Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 606
Instituted on : 23.12.2020
Decided on : 05.08.2024
Sudesh age 37 years wife of Sh. Rajesh Kumar resident of village Polangi(53), District Rohtak.
……….………….Complainant.
Vs.
Reliance General Insurance,No.1-89/3/B/40 to 42/Ks/301, 3rd Floor, Krishe Block, Krishe Sapphire, Madhopur, Hyderabad-500081.
...........……Respondent/opposite party.
COMPLAINT U/S 35 OF CONSUMER PROTECTION ACT2019
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR. VIJENDER SINGH, MEMBER
Present: Sh.RishipalDeswal, Advocate for the complainant.
Sh.Gulshan Chawla, Advocate for the opposite party.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case as per the complainant are that she had taken health policy of opposite party vide policy No.2013732828000198 on dated 04.03.2014 in her name and two minor children namely Navdeep and Prince. Thereafter complainant and her husband regularly renewed their policy from the year 2015 to 2020. At the time of proposal on 04.03.2014 and thereafter on every renewal and lastly on 30.03.2019 every formalities and verification about the health of complainant and her family members were performed by the opposite party and the complainant paid a sum of Rs.13719/- towards the policy premium. On 11.03.2020, the complainant visited Mansarover Hospital,Rohtak for treatment. Complainant was admitted in the alleged hospital on 11.03.2020 and the doctor performed with the diagnosis of G.B.Syndrom and treated with steroids, antibiotics, anti inflammatory, MVI and discharged the complainant on 16.03.2020 from the hospital. . Complainant spent an amount of Rs.73050/- on her treatment which was paid by the complainant herself though it was a cashless policy. After discharge from the hospital, complainant filed all bills and treatment papers to the opposite party and requested them to pay the claim as per terms and guidelines of the policy. But the opposite party repudiated the genuine and legal claim of the complainant. The act of opposite party is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite party may kindly be directed to pass the insurance claim of Rs.73500/-, to pay a sum of Rs.300000/- as compensation on account of mental agony and harassment and Rs.22000/- as litigation expenses to the complainant.
2. After registration of complaint, notice was issued to the opposite party. Opposite party filed its written statement submitting therein that cashless request alongwith documents were submitted and on evaluation several discrepancies were noted, thus constraining the opposite party to allow the cashless benefits. It was advised to get her treatment and to submit original bill and medical documents post treatment for evolution of claim on merits. Only the cashless facility was denied vide letter dated 16.02.2020. The complainant should submit the original bills and medical documents with the opposite party to assess the claim. But complainant failed to submit the final bill alongwith the medical documents for adjudication of the claim on merits. Hence the present complaint is pre-mature and liable to be dismissed. It is also submitted that the pre authorization request was for Rs.61400/- whereas complainant is demanding an amount of Rs.73050/- which requires adjudication. There is no deficiency in service on the part of opposite party and dismissal of complaint has been sought.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C2 to Ex.C8 and closed his evidence on 31.10.2022. On the other hand, Ld. counsel for the opposite party has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R3 & Ex.R3/A to Ex.R3/C and closed his evidence on dated 06.10.2023.
4. We have heard learned counsel for the parties and have gone through the material aspects of the case very carefully.
5. In the present case the contention of the complainant is that the respondent insurance company has not paid the amount of Rs.73050/- which was spent on the treatment of complainant in Mansarover Multispecialty Hospital, Rohtak. On the other hand, the respondent insurance company has submitted that the complaint is pre mature as the complainant has not submitted the required bill and other medical documents of the treatment with the insurance company for evaluation of claim on merits. In fact the insurance company only denied the cashless facility. The insurance company further submitted that some discrepancies were noted in the documents of the complainant which are as under: “Through as per ICP, patient was conscious, obeying command and all vitals are stable throughout the admission. As per insured, she presented with c/o fever but at the time of admission, temperature is normal and as per ICP, patient is having c/o respiratory distress but SPO2 level is normal. Only investigations such as MRI cervical spine and dorsolumbar spine were conducted during admission, seem as if patient hospitalized for investigation and evaluation purpose. Claim will be repudiated for investigation and evaluation purpose as well vitals are stable throughout the admission”. We have minutely perused the documents placed on record by both the parties. At the time of arguments complainant has placed on record document Annexure JNA. The perusal of this document shows that this is a rejection letter issued to the complainant. It is only of denial of cashless facility. Further perusal of documents shows that original documents i.e.bill Ex.C7 and discharge summary Ex.C8 are placed on record by the complainant herself. At the time of arguments it has been submitted by the complainant that the complainant has submitted photocopy of all the documents with the insurance company. On the other hand, the main plea of the respondentsis that original documents have not been submitted by the complainant with the insurance company. Perusal of the documents submitted by the respondent itself shows that patient was admitted in the hospital on 11.03.2020 and was discharged on 16.03.2020. To prove this fact respondent has placed on record document Ex.R3/A and RCU Final report as Ex.R3/B. In this report the date of discharge has been wrongly mentioned as 13.03.2020 whereas the respondent documents itself shows that patient was discharged on 16.03.2020. Meaning thereby the detailed investigation has been conducted by the respondent insurance company regarding the admission, discharge and bills etc. So the insurance company cannot take the objection that the bills and other relevant documents have not been submitted by the complainant with the respondent office.Hence the claim of the complainant has been wrongly repudiated by the opposite party and the opposite party is liable to pay the claim amount to the complainant. As per bill Ex.C7, complainant had spent an amount of Rs.73050/- on her treatment and she is entitled for the alleged amount.
6. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite party to pay the amount of Rs.73050/-(Rupees seventy three thousand and fifty only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 23.02.2020 till its realisation and also to pay a sum of Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the to the complainant within one month from the date of decision.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
05.08.2024.
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Nagender Singh Kadian, President
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TriptiPannu, Member.
……………………………….
Vijender Singh, Member
