District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.28/2021.
Date of Institution: 19.01.2021.
Date of Order: 18.01.2023.
Suresh Shash aged about 38 years Son of Sh. Buni Lal Shah r/o Uttam Nagar, Dabua Colony, NIT, Faridabad – 121001, Haryana,
…….Complainant……..
Versus
1. M/s. Religare Health Insurance Company Limited, Office: Unit NO. 607-607, 6th floor, Tower-C, Unitech Cyber Parkm Sector-39, Gurugram – 122001, Haryana through its Managing Director/Director/Principal Officer.
Service also effected at:-
C/o Religare Finvest Ltd., SCO NO.6, Above HDFC Bank, Sector-16, Faridabad – 121002.
2. QRG Medicare Limited, Plot No.1, Sector-16, Faridabad – 121002 through its Chairman/Principal Officer.
…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. Ashwani Tirkha, counsel for the complainant.
Sh. N.K.Garg, counsel for opposite party No.1.
Sh. Arun Kathoch, counsel for opposite party No.2.
ORDER:
The facts in brief of the complaint are that the husband of the complainant availed the mediclaim for himself and for his family members t (two sons namely Ajit Kumar, Abhinav Kumar, wife-Smt. Prabha Devi/complainant and daughter –Priyanka) bearing policy No 17415020, cover type-floater, valid from 28.05.2020 to 27.05.2021 covering Rs.5,00,000/-. The complainant and her family members went to their native place in District East Champaran (Bihar) and the complainant alongwith her family members was returning to Faridabad on 05.12.2020 in vehicle No. HR-51-BC-3606 and when the said vehicle reached near Hodal at about 01:30 (intervening night of 05/06-12-2020), in the meantime 3-4 Neelgai suddenly came on road, the driver of said vehicle tried to save said Neelgai, the said vehicle struck with bridge/pulia situated adjacent to the road, due to which the complainant and her family members sustained injuries. The complainant sustained severe fractures on his chest and his 07 ribs were badly fractured. The police also came at the spot and brought all the injured to Civil Hospital, Palwal and Dr. Tarun Kumar Gola, MO Civil Hospital, medically examined the complainant vide MLR NO. TG/873/GHP/2020 dated 05.12.2020, but seeing the critical condition of the patient/complainant, Medical Officer referred him to some other hospital and hence, the complainant admitted in QRG Medicare Ltd. and opposite party No.2 informed opposite party No.1 and requested for providing cashless facility and the opposite party No.1accepted the request and hence, doctors of opposite party No.2 started treatment of the complainant. But the opposite party No.1 vide letter dated 12.12.2020 denied the pre-auth for Suresh Shah/complainant on the ground that “Non Disclosure of material facts/pre-existing ailments at time of proposal – (tobacco habit of patient and non disclosure for diabetes in patient spouse). It was pertinent to mention here that the complainant suffered accidental injuries and not of pre-existing ailment, hence the plea taken by opposite party No.1 for denial of cashless facility was false and frivolous. However, the Medical Officer/treating doctor of opposite party No.2 issued certificate that “In this case there was no H/o Tobacco…” The opposite party No.2 treated and managed the complainant and discharged him in a stable condition on medication on 12.12.2020 and the hospital raised the bills for Rs.2,68,583/- and besides the said bill, the complainant also spent amount on OPD and medicines and he spent a total sum of Rs.3,00,000/-. Due to refusal of cashless facility, the complainant had to pay the entire medical/treatment expenses on his own pocket. The complainant submitted all the requisite documents as demanded by opposite party No.1 and the opposite party No.1 assured that the claimed amount should be disbursed shortly. However, even the complainant and her husband had removed all the quarries as demanded by opposite party No.1. Thereafter, the complainant made several visits to opposite party No.1 and requested to make the above said payment, but the opposite party No.1 did not pay any heed towards the requests of the complainant and avoided the matter on one pretext or the other. 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/disburse the claimed amount of Rs.3,00,000/- (treatment expenses incurred by the complainant on his treatment) with interest @ 18% p.a. from the date of bill 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 party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the answering opposite party company issued a policy under the plan namely “Care Floater” bearing policy NO. 17415020 in favour of the complainant namely Suresh Shah having policy coverage of his wife namely Smt. Prabha Devi, 2 sons namely Ajit Kumar and Abhinav Kumar as well as his daughter Priyanka. The said policy was effective w.e.f 28.5.2020 till 27.05.2021 for a total sum insured of Rs.5,00,000/- subject to policy terms & conditions. A cashless request was received from the hospital on behalf of the insured/complainant as she was admitted to QRG Hospital Health City, Faridabad from 05/06.12.2020 claiming road side accident at Hodal (Palwal), Haryana. As per the medical documents submitted alongwith pre-authorization form, the insured was admitted to the hospital for C/o Chest and Ribcage pain with breathing difficulty. As per the discharge summary dated 12.12.2020, insured was diagnosed with hemothorax with multiple ribs fracture and sterna fracture with ICD in situ. Meanwhile an investigation was triggered by the opposite party company to check the veracity of the claim. In view of investigation the respondent company raised a query to the hospital vide query letter dated 05.12.2020 seeking following information/documents:
i) Copy MLC/FIR Copy
The query reply was received from the hospital providing MLC and other investigation reports without copy of police report.
a) The opposite party company thereafter made an initial approval of Rs.99,000/- and the same was intimated to the treating hospital vide Cashless Authorization letter dated 07.12.2020.
The opposite party Company during investigation came up forefront with the following documents and findings as under:
- As per Audio Vedio recording (AVR), insured has H/O Tobacco intake 10 gm, daily since 28 years, fatty liver in 2018 and alcohol 250 ml in a week/15 days in 4-5 days.
- As per the Audio-Video recording (AVR), the insured’s spouse had H/O diabetes since 4-5 years.
- As per PAC form of QRG Hospital dated 6.12.2020 (the insured wife of complainant namely Smt. Prabha Devi was stated to have history of DM on oral Hypoglycemic but left medicines for past 5-6 months.)
In view of the above findings, since there was non-disclosure of pre-existing ailments/diseases on part of insured, the opposite party company repudiated the cashless and intimated the same to the hospital vide denial letter dated 12.12.2020. Therefore, the cashless claim of the complainant was rejected by the opposite party company vide claim denial letter dated 12.12.2020 in accordance with clause No. 7.1 of the policy terms & conditions for non-disclosure of material facts/pre-existing ailments at the time of proposal since before policy inception. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Opposite party No.2 put in appearance through counsel and filed written statement wherein Opposite party No.2 refuted claim of the complainant and submitted that the complaint of the complainant was bad for mis-joinder of necessary parties. Admittedly, the complaint clearly shows that the allegations and relief prayed for was only against opposite party No.1 and not against the answering opposite party. The dispute was solely between the complainant and opposite party No.1 and answering opposite party was only a proforma party. Hence, the name of answering opposite party was liable to be deleted from the array of opposite parties in this case. There was no cause of action to file complaint against answering opposite party, as the issues in the present case pertains to service provided by opposite party No.1 and not by answering opposite party. Opposite party No. 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties– M/s. Religare Health Insurance Company Ltd. with the prayer to: a) pay/disburse the claimed amount of Rs.3,00,000/- (treatment expenses incurred by the complainant on his treatment) with interest @ 18% p.a. from the date of bill 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 Suresh Shah, Ex.C-1 policy,, Ex.C-2 – Medical Legal Report,, Ex.C-3 – Cashless Authorization Letter, Ex.C-4 – Denial letter dated 12.12.2020,, Ex.C-5 – Certificate, Ex.C-6 – DD, Ex.C-7 – Discharge summary, Ex.C-8 – Final Bill of Supply Summary, Ex.C-9 & 10 – Bill of supply, Ex.C-11 &12- Tax invoice, Ex.C-13 –Bill/Cash memo, Ex.C-14 – GST invoice, Ex.C-15 – Tax invoice,, Ex.C-16 & 17 – invoices, Ex.C-18 – adhaar card,, Ex.C-19 – renewal of policy
On the other hand counsel for the opposite party No.1 strongly
agitated and opposed. As per the evidence of the opposite party No.1 – Ex.RW-1/A – affidavit of Lakshay Juneja of M/s. Care Health Insurance Ltd., (formerly known as M/s. Religare Health Insurance Co. Ltd.), Ex.R-1 – policy with terms and conditions, Ex.R-2 – Request for cashless, Ex.R-3 – Discharge summary, Ex.R-4 – deficiency letter,Ex.R-5 – Cashless Authorization letter, Ex.R-6 – CD,
Ex.R-7 – PAC Form,, , Ex.R-8 – Denial letter, Ex.R-9 – Proposal Form “CARE”, Ex.R-10 – DD.
Opposite party No.2 has made a statement that reply already filed o behalf of opposite party No.2 be read as evidence of opposite party No.2. Accordingly, evidence on behalf of opposite party No.2 has been closed vide order dated 29.09.2021.
7. In this complaint, the complaint was filed by the complainant with the prayer to pay/disburse the claimed amount of Rs.3,00,000/- (treatment expenses incurred by the complainant on his treatment) with interest @ 18% p.a. from the date of bill till actual payment.
8. After going through the evidence led by the parties, the Commission is of the opinion that as per renewal policy vide Ex.C-32, when the opposite party has cancelled the policy why opposite party is renewing the policy. Opposite party has repudiate the claim of the complainant on the ground that “Initial approval Null and void Non Disclosure of material facts/pre-existing ailments at the time of proposal – (Tobacco habit of patient and non disclosure for diabetes in patient spouse). Non Disclosure of material facts/ pre-existing ailments at time of proposal. As per certificate issued by QRG Health City dated 18.12.2020 vide Ex.C-5 in which it has been mentioned that “ In this case, there is no H/O Tobacco intake” Hence, the repudiation made by the opposite party is unjustified.
9. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed
10. Opposite part No.1 is directed to process the claim of the complainant as per the T&C of the policy 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 party No.1 is also directed to pay Rs.11,000/- as compensation on account of mental tension, agony and harassment alongwith Rs.11,000/- 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: 18.01.2023 (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.
