Chandigarh

DF-I

CC/883/2019

Amrik Singh - Complainant(s)

Versus

Religare Health Insurance Co. Ltd. - Opp.Party(s)

Arun Kumar & Varun Bhardwaj

06 Jul 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

============

Consumer Complaint  No	:	CC/883/2019
Date  of  Institution	:	28/08/2019
Date   of   Decision	:	06/07/2020

 

 

 

 

 

Amrik Singh S/o Sh. Raja Ram, Resident of House No. 118-A, Ward No.9, Village Bhabhat, S.A.S. Nagar, Mohali.

……… Complainant

 

Versus

 

[1]  Religare Health Insurance Co. Limited, Regd. Office 5^th Floor, 19 Chawla House, Nehru Place, New Delhi – 110019, through its Managing Director.

 

[2]  The Managing Director, Religare Health Insurance Co. Limited, Regd. Office 5^th Floor, 19 Chawla House, Nehru Place, New Delhi – 110019.

 

[3]  The Branch Manager, Religare Health Insurance Co. Limited, SCO 56-58, 2^nd Floor, Madhya Marg, Sector 9-D, Chandigarh.

……. Opposite Parties

 

BEFORE:   RATTAN SINGH THAKUR     PRESIDENT

SMT.SURJEET KAUR             MEMBER

DR.S.K. SARDANA              MEMBER

                               

 

For Complainant	:	Sh. Varun Bhardwaj, Advocate.
For Opposite Parties	:	Ms. Niharika, Vice Counsel for Sh. Paras Money Goyal, Advocate.

 

PER SURJEET KAUR, MEMBER

 

 

          Adumbrated in brief, the facts necessary for the disposal of the instant Consumer Complaint are, the Complainant purchased Religare Health Insurance Plan namely, CARE for himself and for his family members bearing Policy No. 10839534 on 18.10.2016 and got the same renewed from time to time. The Complainant was having stone in his Kidney and admitted to Alchemist Hospital, Panchkula on 31.05.2019. The Complainant got operated on 01.06.2019 for removal of Stone. It has been alleged that despite having been a pre-approved cashless claim of the Complainant to the tune of Rs.70,000/-, the Opposite Parties denied the claim, due to which the Complainant had to foot the expenses of Rs.51,541/- to the Hospital on 02.06.2019. Thereafter, the Complainant again went to Alchemist Hospital on 13.06.2019 for removal of Stent in the Kidney and the same was removed on the same day and the Complainant was charged a sum of Rs.14,073/-. On being approached, the Opposite Parties informed the Complainant that his date of birth was wrongly mentioned and for rectifying the same demanded a sum of Rs.10,802/-, which the Complainant paid having been left with no alternative. Thereafter, on 11.07.2019, the Complainant submitted claim form with the Opposite Parties, but vide letter dated 29.07.2019 the same was rejected on erroneous grounds. Eventually, the Complainant got served a legal notice dated 01.08.2019 upon the Opposite Parties, but the same did not fructify. With the cup of woes brimming, the Complainant has filed the instant Consumer Complaint, alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties.

 

2.      Notice of the complaint was sent to Opposite Parties seeking their version of the case.

 

3.      Opposite Parties contested the claim of the Complainant and filed their joint written statement, inter alia, admitting the basic facts of the case. It has been pleaded that the Complainant along with his spouse were covered under the policy in question for a sum insured of Rs.5,00,000/- subject to Policy Terms & Conditions. It has been pleaded that the Complainant filed cashless request with the answering Opposite Parties and was admitted at Alchemist Hospital, Panchkula on 31.05.2019 where he was diagnosed for Kidney Stone. The said request of the Complainant was rejected vide letter dated 01.06.2019 under Policy Terms & Conditions for non-submission of required necessary documents. Hospitalization of the Complainant at Alchemist Hospital, Panchkula on 13.06.2019 for removal of Stent in the Kidney has not been disputed. The date of birth of the Complainant was changed on his request and was charged accordingly by the answering Opposite Parties. The Complainant raised his claim for removal of Stent in Kidney (second hospitalization), which was also rejected vide letter dated 02.08.2019 under Policy Terms & Conditions. Admitting the factum of having been served with a legal notice, Opposite Parties have contended that the same was duly replied, explaining in detail the reasons for denial of claim. Thus, denying all other allegations and stating that there is no deficiency in service or unfair trade practice on their part, Opposite Parties have prayed for dismissal of the complaint.

 

4.      Replication was filed and averments made in the Consumer Complaint were reiterated.

 

5.      Parties were permitted to place their respective evidence on record in support of their contentions.

 

6.      We have heard the learned counsel for the Parties, through video conferencing, and also perused the record with utmost care and circumspection.

 

7.      The sole grouse of the Complainant is that he and his family being covered with the Health Insurance Plan of the Opposite Parties, the Complainant was denied the genuine claim when he applied for the same being duly covered under the Policy. It is an admitted fact that the Policy in question was renewed from time to time.

 

8.      The stand taken by the Opposite Parties is that the Complainant did not submit the required necessary documents well in time and also the Complainant did not disclose his pre-existing disease i.e. he was having a past history of hypertension.

 

9.      Pertinently, the Policy in question is Religare Health Insurance Plan which to our mind the Complainant purchased for caring himself and his family members in case of medical emergency. Admittedly, the problem of the Complainant was of Kidney Stone and he was operated for the same and thereafter, later on, again he got the treatment for the removal of Stent in the Kidney and hence he applied for the claim. Evidently, he got the surgery done and paid a sum of Rs.51,541/- and thereafter for the purpose of removal of Stent in the Kidney he was charged a sum of Rs.14,073/- again. Interestingly, his claim was pre-approved by the Opposite Parties to the tune of Rs.70,000/- vide letter Annexure C-5 and also there is another letter Annexure C-4 which is a copy of the Certificate issued by the concerned doctor. Undoubtedly, the Opposite Parties have produced on record Annexure OP-9 revealing that in the year 2016 when the Complainant purchased the Policy in question he was suffering from Hypertension, but in the present case there is no relevance of the Hypertension with the treatment of the removal of Stone from the Kidney. If the Opposite Parties can produce this document during the proceedings of the present case, then, it is out of our understanding, how the Opposite Parties issued specifically the Health Insurance Policy without the prior health check-up of the Complainant and other members of his family who were being covered under the same. This conduct of the Opposite Parties itself shows the deficiency in service on their part.

 

10.      It is thus legitimately proved that the Opposite Parties caused great harassment, inconvenience and mental torture agony and suffering to the Complainant, despite getting the requisite premiums for the policy and thereafter for the renewal of the policy and later denying the benefit of cashless treatment to the Complainant in case of emergency, proves deficiency in service and their indulgence into unfair trade practice. 

 

11.      The Complainant in his prayer clause has prayed for the refund of Rs.10,802/- charged by the Opposite Parties with regard to change in date of birth of the Complainant. However, per material on record, to our mind, we cannot grant such a relief to him, as there is nothing on record which could substantiate that the Opposite Parties had in fact over-charged from the Complainant. However, since the Opposite Parties pre-approved the claim of the Complainant to the tune of Rs.70,000/- vide their letter dated 31.05.2019 believing which the complainant underwent surgery, in our considered opinion, if the said amount, along with compensation, in the sum of Rs.15,000/-, along with Rs.10,000/- towards costs of the present proceedings, is granted to him, it would be reasonable, fair and adequate.

 

12.      In the light of above observations, we are of the concerted view that the Opposite Parties are found deficient in giving proper service to the complainant. Hence, the present complaint of the Complainant deserves to succeed against the Opposite Parties, and the same is partly allowed, qua them. The Opposite Parties are, jointly and severally, directed to:-

 

[a]  To pay Rs.70,000/- to the Complainant along with interest @9% per annum from the date of repudiation, till its realization;

 

[b]  To pay Rs.15,000/-on account of deficiency in service and causing mental and physical harassment to the Complainant; 

 

[c] To pay Rs.10,000/- as cost of litigation;

 

13.      The above said order shall be complied within 30 days of its receipt by the Opposite Parties; thereafter, Opposite Parties shall be liable for an interest @12% p.a. on the amount mentioned in sub-para [a] above from the date of repudiation, till it is paid. The compensation amount as per sub-para [b] above, shall carry interest @12% p.a. from the date of institution of this complaint, till it is paid, apart from costs of litigation of Rs.10,000/-.  

 

14.      Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.
15.  

06^th July, 2020                                                           

Sd/-

(RATTAN SINGH THAKUR)

PRESIDENT

 

Sd/-

 (SURJEET KAUR)

       MEMBER

 

Sd/-

 (DR.S.K. SARDANA)

       MEMBER

 

“Dutt”