District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.205/2022.
Date of Institution: 11.04.2022.
Date of Order: 18.11.2022.
Om Prakash, aged about 47 years S/o Sh. Sahi Ram, r/o H.No. 106, Badi Bhati, Fatehpur Beri, South Delhi. Aadhaar No. 8849 0345 9523.
…….Complainant……..
Versus
1. M/s. Care Health Insurance Ltd.., (Formerly known as M/s. Religare Health Insurance) corporate Office: Vipul Tech Square, Tower-c, 3rd floor, Golf course Road, Sector-43, Gurgaon – 122009 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. Yogesh Nagar, counsel for the complainant.
Sh. Bharat Garg, counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant alongwith his wife Smt. Rekha were regular mediclaim cashless policy holder of opposite parties since 7.5.2019 vide Family Floater Insurance policy NO. 14155739 valid from 7.5.2019 to 6.5.2020 for sum assured of Rs.5,00,000/- and the opposite parties had issued cashless card to the complainant and thereafter the said policy was still continue further. At the time of issuance of policy opposite parties assured that all the daily medical expenses, tests, routine checkup were fully covered with the said policy. During the period of insurance policy on 12.09.2020 complainant was admitted in Kedar Hospital, 3B/3, NIT, Faridabad with the complaint of fever, multiple episode of vomiting, pain abdomen, ghabrahat etc. 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 and after their approval the doctor had admitted the complainant in the hospital. The complainant after diagnosed had discharged on 19.09.2020 and the said hospital had charged the amount of Rs.54,656/- from the complainant. The complainant had lodged claim with the opposite parties alongwith all the requisite documents which was required by the opposite parties, which was duly received by them with a request to disburse the claimed amount. The complainant many a times visited the opposite party offices of and requested their officials to release the claimed amount, but the opposite parties did not paid any heed upon the request of complainant and refused to release the claimed amount vide letter dated 24.03.2021 with false reason. Thereafter on 31.05.2021complainant was again admitted in QRG Medicare Ltd., Plot No.1, Sector-16, Faridabad with the complaint of left jaw pain and heaviness of arm, left face severe pain associated with generalized weakness, vertigo, pre syncope, giddiness epigastric discomfort for few days etc., 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, and after their approval the doctor had admitted the complainant in the hospital. The complainant after diagnosed had discharged on 03.06.2021 and the said hospital had charged the amount of Rs.73,390/- from the complainant. The complainant had lodged claim with the opposite parties alongwith all the requisite documents which was required by the opposite parties, which was duly received by them with a request to disburse the claimed amount. The complainant many a times visited the opposite party offices of and requested their officials to release the claimed amount, but the opposite parties did not paid any heed upon the request of the complainant and refused to release the claimed amount vide letter dated 21.06.2021 with false reason. 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) pay the claimed amount of Rs.1,28,406/- alongwith interest @ 24% p.a. from the date of due till actual payment.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-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 complainant Om Prakash had taken a Health Insurance Care Policy bearing NO. 14155739 covering the complainant namely Om Prakash and his wife Rekha w.e.f. 7.5.2019 to 6.5.2020 for a sum insured of Rs.5,00,000/-. The said policy was further renewed till 6.5.2022 on annual basis. The policy insurance and its subsequent renewal were subject to policy terms & conditions governing the policy. The complainant approached the opposite party company with a reimbursement claim No. 19451083 with respect to treatment undergone at Kedar Multispecialty Hospital, Faridabad wherein he was admitted w.e.f 12.09.2020 till 19.09.2020. He was provisionally diagnosed with UTI pain abdomen AFL. He was finally diagnosed with UTI Leucocytosis with electrolyte imbalance with TCP with HSM. He was admitted with complaints of fever, multiple episodes of vomiting, pain in abdomen gabrahat. The opposite party company on receipt of the claim sent a deficiency letter dated 29.10.2020, reminder dated 08.11.2020 and 18.11.2020 to provide the following documents necessary for proper assessment of the claim:
(i) Pre-hospitalization and OPD treatment record.
(ii) Complete indoor case papers with admission notes, history sheet, doctor’s notes, nursing notes and vital chart;
The company initiated claim investigation to process the claim in a more efficient way. The opposite party company rejected the claim of the complainant vide denial letter dated 24.3.2021 with the following observation:
- Deficiency not replied hence rejected.
- Deficiency not replied
Second cashless request claim NO. 80513328:
The complainant applied for second cashless request through the treating hospital i.e. QRG health City, Faridabad to claim charges that were to be incurred in hospitalization w.e.f 31.5.2021. As per the pre auth form, he was provisionally diagnosed with syncope, cardiac. He had presenting complaints of left jaw pain and heaviness of left arm, severe generalized weakness, 2-3 episodes of chaklar, pre-syncope, blackout, giddiness k/c/o epigastric discomfort. The company also sent a quarry letter to the complainant vide letter dated 31.05.2021 to seek the below documents:
Provide
i. Exact duration and past history of present ailment with Ist consultation paper and all past treatment records.
ii. Investigation report supporting diagnosis.
The company denied the cashless claim on the grounds vide denial letter dated 2.6.2021. Post Denial of Cashless request, the complainant filed e-imbursement claim for hospitalization at QRG Health City, Faridabad w.e.f 31.5.2021 to 3.6.2021. he was diagnosed with hypertension with Vascular Headache with right Hypoplastic vertebral artery vertigo. The opposite party company rejected the claim of the complainant vide claim denial letter dated 21.6.2021 with the following observations:
Denial Non disclosure of Smoking at the time of policy inception.
Non Disclosure of material facts/pre-existing ailments at the time of proposal.
As per statement of the patient: history of smoking 12 bidi per day since 20 years and left drinking 12 years back. Annexure R-11.
The complainant had an opportunity to declare his history of pre-existing ailments at the time of filing of proposal form, but the complainant intentionally did not disclose the same to the opposite party company “which itself is a concealment on the part of complainant and to put the principle of at most good faith regarding policy was not at all followed by the complainant”. 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 Insurance Co. Ltd. with the prayer to: a) pay the claimed amount of Rs.1,28,406/- alongwith interest @ 24% p.a. from the date of due till actual payment. b) pay Rs. 1,00,000/- 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 Om Prakash, Ex.C-1 – policy, Ex.C-2 – Discharge summary,, Ex.C-3 – In patient bill,, Ex.C-4 – Denial letter, Ex.C-5 – Discharge summary, Ex.C-6 – Final Bill of supply summary (Cash), Ex.C-7 – Claim denial letter.
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 Shri Ravi Boolchandani of Care Health Insurance Company Limited, Ex.R-1 – Discharge summary, Ex.R-2 (colly) – deficiency letter, Ex.R-3 – Claim Denial letter, Ex.R-4 – Pre-Authorisation Form – care, Ex. R-5 – Deficiency letter, Ex.R-6 – letter dated 08.05.2019, Ex.R-7 – denial letter , Ex.R-8 – Claim form-Care, Ex.R-9 – Discharge summary, Ex.R-10 – Claim denial letter, Ex.R-11 – statement of Om Parkash, Ex.R-12 – Proposal Form.
6. In this case, the repudiation was made only for non disclosure of smoking at the time of policy inception & non disclosure of material facts/pre-existing ailments at the time of proposal. As per settled by Apex Court now-a- days it is a life style. Opposite parties cannot repudiate the claim of the complainant only smoking. After through the evidence led by both the parties and as per the repudiation letter, the Commission is of the opinion that the complaint is allowed
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 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: 18.11.2022 (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.
