BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI
Complaint Case No. 82 of 2019
Date of Institution: 22.3.2019
Date of Decision: 29.10.2021
Kavita Devi aged about years wife of Sh. Sanjay Kumar, resident of Medicine House, Opposite Civil Hospital Gali No. 01, Bhiwani, at present village Bardu Dhirja, Tehsil Loharu, District Bhiwani.
….Complainant.
Versus
- The Manager/Authorized Signatory, Religare Health Insurance Company Ltd. GYS Global, Plot No. A3, A4, A5, Sector 125, Noida, UP-201301.
- The Manager/Authorized Signatory/Secretary Religare Health Insurance Company Limited, Vipul Tech Square, Tower-C, 3rd Floor, Golf Course Road, Sector-43, Gurugram-122009.
…....Respondents.
COMPLAINT UNDER SECTION 12 OF
THE CONSUMER PROTECTION ACT, 1986
Before: - Dr. J.R. Chauhan, President.
Sh. Shriniwas Khundia, Member.
Present: Sh. Ghanshyam Sharma, Advocate for complainant.
Sh. Sudhir Kumar, Advocate for respondents-OPs.
ORDER
Kavita Devi (hereinafter referred to as “the complainant”) has filed the present complaint against the opposite parties (hereinafter to as “the OPs”) with the averments that the complainant has purchased medical policy bearing No. 10738690 valid from 14.8.2016 to 13.8.2017. The complainant was operated at the Medanta, The Medicity Hospital, Gurgaon for her fracture on 11.11.2016 and was admitted in the said hospital on 7.11.2016 and was discharged on 14.11.2016. The complainant spent Rs. 3,25,926/-as per bill issued by Medanta, The Medicity Hospital, Gurugram but the OP No. 1 Religare Health Insurance Company Ltd. refused to pay the said amount to the complainant. The OPs also ignored the legal notice dated 24.1.2018 served by the complainant through registered post and did not reply satisfactorily. The complainant has suffered mental agony, harassment and pecuniary loss due to the act and conduct of the OPs. Therefore, the complainant prayed for acceptance of her complaint directing the OPs to pay the policy claim amount of Rs. 3,25,926/-along with interest, compensation besides any other relief for which the complainant is found entitled.
2. On notice, the OPs appeared and filed the written version. In their written reply, the OPs took some preliminary objections regarding maintainability, locus standi, cause of action etc. It is averred by the OPs that the OPs/company is well known insurance company and working as per rules and regulations set by the IRDA. While applying for getting the insurance policy, the policy holder had admitted all the terms and conditions of the policy and has chosen the policy being best policy for him, so the policyholder is bound to comply with all the terms and conditions of the policy i.e. insurance policy No. 10738690 (Product Care) issued to the complainant. Upon submission of cashless request claim submitted by the complainant regarding hospitalization at Medanta Hospital, Gurgaon on 7.11.2016 for the treatment of spinal fracture D-12, the OPs company vide letter dated 8.11.2016 have sought certain documents and clarifications in order to properly assess the loss but the concerned hospital did not provide any satisfactory medical documents and clarifications and therefore, the OPs repudiated complainant’s cashless facility request stating the reason that “as per documents submitted pre-existing nature of ailment could not be ruled out, hence, liability of the insured could not be taken at present juncture and cashless facility is being denied.” The same was duly communicated to the hospital authority vide letter dated 9.11.2016. The OPs company received the legal notice dated 24.1.2019 by the complainant’s Advocate, the same was duly replied by the respondent company. In view of above said facts and circumstances, it is apparently clear that the complaint filed by the complainant is based on misrepresentation and concealment of true and material facts. Hence, the complaint is liable to be dismissed and accordingly, dismissal of complaint has been sought by the respondents-OPs.
3. The complainant tendered into evidence her affidavit Ex. CW-1/A, affidavit Ex. CW-2/A of Sanjay Kumar and documents Annexure C-1 to Annexure C-3 and closed the evidence.
On the other hand, the OPs tendered into evidence affidavit Ex. RW-1/A of Ms. Shreya Chansoria Manager (Legal) and documents Annexure R-1 to Annexure R-6 and closed the evidence.
4. We have heard the arguments of learned counsel for both the parties and gone through the entire evidence produced on record by the parties very carefully and minutely.
5. As per letter Annexure R-4 dated 9.11.2016 pre authorization cashless claim of the complainant was rejected on the ground that pre-existing nature of ailment could not be ruled out hence liability of insured could not be taken at present juncture and cashless facility was denied. It was advised to the complainant that to seek reimbursement with all supportive documents. In reply of legal notice, the OPs referred that claim request of the patient was rejected by the company vide letter dated 9.11.2016. However, as a customer gesture, the company is ready to re-consider the claim request of the patient and the patient is required to file for reimbursement alongwith the documents. The reply of legal notice is Annexure R-5 on the record. The OPs have produced documents Annexure R-1 to Annexure R-6 and there is no document on record in order to support the plea of pre-existing ailment of the complainant. It was necessary for the Ops to produce documentary evidence regarding pre-existing nature of ailment of the complainant and merely on this assumption, the rejection of pre-authorization of cashless claim vide letter Annexure R-4 is totally unjustified.
6. The complainant sought his treatment from Medanta, The Medicity Hospital, Gurugaon where she remained admitted from 7.11.2016 to 14.11.2016 for treatment of her fracture at D. 12 Vertebra and posterior fixation of spine. The complainant in her sworn affidavit Exhibit CW1/A has supported all the allegations as made in the complaint. The complainant’s husband namely, Sanjay Kumar vide his sworn affidavit Exhibit CW2/A has fully supported the deposition of the complainant as well as allegations of the complaint. The complainant has produced on record hospital bills and payment receipt Annexure C-3 containing page 1 to 12 whereby she has paid Rs.3,25,926/- to the hospital. When the cashless claim of the complainant was not honoured by the OPs, then the complainant paid the hospital bill worth Rs.3,25,926/- and now seeking reimbursement of the same from the OPs.
7. The OPs have filed sworn affidavit Exhibit RW1/A of Ms. Shreya Chansoria working as Manager-Legal at Care Health Insurance Limited and she has reiterated the same version as alleged in the written statement. In the entire deposition the existence of policy has not denied. The treatment from Medanta Hospital, Gurugaon taken by the complainant has not been disputed. But cashless claim was declined due to pre-existing nature of ailment. From the language of Annexure R-4, it reflects that even the Ops were not definite about the pre-existing ailment of the complainant but mentioned that as per documents submitted, pre-existing nature of ailment could not be ruled out. Therefore, the rejection of claim of the complainant on the basis of assumptions is totally unjustified and the complainant is entitled to reimbursement of the amount paid to the hospital regarding her treatment as the same was covered under the insurance policy bearing no. 10738690.
8. For the reasons recorded above, the present complaint of the complainant is allowed and Ops are directed to make reimbursement to the complainant worth Rs.3,25,926/- alongwith interest at the rate of 9 per cent per annum from the date of filing of this complaint till its realization. The OPs are further directed to pay compensation for Rs.40,000/- to the complainant on account of physical harassment and mental agony. The OPs are further directed to pay Rs.5500/- as litigation expenses.
9. Copy of this order be communicated to the parties, free of costs.
10. File be consigned to the records after due compliance.
Announced in open Commission.
Dated: - 29.10.2021
(Shriniwas Khundia) (Sh. J.R. Chauhan)
Member. President,
District Consumer Disputes
Redressal Commission, Bhiwani.
