Haryana

Kurukshetra

CC/294/2019

Poonam Rani - Complainant(s)

Versus

Religare Health Ins - Opp.Party(s)

Balinder Pal Saini

07 Apr 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL  COMMISSION, KURUKSHETRA.

                                                     Complaint Case No.294 of 2019

                                                     Date of institution: 22.07.2019

                                                     Date of decision: 7.04.2021.

 

Poonam Rani, aged 45 years, wife of Sh.Rajender Kumar, resident of village Chhiba, P.O.Dhurala, Tehsil Thanesar, District Kurukshetra.

                                                                …Complainant.

                        Versus

1. Religare Health Insurance Company Limited, 5^th Floor, 19, Chawla House Nehru Place, New Delhi – 110019 through its M.D.

2.Sh.Ashish Kumar, Agent Religare Health Insurance Company Limited, Punjab National Bank, Kurukshetra Code 20065383, Mob.87089-06557.

….Opposite parties.

Before:      Smt. Neelam Kashyap, President.

                Ms. Neelam, Member.

                Sh. Issam Singh Sagwal, Member.

       

Present:     Sh. Love Kumar, Advocate for complainant.   

                Sh. Rajesh Kaushik Advocate for opposite party No.1.

                OP No.2 given up.

               

ORDER

               

                This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Smt. Poonam Rani against Religare Health Insurance Company etc.- the opposite parties.

2.            It is stated in the complaint that  the complainant  got herself alongwith her husband Rajender Kumar and son Harshil  for health insurance on 11.9.2018 vide policy No.12981029  for the sum assured Rs.10.00 lacs with the OP. The complainant also disclosed about her health and nothing was concealed at the time of opting for insurance.  It is further argued that in the month of Feb. 2019, the complainant fell ill and got treated by the doctors of Shri Krishana Ayurvedic College, Kurukshetra and the doctors started  treatment of the complainant. In the tests of the complainant typhoid and live infection were found  and thereafter Doctors of .S.K.G.M. Kurukshetra started the treatment of the complainant of both the diseases  got treated from Shri Krishana Govt. Ayurvedic Medical College, Kurukshetra  continuously and she got some relief but after three months the complainant again fell ill and on the advise of the doctors she got tested from Bharat Diagnostic Laboratory, Kurukshetra on 20.6.2019 and in the said test, typhoid fever was found to be positive and doctors of the said hospital started treatment  but she could not felt relief.  She  went to Alchemist Hospital, Panchkula on 28.6.2019 and doctors of the said hospital after seeing the reports admitted in the hospital due to serious condition and after the advise of the doctors she was got admitted in the said hospital. Doctors of the said hospital started her treatment.  On receipt of the information from Alchemist Hospital, OP send the query letter and inquired about the disease from the doctor of the hospital and the complainant send all the information submitted to the OPs with regard to the disease. Even after submission of all the documents and information, OP repudiated the claim of the complainant  and denied to give any amount incurred by the complainant on her  treatment. The  learned counsel for the complainant has argued  that she incurred Rs.60,000/- on her treatment including transportation etc but the OPs denied to pay the same, which amounts to deficiency in services on the part of the OP. Thus, the complainant has filed  the present complaint alleging deficiency in services on the part of OP and prayed that the OP be directed  to pay the amount of claim to the complainant alongwith compensation for the mental harassment and agony caused to her and the litigation expenses.

3.             Upon notice OP appeared and filed written statement disputing the claim of the complainant. Issuance of the insurance policy by the OP has been admitted but with the exception that the insurance policy was  issued subject to terms and conditions of the policy. On receipt of information regarding admission the OP sent the letter dated 28.6.2019 and asked to submit the complete indoor case papers with admission notes, history sheet, doctor’s notes, nursing notes and vital chart and documents regarding past 5-6 months back treatment  records, investigation report, supporting diagnosis and all papers.  On the basis of documents received, the OP rejected the cashless request of the complainant vide letter 29.6.2019 under clause 4.2 of the policy terms and conditions as hospitalization for evaluation/diagnostic purpose is permanently excluded from the scope of the policy.  The complainant was hospitalized only for investigation/evaluation purpose. No active line of treatment was  taken by the complainant and only the complainant could be treated as OPD only. As per history and physical examination form dated 28.6.2019, in History of present illness, it is clearly mentioned that complainant is admitted for evaluation management. As per history and physical examination form, the complainant was diagnosed with viral fever and complainants BP and pulse including temperature were found normal.  She was  in conscious state at the time of admission in the hospital. Thus, it is clear that the complainant was admitted in the hospital for investigation and evaluation purpose only and the treatment provided to the patient could have been managed  on OPD basis only. Thus, it is submitted that there is no deficiency in services on the part of the OP and prayed for dismissal of the present complaint.

3.             Vide order dated 15.10.2019, on the statement of learned counsel for the complainant, the OP No.2 was given up. Therefore, name of the OP No.2 was ordered to be deleted from the array of OPs.

4.             The complainant in support of her case has filed her affidavit Ex.CW1/A and tendered documents Ex.C-1 to  Ex.C-19 and closed her evidence.

5.             On the other hand, OP in support of its case has filed affidavit Ex.RW1/A and tendered documents Ex.R-1 to Ex.R-6 and closed its evidence.

6.             We have heard the learned counsel for the parties and gone through the material available on the file.

7.             Learned counsel for the complainant while reiterating the averments made in the complaint has argued that complainant  got herself alongwith her husband Rajender Kumar and son Harshil  for health insurance on 11.9.2018 vide policy No.12981029  for the sum assured Rs.10.00 lacs with the OP. The complainant also disclosed about her health and nothing was concealed at the time of opting for insurance.  It is further  argued that in the month of Feb. 2019, the complainant fell ill and got treated by the doctors of Shri Krishana Ayurvedic College, Kurukshetra and the doctors started  treatment of the complainant. In the tests of the complainant typhoid and live infection were found  and thereafter Doctors of S.K.G.M. Kurukshetra started the treatment of the complainant of both the diseases  got treated from Shri Krishana Govt. Ayurvedic Medical College, Kurukshetra  continuously and she got some relief but after three months the complainant again fell ill and on the advice of the doctors she got tested from Bharat Diagnostic Laboratory, Kurukshetra on 20.6.2019 and in the said test, typhoid fever was found to be positive and doctors of the said hospital started treatment  but she could not felt relief.  She  went to Alchemist Hospital, Panchkula on 28.6.2019 and doctors of the said hospital after seeing the reports admitted in the hospital due to serious condition and after the advise of the doctors she was got admitted in the said hospital. Doctors of the said hospital started her treatment.  On receipt of the information from Alchemist Hospital, OP send the query letter and inquired about the disease from the doctor of the hospital and the complainant send all the information submitted to the OPs with regard to the disease. Even after submission of all the documents and information, OP repudiated the claim of the complainant  which amounts to deficiency in services on the part of the OP. Thus, the complainant has filed  the present complaint alleging deficiency in services on the part of OP and prayed that the OP be directed  to pay the amount of claim to the complainant alongwith compensation for the mental harassment and agony caused to her and the litigation expenses.Reliance has been placed on the law laid down in case OIC  Versus Shankar Lal R.Patnani  (2005) 3 CPJ 204 and Shyama Nanda Jalan Vs. NIC  (2001) 2 CPJ 108.

8.             On the other hand, learned counsel for OP while reiterating the contentions made in the  written statement has argued that policy was  issued subject to terms and conditions of the policy. On receipt of information regarding admission the OP sent the letter dated 28.6.2019 and asked to submit the complete indoor case papers with admission notes, history sheet, doctor’s notes, nursing notes and vital chart and documents regarding past 5-6 months back treatment  records, investigation report, supporting diagnosis and all papers.  On the basis of documents received, the OP rejected the cashless request of the complainant vide letter 29.6.2019 under clause 4.2 of the policy terms and conditions as hospitalization for evaluation/diagnostic purpose is permanently excluded from the scope of the policy.  The complainant was hospitalized only for investigation/evaluation purpose. No active line of treatment was  taken by the complainant and only the complainant could be treated as OPD only. As per history and physical examination form dated 28.6.2019, in History of present illness, it is clearly mentioned that complainant is admitted for evaluation management. As per history and physical examination form, the complainant was diagnosed with viral fever and complainants BP and pulse including temperature were found normal.  She was  in conscious state at the time of admission in the hospital. Thus, it is clear that the complainant was admitted in the hospital for investigation and evaluation purpose only and the treatment provided to the patient could have been managed  on OPD basis only. It is submitted that the  complainant has failed to place ;on record proof to show the date of admission and discharge like discharge summary and as such admission of the complainant in the hospital is not proved and alleged treatment, if any, falls under the exclusion clause of the policy and the OP is not liable to pay any claim to the complainant.  Thus, it is submitted that there is no deficiency in services on the part of the OP and prayed for dismissal of the present complaint. Reliance has been placed on the law laid down in case  The New India Assurance Vs. Dr.Girish M. Wagher First appeal No.135 of 2011 decided on  31.1.2017 of the Hon’ble National Commission.

9.             In this case, on receipt of the information regarding illness of the complainant, OP issued the query letter Ex.C-14 dated  28.06.2019 and in the said letter demand of admission notes  and past 5-6 months back treatment record was sought by the OP but the perusal of file shows that the complainant has not placed on the file any document showing the past 5-6 months back treatment. Ex.C-18 is request for cashless hospitalization. In the said document, doctor Daksh Khurana has shown Medical Management for  purpose of treatment and he has no where mentioned any emergency for admission for  treatment. Likewise in the document Ex.C-6, it is mentioned that “ now admitted for further evaluation management” and in this way no emergency for admission of the insured is shown in this document also. In the document Ex.C-19, no emergency is shown for admission rather history of fever is shown. Thus, from the papers especially Ex.C-18 and Ex.C-6, purpose  for admission is shown  for evaluation/diagnostic purpose and as per  condition no.69 of the terms and conditions of the policy,  admission for evaluation/diagnostic purpose falls under the exclusion clause of the policy, therefore, the claim of the complainant has rightly been denied by the OP because the complainant was not required to be given indoor treatment for the said disease and further the complainant has also failed to prove admission and discharge from the hospital either from the certificate of the doctor or by producing the discharge summary on the file. Therefore, claim of the complainant has been rightly denied by the OP. The authority given on behalf of the OP is fully applicable to the facts and circumstances of the present case whereas the authority given by the complainant is not applicable to the facts and circumstances of the case in hand.

10  .          In view of the above discussion, we do not find any merit in the present complaint, therefore, the same is hereby dismissed. Certified copy of the order be supplied to the parties concerned as per rules and the file be consigned to the record room after due compliance.

Announced in open Commission

Dt.: 7.04.2021.                                           (Neelam Kashyap)

                                                                       President.

 

 

  (Issam Singh Sagwal),                (Neelam)       

       Member                                Member