District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.319/2022.
Date of Institution: 09.06.2022.
Date of Order: 09.12.2022.
Vikash Choudhary son of late Sohan Lal resident of House No. 2826, Jawahar Colony, Near Air Force Road, NIT, Faridabad, Mobile 9540850400. Adhaar card No. 8954 5723 3162.
…….Complainant……..
Versus
1. Care Health Insurance Limited, (formerly known as Religare Health Insurance Company Limited) unit No. 604-607, 6th floor, Tower-c, Unitech Cyber Park, Sector-39, Gurgaon – 122001 (Haryana) through its authorized person.
2. Care Health Insurance Limited (formerly known as Religare Health Insurance company Limited) Regd. Office 5th floor, 19 Chawla House, Nehru Place, New Delhi – 110 019 through its authorized person.
…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. Vikash Chaudhary, complainant in person.
Sh. P.L.Garg, counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant
alongwith his family members i.e Vasu Choudhary, Khushi Rani, Kavita Rani had taken the health care policy in Plan Care advantage vide policy NO. 30170445 client ID No. 84528826 and the premium amount had been paid by the complainant i.e. Rs.32,346/- and the private room was covered in the said policy and the policy had been started from the 2014 and coming upto now w.e.f. 1.4.2022 to 3.4.2023 sum insured of Rs.50,00,000/- and during the insurance mediclaim policy the opposite parties had also given the no claim bonus to the complainant i.e. Rs.5,00,000/- and the complainant never taken the claim on the above said policy. During the mediclaim policy the complainant the was admitted in Metro Heart Institute, sector-16A, Faridabad on 25.4.2022 for the treatment of acute gastroenterties with pain in abdomen with acute vascular heacache and was discharged on 27.4.2022 and the hospital had raised the bill i.e. amount of Rs.32,753.18 and at that time the complainant intimated to the representative of the opposite parties but no fruitful result came out and the said amount had paid by the complainant from his own pocket. Due to non making the insured amount the treatment of the complainant could not be done in a proper manner and in this regard cross consultation form had been issued by the doctor Metro Hospital. The complainant had submitted the original medical bills with complete claim documents etc. to the opposite parties for the reimbursement of the said amount. On the basis of the reimbursement of the claim no result came out and the opposite parties with an intention not to make the insured amount and in this regard the opposite parties intentionally and knowingly denial letter on 27.4.2022 by making the alleged query. The complainant several times requested to the opposite parties to make the mediclaim amount of Rs.32,753/- but the opposite parties linger on the matter on one pretext to the another. 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) make the claim amount of Rs.32,753.18 alongwith interest @ 17% p.a. to the complainant which had been beard by the complainant from his own pocket during the insurance mediclaim policy .
b) pay Rs. 4,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 22,000 /-as litigation expenses.
2. Opposite parties Nos.1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 & 2 refuted claim of the complainant and submitted that the opposite party company issued a health insurance policy under the plan namely Care advantage bearing No. 30170445 to the complainant Vikas Choudhary w.e.f.5.3.2021 till 4.3.2022 providing policy coverage to himself, his spouse, his daughter and his son for a sum insured of Rs.50,00,000/- subject to policy terms & conditions. A cashless request was received from Metro Heart Institute, Faridabad on behalf of the complainant for his hospitalization on 25.4.2022 with complaint of pain, abdomen, headache, vertigo (chakkar aana), loose motion and cramps and was stated to be provisionally diagnosed with AGE (Acute gastroenteritis) with committing, abdomen pain and acute vascular headache. In order to check the veracity of the claim, the opposite party Co. triggered a claim investigation and issued deficiency letter dated 26.4.2022 to the treating hospital seeking investigation reports supporting diagnoses and pre-hospitalization OPD treatment records and further sought complete ICPs with admission notes, history sheets, doctor note, nursing notes and vital charts. Upon perusal of the medical documents by the treating hospital and additional documents received in quarry reply such as investigation report, daily plan care sheet of the hospital and vital charts. It came to the light that all the body vitals were within normal range limits and reports were found to be normal which means that there was no need for hospitalization and thus the insured could have been managed on OPD basis; that was why the complainant did not file reimbursement claim and did not file any claim form knowingly and intentionally to conceal the true facts. Therefore, in these circumstances, the opposite party company rejected the cashless request vide denial letter dated 27.04.2022 with reads as under:
“Admission not justified patient can be treated on OPD Basis”.
Opposite parties Nos. 1 & 2 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 Ins. Co. Ltd. with the prayer to: a) make the claim amount of Rs.32,753.18 alongwith interest @ 17% p.a. to the complainant which had been beard by the complainant from his own pocket during the insurance mediclaim policy . b) pay Rs. 4,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 22,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A- affidavit of Vikas Choudhary, Photocopies of insurance policy,, denial letter,, Deficiency letter,, cross consultation form,, discharge summary,
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, Care Health Insurance Ltd. Ex.R-1 – insurance policy alongwith terms and conditions, Ex.R-2 - Request for Cashless Hospitalization for Medical Insurance Policy, Ex.R-3 – Deficiency letter, Ex.R-4 – Deficiency letter, Annx.R-5 – query letter dated 26.4.2022, Ex.R-6 – denial letter dated 27.04.2022,
6. In this complaint, the complainant alongwith his family members i.e Vasu Choudhary, Khushi Rani, Kavita Rani had taken the health care policy in Plan Care advantage vide policy NO. 30170445 client ID No. 84528826 and the private room was covered in the said policy and the policy had been started from the 2014 and coming upto now w.e.f. 1.4.2022 to 3.4.2023 sum insured of Rs.50,00,000/- and during the insurance mediclaim policy the opposite parties had also given the no claim bonus to the complainant i.e. Rs.5,00,000/-. During the mediclaim policy the complainant the was admitted in Metro Heart Institute, Sector-16A, Faridabad on 25.4.2022 for the treatment of acute gastroenterties with pain in abdomen with acute vascular heacache and was discharged on 27.4.2022 and the hospital had raised the bill i.e. amount of Rs.32,753.18 . Opposite party repudiated the claim of the complainant vide letter dated 27.04.2022(Ex.R-6) on the ground that the cashless hospitalization cannot be approved as per the terms and conditions of the policy stated below:
- Admission not justified patient can be treated on OPD basis.
- Admission not justified.
7. After going through the evidence led by parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant, subject to submission of documents 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 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 concerned free of costs and file be consigned to record room.
Announced on: 09.12.2022 (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.
