Chandigarh

DF-I

CC/1027/2019

Karan Vohra - Complainant(s)

Versus

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

Balwinder Singh

03 Jan 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/1027/2019
Date of Institution	:	23/10/2019
Date of Decision	:	03/01/2022

 

Karan Vohra son of Sh.Ajay Kumar Vohra, at present R/o Flat No.502, Block-11, Bollywood Heights-1, Peer Muchalla Zirakpur, Distt. SAS Nagar, Mohali aged about 29 years.

… Complainant

V E R S U S

1. Religare Health Insurance Co. Ltd., Vipul Tech Square, Tower C, 3^rd Floor, Golf Course Road, Sector 43, Gurugram-122009 (Haryana) through its Managing Director/Director.
2. Religare Health Insurance Co. Ltd., SCO 56-57-58, 2^nd Floor, Sector 9-D, Chandigarh-160017 through its Branch Manager.

… Opposite Parties

 

CORAM :	SHRI RAJAN DEWAN	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

 

                                               

ARGUED BY	:	Complainant in person
	:	Ms.Niharika Goel, Vice Counsel for Sh.Paras Money Goyal, Counsel for Opposite Parties(OPs).

Per Surjeet Kaur, Member

1.      The long and short of the allegations are, the complainant took health insurance policy from the OPs on 26.03.2017 and paid premium of Rs.27,827/-. The insurance was cashless. The OPs allotted policy No.11154401 to the complainant for the period 26.03.2017 to 25.03.2018. As per the policy, Smt.Sunita Vohra and Sh.Ajay Kumar Vohra were also insured.

         It is alleged that the father of complainant suffered from acute pain and approached the doctors and he was discovered protrusion in his right lower jaw by the doctor of Dental Care Centre. The doctors after investigation diagnosed the found features of Malignancy and referred the father of the complainant to Tata Hospital, Mumbai for further treatment. The complainant immediately took his father to Sushrut Hospital & Research Centre, Mumbai and the doctors after investigation found that father of the complainant is suffering from Malignancy, carcinoma in situ of skin and admitted him for treatment in the hospital. As per the policy, complainant informed the OPs 48 hrs. in advance about the disease and admission of his father. Complainant requested the OPs for cashless hospitalization of his father and OPs after consulting the doctors of hospital issued the pre-authorization vide letter dated 05.06.2017 (Ex.C-5). It is alleged that after few hours without any verification and investigation, OPs illegally withdrew the pre authorization. The father of the complainant was treated and discharged from the hospital on 12.06.2017 and complainant was compelled to pay the entire amount from his own pocket to the hospital. Thereafter, the complainant submitted his claim in the office of the OPs, but the same was illegally rejected by OPs without investigation of the matter. The appeal filed by the complainant against the said rejection at the IGMS portal of IRDA followed by the office of Insurance Ombudsman, Chandigarh, was also rejected. A legal notice was also sent to the OPs to pay the amount of Rs.2,00,000/- to the complainant alongwith interest @ 12% p.a. from 04.06.2017, but to no avail. Alleging the aforesaid acts amount to deficiency in service and unfair trade practice on the part of OPs, the complainant has filed the instant consumer complaint seeking refund of Rs.2,00,000/- with interest @ 12% p.a. from date of payment i.e. 04.06.2017; Rs.2,00,000/- compensation for mental & physical harassment; Rs.25,000/- as cost of travelling to the office of the OP and Rs.25,000/- as litigation expenses.

2.     OPs contested the consumer complaint. OPs in their written reply stated that the complainant approached them with a cashless request for the planned hospitalization of insured Sh.Ajay Kumar Vohra at Sushrut Hospital, Mumbai w.e.f. 04.06.2017 for treatment of Gian Cell Tumor Fibrosis Tumor (ulcerative legion in right lower molar region). The OPs, after the receipt of the cashless claim of the complainant, scrutinized the documents submitted and came to the conclusion that the complainant was only operated for FNA of the right lower molar region and biopsy report was awaited for the same. In the light of the fact that the insurance biopsy report was awaited and liability of the insured could not be ascertained, the claim of the complainant was denied vide claim rejection letter dated 05.06.2017 (Ex.C-6). Post denial of the cashless facility, the complainant approached the OP company with a reimbursement claim for the hospitalization at Sushrut Hospital. On the basis of documents received, the OP company came upfront with the fact that the treatment undergone by the insured was for Giant Cell Tumor (Fibro-osseous tumor) which is a benign tumor with no indication towards malignancy and is covered only after expiry of first twenty four consecutive months of coverage of insured person from the first policy start date as specified in the policy terms and conditions. Accordingly, the claim of the claim was denied vide denial letter dated 19.12.2017 and pre post claim on 22.12.2017 on the following grounds:

.   2 year waiting period; treatment of internal tumors, skin tumors, cysts, nodules, polyps including breast lumps (each of any kind) Unless Malignant;

.   2 year waiting period.

    Pleading that there is no deficiency in service or unfair trade practice on their part, OPs prayed for dismissal of the complaint.

3.     The complainant filed rejoinder to the written reply of OPs and reiterated averments made in the consumer complaint.
4.     Parties led evidence by way of affidavits and documents.
5.     We have heard the complainant and learned vice counsel for the OPs and gone through the record of the case, including the written arguments. After appraisal of record, our findings are as under:-
6.     The sole grouse of the complainant in the present complaint is that he has been arbitrarily/illegally refused the cashless facility despite the payment of the premium for availing the same. Further, it has been alleged through the present complaint even the genuine claim of the father of the complainant was repudiated without any concrete/valid reason despite his being covered under this policy.
7.     The stand taken by the OPs is that as the ailment of the father of the complainant was not covered under the policy due to the terms and conditions of the policy, the claim of the complainant was denied.    
8.     The first point for consideration is whether the cashless facility denial was as per terms & conditions of the policy or not. The answer to the same is in negative. The policy purchased by the complainant was the cashless policy for which he paid the required premium. As per the case of the complainant and record of the file, the prescription reports by Oncologist Dr.Advani (Ex.C-3) and Surgeon Dr.Suhail Syed (Annexure/Ex.C-21) adequately clarify that the surgery was being conducted based on the recommendation of FNAC report. In these documents, no biopsy was prescribed/recommended by the treating doctors prior to the surgery. Hence, denial of the cashless facility in lieu of waiting of the biopsy report is berefit on merit. Complainant with due diligence initiated the process for the purpose of availing the cashless facility from the OPs within the prescribed time. Based on the submitted documents, evidently the cashless pre authorization was granted to the insured vide letter dated 05.06.2017 (Ex.C-5) based on which the hospital initiated the surgical preparations. There is nothing on record which proves that any other follow up document was asked by the OPs. Hence, we are of the opinion that denial of cashless claim of the critical illness was illegal and arbitrary.
9.     The second point for consideration is whether the repudiation of the claim of the complainant is justified or not. Again the answer to the same is negative. Perusal of Ex.C-2 page 31 dated 10.05.2017 clearly shows that the doctor referred the patient to Tata Hospital, Mumbai for further follow up by giving conclusion that the ailment of the father of the complainant is having feature of malignancy. Even page 32 of Ex.C-2 and page 33 of Ex.C-3 are evidence for the fact that ailment was with malignancy.
10.     The claim of the complainant was denied on the following grounds:-

.   2 year waiting period: treatment of internal tumors, skin tumors, cysts, nodules, polyps including breast lumps (each of any kind) Unless Malignant.

.   2 year waiting period.

    Meaning thereby as per the OPs, the hospitalization and the treatment of the insured was for Giant Cell Tumor which is a benign tumor and is covered only after expiry of first twenty four consecutive months of coverage of insured person from the first policy start date as per the terms and conditions of the policy. Hence, the claim of the complainant was denied. But after carefully scrutinizing the entire record, there is nothing on record which proves that the ailment was not malignant. As per record, the hospitalization was done on 04.06.2017; surgery was conducted on 06.06.2017 and the patient was discharged on 12.06.2017 and the report came on 14.06.2017. Pertinently, there is no waiting period in the policy for the patient having malignancy. The OPs have annexed expert opinion dated 27.05.2019 (Annexure OP-7) whereas father of the complainant was operated on 06.06.2017 and report came thereafter on 14.06.2017. We opine that the expert opinion taken by OPs cannot be considered at the later stage. It seems that as if the same has been procured after expiry of two years to defeat the claim of the complainant illegally.

11.      In the present case, reliance has been kept upon Annexure/Ex.C-24 which is the copy of the judgement passed by the Hon’ble National Consumer Disputes Redressal Commission in Revision Petition No.41 of 2017 titled as ‘Religare Health Insurance Company Ltd. vs. Ayush Gupta’ decided on 18.09.2017. The relevant extract of judgement is reproduced as under:-  

     “7.     Though in the said report, there was no specific finding to the effect     that the sample was malignant but it was opined that Morphological         features favoured Neurocytoma, a clear indicator in favour of       malignancy.  At the same time, there is no clear finding that it was           benign.  At this juncture, we may note that now at this stage, an attempt          has been made by the Insurance Company to place on record a report       dated 22.12.2016 by an Expert, opining that according to the documents           placed before him, Hispopathology Report is in favour of benign lesion.         We fail to understand why such report could not be obtained by the      Insurance Company before repudiating the claim or before filing its Written Version in opposition.  Apart from the fact that under our limited    Revisional jurisdiction under Section 21(b) of the Consumer Protection    Act, 1986 (for short “the Act”), no additional evidence can be permitted,        even otherwise the said Report does not advance the case of the Insurance    Company, in as much as the Report is based on the earlier reports placed before him by the Insurance Company in December 2016, for the surgery        performed in September 2014, and not on the said Expert’s own clinical           correlation of these Reports with the slides, etc.  Hence, the said report          cannot be taken into consideration for deciding the question formulated     above.         

12.      Hence, the act of the OPs in denial of the cashless facility with the genuine prayer of the complainant in his hard time and repudiating the genuine claim of the complainant proves deficiency in service.

13.      In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OPs are directed as under :-

1. to refund the amount of Rs.2,00,000/- to the complainant alongwith interest @ 9% per annum from the date of payment i.e. 04.06.2017 till realization.
2. to pay an amount of Rs.50,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay Rs.20,000/- to the complainant as costs of litigation.

14.      This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.

15.      Certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-		Sd/-
03/01/2022	[Surjeet Kaur]		[Rajan Dewan]
as	Member		President