Haryana

Bhiwani

CC/87/2020

Manoj Kumar - Complainant(s)

Versus

Religare Health Care. - Opp.Party(s)

Rajesh Joshi

14 Aug 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                             Consumer Complaint No. :  87 of 2020

                                                        Date of Institution           : 14.08.2020

                                                                  Date of order                  : 14.08.2024

 

Manoj Kumar son of Sh. Shiv Kumar R/o village Bapora, Tehsil and District Bhiwani.

  

           ……Complainant.

 

Versus

 

Religare Health Insurance Company Ltd., Office Unit No.604-607, 6^th Floor, Tower-C, Unitech Cyber Park, Sector-39, Gurugram-122001 Haryana through authorized attorney/Manager.

 

…… Opposite Party

 

COMPLAINT U/S 35 OF CONSUMER PROECTION ACT, 2019.

 

BEFORE:       Mrs. Saroj Bala Bohra, Presiding Member.

  Ms. Shashi Kiran Panwar, Member.

 

Present:-       Sh. Balbir Sharma, Advocate for complainant.

                    Sh. Sudhir Kumar, Advocate for OP.

 

ORDER:

 

Saroj Bala Bohra, Presiding Member:

 

1.                 In brief, facts of this case are that complainant purchased a health insurance policy no.12548784 from OP by paying Rs.12,197/- for a period from 08.06.2018 to 07.06.2019. It is stated that mother of complainant Smt. Bimla Devi, due to illness, was got admitted at Sarvodaya Multispecialty and Cancer Hospital, Hisar and remained admitted there from 02.06.2019 to 05.06.2019. OP was informed about this and claim of Rs.35,000/- was lodged with the OP by submitting all necessary documents. But the OP denied the claim vide letter dated 13.09.2019. Hence, the present complaint has been preferred alleging deficiency in service on the part of OP resulting into monetary loss as well as mental and physical harassment with a prayer for issuance of directions to OP to pay Rs.35,000/- which incurred on treatment besides cost of litigation as Rs.25,000/-. Further to pay Rs.50,000/- on account of compensation for harassment. Any other relief, to which this Commission deems fit, has also been sought.

2.                 OP appeared through counsel and tendered reply raising preliminary objections qua maintainability of complaint, locus standi, cause of action, jurisdiction and mis-joinder & Non-joinder of necessary parties. On merits, it is admitted that the policy was issued to complainant subject to certain terms and conditions. It is submitted that complainant applied for a cashless request for the hospitalization of the insured for the treatment of chest pain and it was came into notice of the OP that the insured is a k/c/o osteoarthritis of knees, dyslipidemia and anemia, therefore, the OP in order to get more clarity sought some additional documents vide letter dated 02.06.2019 with respect to complainant’s history of the above referred ailments but the same were not received from complainant as such claim was denied for want of necessary documents. However, complainant vide letter dated 04.06.2019 was advised to file reimbursement claim. After receipt of such claim, complainant was asked to submit some document but he failed and thus the claim vide letter dated 13.09.2019 was repudiated. In the end, denied for any deficiency in service on the part of OP and prayed for dismissal of the complaint with costs.

3.                 In evidence of complainant, his affidavit Ex. PW1/A documents Annexure P-1 to Annexure P-6 were tendered and then closed the evidence.

4.                 In evidence of OP, documents Annexure R-1 to Annexure R-9 were filed and also stated that their written statement may also be read into evidence and then closed the evidence.

5.                 We have heard learned counsel for the parties and perused the record minutely.  Written arguments submitted on behalf of OP. Case law delivered by Hon’ble Supreme Court of India in Civil Appeal No.1557 of 2004 titled Export Credit Guarantee Corpn. of India Ltd. Vs. M/s Garg Sons International  has also been filed. We have gone through this case law as well as case laws referred in the written statement of OP.

6.                 At the outset, it is admitted case of OP that patient Bimla Devi was covered under the policy during the period of treatment in the alleged hospital. But the reimbursement claim was denied to the complainant vide letter dated 13.09.2019 (Annexure P-4) for want of various documents referred in letters dated  27.08.2019 & 02.06.2019  (Annexure R-7 & R-3) viz. 1.First consultation paper or emergency OPD record prior to admission. 2. Pre Hospitalization OPD treatment record qua Anemia, Dyslipidemia and Osteoarthritis of knee. 1. Complete indoor case papers with admission notes, history sheet, Doctor’s notes nursing notes and vital chart. 2. Provide exact diagnosis with its etiology certified by treating doctor. 3. Investigation report supporting diagnosis.

7.                 It is not in dispute that on the relevant period of time patient Smt. Bimla Devi was under the insurance cover. Complainant in order to prove the treatment of the patient has placed on record discharge summary (Annexure P-1) and a final bill of Rs.27,378/- (Annexure P-2) of the concerned hospital.  The referred documents, itself speak about the queries of the OP insurance company raised through the letters Annexure R-7 & R-3.  If the OP insurance company had any devotion to settle the claim of complainant then it could seek the documents during pendency of the present complaint but they did not opt to do so rather remained adamant on their query letters. Thus, in our view, the OP has repudiated the claim of complainant in a casual manner without mentioning any cogent and convincing reason thereof which shows that the OP insurance company has adopted a trend not to release claim of the poor persons rather compel them to knock the doors of the Consumer Commission. It is worthwhile to mention here that the OP are not settling even genuine claims of consumers/complainants which is illegal and amounts to indulgence into unfair trade practice/malpractice resulting into monetary loss as well as mental and physical harassment.

8.                 In view of the above discussion and going through the situation as well as facts and circumstances of the present case, the complaint is allowed and the OP is directed to comply with the following directions within 40 days from the date of order:-

(i)       To pay a sum of Rs.27,378/- (Rs. Twenty seven thousand three hundred seventy eight) to the complainant so incurred by him on treatment alongwith simple interest @ 9% per annum from the date of filing of complaint till actual realization.

(ii)      To pay Rs.10,000/- (Rs. Ten thousand) as compensation for harassment.

(iii)     To pay Rs.5500/- (Rs. Five thousand five hundred) as cost of litigation.

                    In case of non-compliance, all the awarded amounts shall attract simple interest @ 12% per annum for the period of default. 

                    Further, the complainant shall be entitled to the execution petition under section 71 of Consumer Protection Act, 2019 and in that eventuality, the opposite party may also be liable for prosecution under Section 72 of the said Act which envisages punishment of imprisonment, which may extend to three years or fine upto rupees one lac or with both.  Certified copies of this order be sent to the parties concerned, free of costs, as per rules.  File be consigned to the record room, after due compliance. 

Announced.

Dated: 14.08.2024