District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.187/2021
Date of Institution: 30.03.2021
Date of Order: 18.10.2022.
Sanjay Mangla S/o Shri Rishi Ram Mangla Resident of House No. 319 & 320, Ward No. 6, Jhankar Gali, Agarsain Bazar, Old Faridabad C/o Umang Uniform, Faridabad, Haryana.
…….Complainant……..
Versus
1. M/s. Religare Health Insurance Company Limited, (Formerly known as Care Health Insurance) Regd. office at: 5th Floor 19 Chawla House, Nehru Place, New Delhi - 110019. Through its Assistant Manager Mr. Dhananjay.
Corporate office: Dwarka Complex, SCO 102, 103, Office No. 219,
2nd floor, Sector-16, Faridabad (Haryana) – 121007.
Branch office:- Vipul Tech Square, Tower-C, 3rd floor, Sector-43, Golf Course Road, Gurugram – 122009.
2. Mr. Dhananjay
Assistant Manager, M/s. Religare Health Insurance Company Limited, (Formerly known as Care health Insurance) Regd. office at: 5th floor, 19 Chawla House, Nehru Place, New Delhi – 110 019.
…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. Somdutt Sharma, counsel for the complainant.
Sh.N.K.Garg, counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant was the policy holder of their insurance company mediclaim bearing its insurance policy ID No. 11239886 covered w.e.f . 08.05.2017 to 09.05.2018, 09.05.2018 to 16.05.2019 and 16.05.2019 to 15.05.2020.On 23.6.2019 the complainant became sick of high blood pressure so NTG infusion was started. ECG showed tall in version in V2.V5 each revealed LAD territory hypokinetic, LVEF – 35%. This MI was not related to diabetic its idiopathic. So the complainant was admitted in QRG Health City, Sector-16, Faridabad for the treatment of the said disease. The complainant remained admitted as indoor patient in the said hospital w.e.f. 23.06.2019 to 26.06.2019 wherein the doctors of said hospital after written consent of patient was taken up for CAG which revealed single vessal disease for which PTCA + Stent to LAD done after that TIMI III flow achieved successfully. Post procedure review echo revealed no RWMAQ, LVEF – 60%. Patient respondent well to given treatment and being discharged in the stable condition from the said hospital. The detailed intimation regarding his treatment was communicated to the opposite parties Nos.1 & 2 by the hospital authorities in initial stages. All the concerned documents i.e. discharge slip, treatment records were sent to the opposite parties with a request to make the payment of the mediclaim of Rs.1,27,159/- under the above referred medicalim policy. The TPA department of above said hospital sent opposite party No.1 claim No. 80289063-00 in the name of the complainant but said TPA department of him opposite party No.1 declined the claim of the complainant with the observation that “4 year waiting period for treatment of pre-existing disease and its complications (diabetics) but the treating doctor gave his opinion that MI was not related to diabetic, its idiopathic. The opinion of the treating doctor the opposite parties had declined the claim of the complainant and the complainant was harassed and humiliated by not providing the claim as per the aforesaid policy of the complainant issued by the opposite parties except receiving the charges of Rs.2884/- in respect of pre-existing disease would be subjected to the clause of pre-existing disease coverage as defined by the policy terms and conditions as would be applicable as per first policy inception dated vide receipt dated 29.04.2017. As per the terms and conditions of the mediclaim policy, if any policy holder (patient) becomes sick or injured and remains under the treatment for 24 hours in a minimum 15 bedded hospital, the total treatment expenses should be reimbursed him. But he did not honour the cashless facilities and re-directed their claim to hospital authorities. The complainant made the payment of Rs.1,27,159/- approximately to the said hospital out of his own pocket. Despite going through all the documents on record, facts and circumstances of the case, the opposite party did not make the payment of the claimed amount of Rs.1,27,159/- to the complainant and the opposite parties had caused mental agony and harassment to the complainant therefore, the complainant was entitled to receive the total amount of Rs.1,27,159/- + Rs.1,00,000/- = Rs.2,27,159/- from the opposite parties jointly & severally. The complainant sent legal notice dated 18.07.2019 to the opposite party but all in vain. Earlier the complainant had filed consumer complaint bearing No. 438/2019 on the same subject matter in which the Hon’ble President, DCDRC, Faridabad vide its order dated 07.01.2021 directed the complainant to lodge claim within 15 days with the insurance company and then the insurance company would settled the claim within 30 days from the date of receipt of claim from the complainant. As per the directions of the Hon’ble President the complainant lodged claim with the insurance company alongwith all the required documents demanded by the Legal Manager of Insurance company Mr. Ravi Boolchandani under the stipulated time as direction by Hon’ble President. It was further pertinent to mention that insurance company sent a letter date d08.02.2021 demanding the address proof of proposer/nominee as mentioned in the policy, recent photographs of proposer/nominee. The complainant fulfilled the said necessity of documents but the insurance company declined the claim of the complainant vide its claim denial letter dated 18.02.2021 on the same ground, hence the necessity to file the present claim again with the liberty to afresh as granted by the Hon’ble Commission.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) refund the amount of Rs.2,27,159/- .
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
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 complainant was issued a policy namely Care bearing Group policy NO. 11239886 with insurance coverage to the complainant, his spouse and his daughter w.e.f. 8.5.2017 till 7.5.2018 for a sum of Rs.5,00,000/- subject to the policy terms and conditions. The said policy was renewed from 10.5.2018 till 9.5..2019 and later from 17.5.2019 till 16.05.2020. The complainant was having pre-existing disease as such to cover treatment of pre-existing disease, the complainant deposited extra premium of Rs.2,884/- but the said coverage was applicable as per policy after 4 years of its inception date whereas claim was in3rd year of policy. Thus, the claim in question was not admissible. The complainant was diagnosed with ACS-AWMI CAG – Single vessel disease (23.6.2019) Primary PTCA + Stent to LAD (23.6.2019) LVEF -60% DM2. Thus the claim in question as per terms of the policy 4.1 (iii) was not admissible. The terms of the policy was as under:
“Pre existing disease i.e. claims would not be admissible or any medical expenses incurred for hospitalization in respect of diagnoses is/treated of any pre-existing disease until 48 months of continuous coverage as left elapsed since the inception of the first policy with the Co.”
Thus the claim in question was rightly and legally declined as per terms and conditions of the policy and even to the knowledge of the complainant. The complainant earlier also filed a consumer complaint bearing NO. 438/2019 on the same subject matter. The same was dismissed by DCDRF, Faridabad vide its order dated 7.1.2021 with direction to file the claim afresh and direction to the company to process the claim again without assigning any reason was directed to re-process the claim. The claim was premature since only cashless claim was filed. Rejection of cashless claim was not denial of claim in toto. The company cannot ascertain the exact liability prior to filing the reimbursement claim. Hence, the company requested the court that the matter was premature and a reimbursement claim should be filed.
As per direction to the DCDRF, Faridabad, the complainant submitted the fresh/reimbursement claim and the opposite party company registered it. The complainant approached opposite party company with the request to his hospitalization i.e. from 23.6.2019 to 26.6.2019 at QRG Health City, Faridabad. As per the documents and discharge summary of hospital, the complainant was diagnosed with ACS-AWMI, CAG- Single vessel disease (23.6.2019), Primary PTCA + Stent to LAD (23.6.2019), LVEF – 60%, DM2. The reimbursement claim was rejected under policy terms & conditions 4.1(iii) because it was related to and a complication of pre existing disease and for that the coverage was having a 4 year waiting period whereas the claim in question was within3rd year of the policy. Thus, as per admitted terms & conditions of the policy, the claim was not admissible. As per the Medical Examination, his blood glucose and dyslipidemia were elevated, hence 4 year waiting period was applied on pre existing disease and loading was charged as well. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Shir P.L.Garg, counsel for opposite parties Nos.1 & 2 has made a statement that written version filed on behalf of opposite party No.1 may also be read as such on behalf of opposite party No.2. vide order dated 20.07.2022.
4. Shri Somdutt Sharma, counsel for the complainant has made a statement that complaint alongwith documents already filed by him be read as the evidence of complainant and closed the same. Accordingly, evidence of the complainant has been closed vide order dated 16.09.2022.
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 Limited with the prayer to: a) refund the amount of Rs.2,27,159/- . b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
To establish his case the complainant has led in his evidence, Annexure C-1 – letter dated 16.05.2019, Annexure C-2 – treatment record,, Annx.C-3 – Request for cashless hospitalization for medical insurance policy, Annx.C-4 – TPA deduction of patient/, Annx.C-5 – Invoice,, Annx.C-6 – Tax invoice (cash sale),, Annx.C-7 – Initial assessment sheet,, Annx. C-8 C9 – Case summary, AnnxC-10 - letter dated 29.04.2017, Annx. C-11 – Final Bill of supply summary (Cash), Annx.C-12 & 13– Advance Deposit Receipts, Annx.C-14 – Discharge summary, Annx.C-15 – Coronary Angiography report, Annx. C-16 – Request for cashless hospitalization for medical insurance policy, Ex.C-17 – letter dated 23.06.2019 regarding non-registration of claim, Annx. C-18 – RE:Sanjay Mangla- CC No. 438/2019 – CDRF, Faridabad,, Annx.C-20 –letter dated 08.02.2021 regarding deficiency letter,, Annx.C-21 – letter dated 18.02.2021 regarding claim denial letter,, Annx.C-22 – legal notice,, Annx.C-23 – postal receipt, Annx.C-24 – reply to legal notice.
On the other hand counsel for the opposite parties strongly agitated
and opposed. As per the evidence of the opposite parties – Ex. RW1/A – affidavit of Ravi Boolchandani, Religare Health Insurance co. Ltd. (Now known as Care Health Insurance Ltd.), Ex.R-1 – policy certificate, Ex.R-2 – Discharge summary, Ex.R-3 – claim denial letter, Ex.R-4 – Basic details, Ex.R-5 - reply to legal notice,Ex.R-6 –claim form.
7. In this case, the complainant was the policy holder of their insurance company mediclaim bearing its insurance policy ID No. 11239886 covered w.e.f . 08.05.2017 to 09.05.2018, 09.05.2018 to 16.05.2019 and 16.05.2019 to 15.05.2020. On 23.6.2019 the complainant became sick of high blood pressure so NTG infusion was started. ECG showed tall in version in V2.V5 each revealed LAD territory hypokinetic, LVEF – 35%. This MI was not related to diabetic its idiopathic. So the complainant was admitted in QRG Health City, Sector-16, Faridabad for the treatment of the said disease. The complainant remained admitted as indoor patient in the said hospital w.e.f. 23.06.2019 to 26.06.2019 wherein the doctors of said hospital after written consent of patient was taken up for CAG which revealed single vessal disease for which PTCA + Stent to LAD done after that TIMI III flow achieved successfully. Post procedure review echo revealed no RWMAQ, LVEF – 60%. Opposite party No.1 has repudiated the claim of the complainant vide letter dated 18.02.2021 (Annexure C-21) on the ground that “Case rejected as 4 years waiting period for pre-existing diseases and its related conditions (“Dyslpidemia and Dm)”.
8. After going through the evidence led by both the parties, the Commission is of the opinion that As per letter dated 29.04.2017 vide Annexure C-10 stating that “Basis the review of your proposal 1120002415143 for health insurance, the premium for your Health Insurance policy has been revised from Rs.24722 to Rs.27606 post Medical Underwriting and examination of Health check up records due to following reason:
Member Name Reason
Sanjay Mangla Abnormal Blood Sugar Values, Evidence of Dyslipidemia.
Please note that any pre-existing disease would be subjected to the clause of pre-existing disease coverage as defined by policy terms and conditions and will be applicable as per first policy inception date.”
Keeping in view of the above that as per the aforesaid policy of the complainant issued by the opposite parties except receiving the charges of Rs.2884/- in respect of pre existing disease would be subjected to the clause of pre-existing disease coverage as defined by policy terms and conditions as will be applicable as per first policy inception date vide receipt dated 29.04.2017.
9. 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: 18.10.2022 (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.
