Complaint Case no. 237/2020

Shri Ranveer vs. Religare Health Insurance

22.12.2020

The matter is taken up through online hearing.

Present: Shri Rajesh Sharma, Counsel for Complainant

Heard the arguments on admissibility.

The case of the complainant is that he is having a health insurance policy from Religare Health Insurance (OP) and the said OP has neither processed the cashless admission of the complainant nor has subsequently made any payment of the expenses incurred by the complainant. 

The complainant’s insurance policy bearing no. 11483952 was valid from 01.08.2019 to 31.07.2020 for a sum insured of Rs. 5,00,00/-.  It is also to be noted that this policy is continuing since 2017 without any break. 

In the month of July 2019, the complainant had some problem and pain in his hand and he was admitted in Jaypee Hospital, Noida (not a party) for his treatment.  He remained in the hospital since 13.07.2019 to 22.07.2019.  At the time of admission, the complainant argues that he has applied for cashless insurance claim from the OP which was not processed and approved by the OP and there is no communication in this regard ever received from the OP.

However, on the discharge of the complainant from the hospital, he made the payment of the bills raised by the Jaypee Hospital, but according to the complainant, the OP has refused to clear these bills.  It is the case of the complainant that he was orally communicated by the officials of the OP company that the bills of the complainant shall not be cleared by the OP company as the treatment of the complainant is not covered under the policy terms and conditions.  This is also an admitted fact that the complainant has not filed the claim for the reimbursement of his expenses with the OP and has directly approached this Forum alleging deficiency in service and unfair trade practice by the OP.

Even the details of the claim filed by the complainant for cashless treatment at the time of admission in the Jaypee Hospital has not been placed on record and the details of the claim of the reimbursement of bills is also not on record.  The only document which the complainant is relying on, in support of his complaint, is the legal notice sent by the Complainant through his Advocate which has not been replied by the OP.

We are of the opinion that this case is premature as the complainant has neither provided the details of the claim submitted before the OP for cashless admission of the complainant nor did he file any claim for reimbursement of his expenses with the OP.  The alleged repudiation of the claim by the OP is only the statement of an official of the OP made to the Complainant which is not sufficient for us to proceed in this matter.  Hence, we dismiss this complaint at admission stage itself being premature with the liberty to the complainant to approach this Forum again once the claim is repudiated by the OP or the Complainant is not satisfied with the reply of the OP.  Needless to say that the complainant shall file claim before the OP and the OP shall take an appropriate decision as per law on the said claim without being prejudiced by any of the observations made in this order within a reasonable time preferably within three weeks from the date of filing of the claim by the Complainant.

With the above observations, this complaint is dismissed with liberty, as explained above.

Order be given Dasti.    

(Member)                                                                                                                  (President)