vide cashless authorization letter dated 16.4.2022.
c. Later, the opposite party company approved the amount of Rs.25,000/- after discharge and intimated that same to the complainant vide claim approval letter dated 19.5.2022. it was submitted that as per the discharge summary provided, the insured underwent urinary surgery i.e. Cystoscopy on 15.4.2022.
d. The opposite party company as per the terms of policy for the disease in question approved the amount of Rs.25,000/- which was paid non 20.05.2022 via NEFT No. N140221966436833 directly to the hospital vide claim approval & settlement letter dated 215,2022. The said payment was made in accordance with the sub limit capping for treatment of urinary surgery.
The said sub-limit capping for urinary surgery had been duly mentioned in the policy certificate itself which was mentioned in Annexure R-1 in the detail of sub limit capping. The limit was related for disease in question were as under:
Dilatation and Curettage of uterus, Lithotripsy | 10,000/- |
Surgery of hydrocele, Gastrecomy | 15,000/- |
Tonsilectoomy, Coronary Angiography | 20,000/- |
Surgery of prostate gland, urinary surgery | 25,000/- |
Appendectomy, kidney stones | 30,000/- |
Cataract (per eye) ENT surgery, Hysterectomy, surgery of hernia. | 40,000/- |
Treatment of fracture/dislocation/knee surgery | 1,00,000/- |
In view of the above, it was cleared that the claim had been approved & paid as per
admitted policy terms and conditions . 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 Ltd.with the prayer to: a) Pay the claimed amount of Rs.77,155/- alongwith interest @ 18% p.a. from the date of due till actual payment. 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 Shiv Singh, Ex.C-1 – policy, Ex.C-2 – Cashless Authorization letter dated 16.4.2022, Ex.C-3 – discharge summary, Ex.C-4 – Final Bill, Ex.C-5 – treatment records, Ex.C-6 – legal notice,, Ex.C-7 & 8 – postal receipts. Ex.C-9 – original envelop.
On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties Ex.RW-1/A – affidavit of Lakshay Juneja of Care health Insurance Ltd., Ex,R-1 – policy with terms and conditions, Ex.R-2 – Request for cashless hospitalization for medical insurance policy, Ex.R-3 – Cashless Authorization letter dated 16.04.2022, Ex.R-4 – Claim approval letter dated 19.05.2022,, Ex.R-5 – claim approval & settlement letter dated 21.05.2022,, Ex.R-6 – reply ot legal notice dated June 06,2022.
6. After going through the evidence led by the parties, the Commission
is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant, after deduction the paid money, within 30 days from the date 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. Opposite parties are also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alognwith 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 this order. File be consigned to the record room.
Announced on: 03.05.2023 (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.
