Chandigarh

DF-I

CC/192/2019

Anshul Garg - Complainant(s)

Versus

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

Ajmer Lal Pundeer

24 Mar 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                                    ========

 

                                     

Consumer Complaint No.	:	CC/192/2019
Date of Institution	:	26/03/2019
Date of Decision	:	24/03/2021

 

Anshul Garg S/o Sh. Kamal Kumar, R/o H.No.8, New Ward No.12, Kurali, VPO – Kurali, District S.A.S. Nagar (Punjab) – 140103.

 

…..Complainant

 

V E R S U S

 

1.      Religare Health Insurance Co. Limited, Service Branch, SCO 56-58, 2^nd Floor, Sector 9-D, Chandigarh – 160017, through its Branch Manager.

 

2.      Religare Health Insurance Co. Limited, Vipul, Tech Square, Tower-C, 3^rd Floor, Sector 43, Golf Course Road, Gurgaon (Haryana) – 122009, through its Chief Regional Manager.

 

3.      Religare Health Insurance Co. Limited, Registered Office, 5^th Floor, Chawla House, Nehru Place, New Delhi – 110019, through its Managing Director.

 

4.      Max Super Speciality Hospital (50616217), Near Civil Hospital, Phase-6, Rupnagar S.A.S. Nagar (Mohali)-160055, through its Chief Executive Officer.

…… Opposite Parties

QUORUM:	SURJEET KAUR	PRESIDING MEMBER
	SURESH KUMAR SARDANA	MEMBER

                                                                       

PRESENT:	:	None for Complainant.
	:	Ms.Niharika Goel, Vice Counsel for Sh.Paras Money Goyal, Counsel for OPs No.1 to 3.
	:	Sh.Saurabh Dalal, Counsel for OP No.4.

 

Per Surjeet Kaur, Presiding Member

 

1.         Adumbrated in brief, the facts necessary for the disposal of the instant Consumer Complaint are, the complainant was holding Health Insurance Policy of the OP-Insurance Company, effective from 31.01.2018 to 30.01.2019, with sum insured of Rs.7,00,000/-. On 25.01.2018, while on a trip to Gulmarg (Srinagar), the Complainant slipped down and dislocated his right shoulder. The Complainant admitted to the SGHS Hospital Sohana on 15.08.2018, underwent surgery of his right shoulder on 16.08.2018 and was discharged on 18.08.2018. It has been alleged that the Complainant approached TPA (Max Healthcare) of Insurer functioning at the office of Opposite Party No.4 to extend cashless facility. However, the request of the Complainant was denied by the Opposite Parties vide letter dated 11.08.2018. Under constrained circumstances, the Complainant made full payment of the hospital charges and thereafter, submitted the requisite bills amounting to Rs.1,35,000/- to Opposite Party No.1 for reimbursement. However, to Opposite Parties vide letter dated 18.01.2019 repudiate the claim on flimsy grounds. Eventually, the legal notice dated 22.02.2019 served upon the Opposite Parties failed to fructify. Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties, the complainant has filed the instant Consumer Complaint.
2.         Notice of the complaint was sent to Opposite Parties seeking their version of the case.
3.         Opposite Parties No.1 to 3 in their joint written statement, while admitting the basic facts of the case, pleaded that Complainant lodged request for cashless hospitalization for medical insurance policy. Immediately after the receipt of the claim, the Complainant was asked to provide the information vide letter dated 10.08.2018. Since the information sought was not supplied by the Complainant as such his request for cashless hospitalization was denied vide letter dated 11.08.2018. Thereafter, the Complainant submitted the claim form towards the reimbursement of hospital expenses. As there was deficiency of some documents and the Complainant even after repeated reminders failed to supply the same, therefore, vide letter dated 18.01.2019 the claim was denied per terms & conditions of the policy. Pleading that there was no deficiency in service on their part, a prayer has been made for dismissal of the complaint.
4.         Opposite Party No.4 in its reply, while admitting the factual matrix of the case has pleaded that the real matter in issue is between Opposite Party No.1 and the Complainant. Opposite Party No.4 has been just roped in for publicity and to gain unlawfully from the same. Pleading that there was no deficiency in service on its part, a prayer has been made for dismissal of the complaint.

 

5.         The complainant has filed rejoinder, wherein he has reiterated all the averments, contained in the complaint, and repudiated those, contained in the written version of Opposite Parties.
6.         Parties were permitted to place their respective evidence on record, in support of their contentions.
7.         We have heard the learned Counsel for the Opposite Parties and have also perused the record, along with the written arguments filed on behalf of both the sides.
8.         The sole grouse of the Complainant, in the present Complaint, is that despite being fully covered for the cashless treatment, the Opposite Parties repudiated his genuine claim, without any concrete reason.
9.         Brief facts of the case are that the Complainant had right shoulder dislocation due to getting slipped down while roaming at Gulmarg (Srinagar). The Complainant took first aid treatment there and returned to his home town. As this was case of dislocation of shoulder, hence local treatment was taken at home town from the experts to get the shoulder relocated at its right location, but failed. Thereafter, the Complainant approached the Hospital and got the treatment done for which he had to spent Rs.1,35,000/-. As per the case of the Complainant, the Opposite Parties denied the cashless treatment as he could not submit certain documents for confirming the injury and therefore he filed the claim later on for reimbursement after spending the entire expenses from his pocket. However, later on due to non submission of the few documents the Opposite Parties finally repudiated the claim of the Complainant.
10.         The stand taken by the Opposite Parties is that on 10.08.2018 vide Annexure OP-3, the Complainant was told to provide the following: -

1.      Ist consultation paper immediately after incident.

2.      Address proof of Proposer/Nominee as mentioned in Policy.

          Mr. Anshul Garg s/o Kamal Kumar, O.P. Garments Main Bazar Kurali – 140103 Punjab.

3.      Detail narration of injury with exact date and time.

4.      Exact duration and past history of present ailment with 1^st consultation paper and all past treatment records.

5.      Photo ID of Proposer/Nominee.

          Mr. Anshul Garg

 

6.      Recent passport size photograph of Proposer/Nominee.  

          Mr. Anshul Garg

 

                Since the aforesaid documents/information could not be submitted by the Complainant in time, therefore, vide letter dated 11.08.2018 (Annexure OP-4), the Opposite Parties denied the cashless treatment and direct the Complainant to file for reimbursement with all supportive documents and consultation papers. But, during the process of the claim, the Complainant could not provide some documents, despite repeated reminders hence, the Opposite Parties repudiated his claim as per the policy terms and conditions vide letter dated 18.01.2019 (Annexure OP-7).   

11.         On Annexure OP-1 annexed with the written version of the Opposite Parties, it is clearly written that “at Religare, it’s our mission to provide you access to the highest quality of healthcare and put you back on the road to a worry free recovery, without a care about medical bills and other related expenses”. Perusal of the available record shows that the Complainant was fully covered for cashless facility, but the same was denied by the Opposite Parties and later on, the Complainant filed his reimbursement claim duly supported by bills and other requisite documents. However, the same was denied by the Opposite Parties for the reasons best known to them. It is clarified by the Complainant that his right shoulder was dislocated when he slipped on and he got the first aid treatment. Therefore, in our opinion, it was not possible for the Complainant to file the documents demanded by the Opposite Parties which were sought by them for the purpose of cashless facility. But, when the Complainant could not be successful for the relocation of his shoulder by the local experts, he approached the Hospital and got it treated there and in the process, he spent the entire expenses from his own pocket, despite being eligible for the cashless facility from the Opposite Parties
12.         Importantly, in the entire record, the treating doctor has not given any adverse remarks with regard to the treatment given. In these circumstances, we feel that the Opposite Parties have illegally repudiated the genuine claim of the Complainant for reimbursement of medical expenses incurred by him for treatment taken from the authorized hospital in terms of the policy terms & conditions. Thus, denial of the claim by the Opposite Parties is arbitrary and against the spirit of insurance contract. Hence, the act of the Opposite Parties for firstly denying the provision of cashless facility and later repudiating the genuine reimbursement claim of the Complainant after raising unwanted queries amounts to deficiency in service and unfair trade on the part of the Opposite Parties.
13.         In the light of above observations, we are of the concerted view that the present complaint of the Complainant deserves to succeed against the Opposite Parties, and the same is allowed, qua them. The Opposite Parties are, jointly & severally, directed:-

(i)      To reimburse amount of Rs.1,07,500/- to the Complainant, along with interest @9% p.a. from the date of repudiation i.e. 18.01.2018, till it is paid;

 

(ii)     To pay Rs.15,000/- to the complainant towards compensation for deficiency in service, unfair trade practice and for causing harassment caused to him.

 

(iii)    To pay Rs.10,000/- as litigation expenses.      

 

14.         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% per annum on the amount mentioned in sub-para [i] above from the date of repudiation, till it is paid. The compensation amount as per sub-para [ii] above, shall carry interest @12% per annum from the date of institution of this complaint, till it is paid, apart from compliance of direction contained in sub-para (iii) above.
15.         Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

24^nd Mar., 2021

                       

Sd/-

(SURJEET KAUR)

PRESIDING MEMBER

 

 

Sd/-

 (SURESH KUMAR SARDANA)

MEMBER

 “Dutt”