Chandigarh

DF-I

CC/299/2023

TAJPREET DAUGHTER OF SH. PARMINDER SINGH - Complainant(s)

Versus

MS RELIANCE GENERAL INSURANCE, RCARE HEALTH THROGH ITS MANAGING DIRECTOR - Opp.Party(s)

03 Jun 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/299/2023
Date of Institution	:	09/06/2023
Date of Decision	:	03/06/2024

 

Tajpreet, daughter of Parminder Singh, resident of House No.1, Civil Dispensary, Opposite Plot No.93, Industrial Area, Phase-1, Chandigarh.

… Complainant

V E R S U S

1. M/s Reliance General Insurance, RCare Health through its Managing Director, HO Office, No.1-89/3/B/40 to 42/KS/301, 3^rd Floor, Krishe Block, Krishe Sapphire, Madhapur, Hyderabad-Telangana-500081.
2. M/s Reliance General Insurance, RCare Health through its Branch Manager, SCO No.56-57, Top Floor, Sector 17, Chandigarh. Director, HO Office, No.1-89/3/B/40 to 42/KS/301, 3^rd Floor, Krishe Block, Krishe Sapphire, Madhapur, Hyderabad-Telangana-500081.
3. M/s Eden Critical Care Hospital through its proprietor, Plot No.115, Near Elante Mall, Industrial Area & Business Park, Phase-1, Chandigarh 160002.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Complainant in person
	:	Complaint against OP-1 dismissed as withdrawn vide order dated 25.10.2023.
	:	Sh. Arun Kumar (through VC) & Sh. Varun Bhardwaj, Advocates for OP-2
	:	OP-3 ex-parte

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Ms.Tajpreet, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that the complainant is a student who, out of her savings, had purchased an insurance policy namely Reliance Health Gain Policy (hereinafter referred to as “subject policy”) in the name of herself and her younger brother, Tejeshwar Singh and the same was valid w.e.f. 13.2.2023 to 12.2.2024 (Annexure C-1).  OPs 1 & 2 are running the business of General Insurance under the name and style of M/s Reliance General Insurance whereas OP-3 is running a hospital in the name of Eden Critical Care Hospital. On 20.3.2023, complainant felt sudden acute headache due to which her health started deteriorating and accordingly she approached Eden Critical Care Hospital, Chandigarh (hereinafter referred to as “Treating Hospital”) where after check-up she was advised for admission in the emergency ward.  At that time, complainant had informed OP-3 about the subject policy. Accordingly, OP-3 had sent pre-authorization request form (Annexure C-2) to OPs 1 & 2/insurer who confirmed vide letter dated 20.3.2023 (Annexure C-3) approval for cashless authorization for treatment and guarantee of payment. Thereafter OP-3 had informed the complainant about the receipt of approval for treatment from OPs 1 & 2. As per the discharge summary (Annexure C-4), complainant remained under treatment in the Treating Hospital upto 24.3.2023 and she was advised to take rest at her home. The Treating Hospital had raised bill (Annexure C-5) amounting to ₹55,741/- to OPs 1 & 2 for payment, but, they refused to make payment vide letter dated 24.3.2023 (Annexure C-6).  Accordingly, parents of the complainant were compelled to make payment of the bill amount in order to avoid further insult and humiliation from the Hospital management. Thereafter, again the complainant took up the matter with OPs 1 & 2 for payment of claim, but, to the utter surprise of the complainant, OPs 1 & 2 sent letter of rejection dated 29.4.2023 (Annexure C-7).  In this manner, OPs have rejected/repudiated the genuine claim of the complainant despite of the fact that earlier cashless approval was given and the said act amounts to deficiency in service and unfair trade practice on their part. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs 1 & 2 resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action and concealment of facts.  However, it is alleged that since the answering OPs have already paid the admissible amount of ₹38,418/- to the complainant as per the terms and conditions of the subject policy and the complainant has concealed the material facts from this Commission, the consumer complaint is liable to be dismissed.  On merits, the facts as stated in the preliminary objections have been reiterated. However, it is admitted that the subject policy was obtained by the complainant and she had lodged claim with the answering OPs and as per terms & conditions of the subject policy, claim of the complainant for admissible amount of ₹38,418/- was paid to her on 13.6.2023. It is further alleged that as per the permanent exclusion clause of the policy, cashless claim of the complainant was repudiated since it appeared from the documents submitted by the Treating Hospital that hospitalization was not required. The answering OPs had deputed investigator on 12.4.2023, who investigated the matter and submitted report to the answering OP on 27.4.2023 and only after that the admissible amount of ₹38,418/- was paid to the complainant.  It is denied that the complainant is entitled for a sum of ₹55,741/-. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. However, subsequently, in view of the statement made by the complainant, consumer complaint against OP-1 was dismissed as withdrawn vide order dated 25.10.2023 of this Commission.
4. OP-3 did not turn up before this Commission, despite proper service, hence it was proceeded against ex-parte vide order dated 28.7.2023.
5. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.   However, it is admitted that an amount of ₹38,418/- was deposited in her account by the OPs.

2. In order to prove their case, contesting parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the complainant in person, learned counsels for OP-2 and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had obtained the subject policy (Annexure C-1) from OP-2/insurer which was valid w.e.f. 13.2.2023 to 12.2.2024 and during its currency complainant had fallen ill and was admitted in the Treating Hospital where she remained hospitalized from 20.3.2023 to 24.3.2023, as is also evident from the discharge summary (Annexure C-4), and the Treating Hospital had raised bill of ₹55,741/-, as is also evident from the bill (Annexure C-5) out of which OP-2 has settled the claim only to the extent of ₹38,418/- by transferring the same in complainant’s saving account on 13.6.2023 and rejected/repudiated the remaining claim, the case is reduced to a narrow compass as it is to be determined if OP-2/insurer is unjustified in not releasing the entire claim amount to the complainant and the same amounts to deficiency in service and unfair trade practice on its part, and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OP-2/insurer is justified in partially allowing the claim of complainant and the instant consumer complaint, being false and frivolous, is liable to be dismissed, as is the defence of the OP-2.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the documentary evidence placed on record by them and the same is required to be scanned carefully to determine the real controversy between the parties.
   3. Perusal of OP-1 clearly indicates that the subject policy was valid w.e.f. 13.2.2023 to 12.2.2024.  The claim of the complainant has only been resisted by the OP-1/insurer on the ground that the investigator has assessed the claim after going through the documents submitted/received by him and after that claim of the complainant to the tune of ₹38,418/- was assessed and the remaining claim was denied.  In this manner, the report of the investigator is required to be scrutinized more cautiously and the relevant portion of the same is reproduced below for ready reference :-

Brief summary of Investigation	Investigation of the case has been done. Findings are noted beneath: This case has been previously investigated in cashless with claim no. 101230014707 Investigation of the case has been done and findings are noted beneath:- Visit to the Hospital has been done and patient was found admitted in the hospital. Patient's father had filled the statement. Patient's father is government employee in the Health Department. Patient residence is just opposite to the hospital. Findings are per the statement are noted beneath: As per the statement given by the patient's father that patient was admitted in the hospital for the complaints of Fever, headache, abdominal pain and Fever. As per the statement given by the patient's father that patient was having the complaint of headache, Stomach pain, Fever and Viral. As per the statement given by the patient's father that patient undergoes the routine lab test, CT scan and Ultrasound and urine test. As per the statement given by the patient's father that patient was having the complaints of Viral fever last 7 days and for the similar complaints patient visited to the Eden Hospital on the date 20-03-2023 and taken treatment under observation at Hospital authority and all lab tests done in Eden Hospital and treatment is still going on. ICP had been collected. Findings as per the ICP:- As per the ICP patient was admitted in the Hospital on the date 20.03.2023 near 4 pm. As per the ICP patient was admitted in the hospital for the complaints of Fever from last 7 days and Epigastric pain. As per the ICP during hospitalization patient was admitted in Private. Patient underwent Chest x-ray on 20/03/2023 but that reports normal. Patient underwent USG on 20/03/2023 and findings are Hepatomegaly. Patient underwent NCCT head on 22/03/2023 and that report is normal. As per patient's statement, patient is having complaints of loose motion but that is not mentioned in the ICP moreover as per the lab reports electrolyte count is normal. Remarks: Claim seems to be repudiated under patient is admitted in the hospital for investigation and observation purpose only as patient general condition is normal and patient underwent different investigations. As patient is admitted in the hospital for the complaints of fever but as noted in the vitals temperature of the patient is normal throughout. Moreover TLC Count is normal. Hence need of hospitalization is not justified. Now visit to the patient residence has been done. Patient statement had been collected. Findings are noted beneath: As per patient statement, she was admitted in the hospital for the complaints of fever, headache, and stomach pain. As per patient statement, she had no h/o any chronic illness. As per patient statement, she was admitted in the hospital on 20/03/2023 and was discharged on 24/03/2023. Doctor statement had been collected. Findings are noted beneath: As per Doctor statement, patient was admitted in the hospital for the complaints of abdomen pain, fever, vomiting. As per Doctor Statement, patient is not suffering from any chronic illness. As noted in the Discharge summary that patient is given medicine Combiflam and Topirol which is used in the treatment of migraine. Query needs to be raised for the justification of doctor statement for the indication of tablets given to the patient.
Discrepancies observed	Now visit to the patient residence has been done. Patient statement had been collected. Findings are noted beneath: As per patient statement, she was admitted in the hospital for the complaints of fever, headache, and stomach pain. As per patient statement, she had no h/o any chronic illness. As per patient statement, she was admitted in the hospital on 20/03/2023 and was discharged on 24/03/2023.
Reason for Investigation	1 months old RHG policy please check for PED NDC with admission justification AL rejected
Is Trigger sufficed	Yes
Justification on Triggers.	Now visit to the patient residence has been done. Patient statement had been collected. Findings are noted beneath: As per patient statement, she was admitted in the hospital for the complaints of fever, headache, and stomach pain. As per patient statement, she had no h/o any chronic illness. As per patient statement, she was admitted in the hospital on 20/03/2023 and was discharged on 24/03/2023.
Investigation trigger	1 months old RHG policy please check for PED NDC with admission justification AL rejected
Trigger Established	Yes
Remark	OPD to IPD conversion admission for evaluation.

 

4. However, perusal of the investigation report nowhere refers that the remaining claim of the complainant is not admissible and the complainant is entitled to an amount of ₹38,418/- only, making it further clear that OP-1 has, of its own, formed the opinion that no hospitalization of the complainant was required and also that the partial claim of the complainant, which has already been denied, was covered under the exclusion clause.  Hence, it is unsafe to hold that the OP-2 is justified in only partially releasing the claim of the complainant and the said act amounts to deficiency in service and unfair trade practice on is part and the present consumer complaint deserves to succeed.
5. Now coming to the quantum of amount, since the complainant has proved bill (Annexure C-4) of the Treating Hospital amounting to ₹55,741/- towards the expenses spent on her hospitalisation/treatment, out of which admittedly an amount of ₹38,418/- has already been paid to the complainant on 13.6.2023, it is safe to hold that OP-2/insurer is liable to pay the remaining amount of ₹55,741 – ₹38,418/- =₹17,323/- to the complainant alongwith interest and compensation etc.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP-2 is directed as under :-

1. to pay ₹17,323/- to the complainant alongwith interest @ 9% per annum w.e.f. 13.6.2023 (i.e. when part payment was released in favour of the complainant) onwards.
2. to pay ₹7,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by OP-2 within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Since no deficiency in service or unfair trade practice has been proved against OP-3, the consumer complaint against it stands dismissed with no order as to costs.
7. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
8. Certified copies of this order be sent to the parties free of charge. The file be consigned.

03/06/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member
	Sd/- [Suresh Kumar Sardana] Member