BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.512 of 2019
Date of Instt. 29.10.2019
Date of Decision: 19.04.2024
Mrs. Gurvinder Kaur wife of Shri Kamaljit Singh, resident of 488, Guru Teg Bahadur Nagar, Jalandhar.
..........Complainant
Versus
1. M/s Religare Health Insurance Co. Ltd., RHICL, Opposite DC Office, Jalandhar through its Branch Manager.
2. M/s Religare Health Insurance Co. Ltd., Regd. Office 5th Floor, 19 Chawla House, Nehru Place, New Delhi through its Managing Director.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Gulshan Arora, Adv. Counsel for the Complainants.
Sh. R. K. Sharma, Adv. Counsel for OPs.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainants, wherein it is alleged that the complainant purchased Health Insurance Policy from Star Health & Allied Insurance Company on 12.1.2017 and paid premium of Rs.35,731.00 for two adults and one child. It was got renewed on 10.1.2018 and the complainant again paid premium of Rs.36,662.00. Thereafter, the representative of OP No.1 approached the complainant and told that the premium of their Health Insurance Policy was quite less than that of Star Health and the OP No.1 also induced to provide more facilities to the customers and on such inducements and assurances, the complainant got ported the said policy with the OPs No.1 and 2. After proper and thorough medical examination and verification, the complainant paid premium of Rs.34,626.00 and the opposite parties, issued Insurance Policy bearing No.1343879 against Rs.5,00,000/- in the name of the complainant and her husband. Thereafter, the complainant suffered eye problem and consulted Dr. Thind Eye Hospital, 701-L, Mall Road, Jalandhar and the Doctor diagnosed the disease at ISC Right Eye. The complainant apprised the Doctor with regard to the policy purchased by her. The complainant completed and submitted the form and the Doctor attending the patient referred the matter to the opposite parties. Letter dated 17.4.2019 was sent by the OP No.1 to Thind Hospital, Jalandhar wherein the OPs, denied the claim of the complainant on the ground that the complainant had suppressed the information of hypertension and suffering from eye problem prior to purchase of the policy. In fact, the complainant never suffered from any eye disease prior to purchase of the policy. She was simply wearing glasses and nothing else. The complainant admitted in DMC Hospital and Trauma Centre, Shaheed Udham Singh Nagar, Jalandhar and got the treatment and spent a sum of Rs.25,000.00. The complainant approached the OPs, for reimbursement of the amount, but OPs have been lingering on the matter on one or the other pretext. The OPs, again sent letter dated 9.5.2019 in which, it is mentioned that the complainant has concealed the material facts in the proposal form and why the policy should not be cancelled. As stated above, the complainant had not concealed any fact nor she was suffering from any serious eye problem. The complainant has not concealed anything nor she was suffering from any eye problem or hypertension and the OPs have concocted the story just to deny the legal and genuine claim of the complainant. The OPs have illegally and unlawfully failed to reimburse the claim and also threatened to cancel the policy, which is clear cut negligence and deficiency in service, which has caused mental tension, loss of money, agony. The complainant served a legal notice dated 21.5.2019 upon the OPs, but all in vain and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse the medical insurance claim of the complainant immediately and to pay interest @18% per Annam from the date till realization. Further, OPs be directed to pay a sum of Rs.1,00,000/- as damages, on account of negligence and deficiency in service, causing trauma, mental agony, tension, undue harassment, inconvenience, loss of money and time and Rs.50,000/- as litigation expenses.
2. Notice of the complaint was given to the OPs, who filed reply and contested the complaint by taking preliminary objections that the complaint is not maintainable against the OPs as the complainant cannot take advantage of his own wrongs. The complainant herself is guilty of Non-Disclosure of material facts at the time of taking policy, as such the complaint is liable to be dismissed. It is further averred that the complainant was issued Insurance policy bearing No.13439879 for the period 12-01-2019 to 11-01-2020 subject to terms and conditions of the insurance policy by OP No.2 and the complainant filled the Proposal Form for taking the policy. The complainant applied for Cashless Facility and request for the same was received through Thind Eye Hospital, Jalandhar for an amount of Rs. 36,000/-. As per the Pre-authorization Form, the Insured was to be admitted on 20.04.2019 at Thind Eye Hospital, Model Town, Jalandhar. As per Pre-Auth form, the Insured was diagnosed with ISC Right Eye. Upon receiving the request the Respondent Company triggered an investigation in order to check the veracity of the cashless request. On receipt of cashless request, the OP sent a Query Letter dated 17-04-2019 to the Hospital and asked for the following documents:
i. Exact duration and past history of present ailment with 1st consultation paper and all past treatment records.
ii. pre hospitalization OPD treatment record.
On scrutiny of documents supplied by the Hospital and findings of investigation undertaken, the Respondent Company denied the Cashless request of the complainant vide denial letter dated 17.04.2019 for the following reasons:-
Non-disclosure of material facts/pre-existing ailments at the time of proposal. Patient is known case of Hypertension and also suffering from eyes problem prior to policy inception).
As per the Insured's Statement dated 17.04.2019 signed by the complainant/insured and her husband Mr. Kamaljit Singh, the Insured is case of Hypertension from June 2018 and insured/complainant had been suffering from eye problem from past 10-12 years. It is further averred that there is neither any deficiency in service nor any negligence in service nor any unfair trade practice on the part of the OPs. Declining the Cashless treatment which was not payable as per terms and conditions of the insurance policy does not amounts to any deficiency in service nor any negligence in service nor any unfair trade practice, as such the complaint is liable to be dismissed. The cashless claim of the complaint was repudiated as per terms and conditions of the insurance policy after due application of mind vide denial letter dated 17.04.2019. On merits, it is admitted that the complainant was issued Insurance policy bearing No.13439879 for the period 12-01-2019 to 11-01-2020 by OP No.2 and the complainant filled the Proposal Form for taking the policy. It is also admitted that the complainant applied for Cashless Facility and request for the same was received through Thind Eye Hospital, Jalandhar for an amount of Rs.36,000/-. It is also admitted that the complainant lodged a cashless claim and the same was declined, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
6. It is admitted that the complainant took an insurance policy from OP No.2 Ex.C-1/O-1, which was effective from 12-01-2019 to 11-01-2020. The complainant suffered eye problem and consulted Dr. Thind Eye Hospital and the Doctor diagnosed the disease at ISC, Righ Eye. Thereafter the complainant submitted the form for taking cashless insurance, which was submitted to OPs by the doctor. The OP No.1 denied the claim of the complainant, vide letter dated 17.04.2019 Ex.C2, on the ground that the complainant had suppressed the information of hypertension and suffering from eye problem prior to purchase of the policy. The complainant was admitted in DMC Hospital and Trauma Centre, Jalandhar and she got the treatment by spending Rs.25,000/-. The complainant approached the OPs for reimbursement, but instead of reimbursing the claim of the complainant, the OP sent a notice dated 09.05.2019 Ex.C-3 for cancellation of policy on the ground of concealment of the material facts in the proposal form by the complainant. The complainant also served a legal notice upon the OPs dated 21.05.2019 Ex.C-4, but no action was taken.
7. Though the complainant has alleged that the complainant approached OP for reimbursement, but no document has been filed by the complainant to show that she ever submitted claim for reimbursement with the OP. Even the OPs have alleged that no reimbursement claim has been lodged by the complainant. In reply to the legal notice Ex.O9, the OPs asked the complainant to lodge the reimbursement claim alongwith the requisite documents/bills/treatment record etc., but the complainant did not lodge the claim and complete the formalities. Ex.C-2 shows that it is denial of pre-auth for the complainant, meaning thereby that it is the denial of cashless facility and there is no denial of claim as no claim for reimbursement has been filed.
8. In such circumstances, the complainant is directed to lodge the reimbursement claim, if any, alongwith the requisite documents/bills/treatment record etc., within 15 days from the date of receipt of the copy of the order and then the OPs will settle the claim of the complainant within 15 days from the date of lodging the reimbursement claim alongwith the requisite documents/bills/treatment record etc., failing which the OPs will be liable to pay compensation of Rs.20,000/- to the complainant. It is further ordered that if the complainant is not satisfied with the settlement of the claim made by the OPs, then she is at liberty to file a fresh complaint. Thus, the complaint of the complainant is disposed of. This complaint could not be decided within stipulated time frame due to rush of work.
9. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
19.04.2024 Member Member President
