Delhi

North East

CC/79/2021

Mrs. Komal Malhotra - Complainant(s)

Versus

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

01 Aug 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No.79/21

 

 

In the matter of:

 

	Mrs. Komal Malhotra, W/o Shri Manish Malhotra R/o C-374, Pocket J & K, Dilshad Garden, Delhi 110095	Complainant
	Versus
1.	Religare Health Insurance Co. Ltd., Through its Chief Medical Officer/Director/Chief Manager/Manager Having its registered office at 5th Floor, 19-Chawla House, Nehru Place, New Delhi 110019	Opposite Party

 

DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                        DATE OF ORDER  :

02.07.2021 29.03.2023 01.08.2023

 

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

 

ORDER

Anil Kumar Bamba, Member

The Complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that the Complainant obtained a Floater Mediclaim Policy vide policy No. 12453361 from the Opposite Party in the name of her husband Shri Manish Kumar, covering the health cover of Shri Manish Kumar, the Complainant and two sons. The period of the policy was from 12.05.2018 to 11.05.2020. Husband of the Complainant paid a sum of Rs. 32,128/- being premium with sum assured to the tune of Rs. 10,00,000/-. On 02.05.2019, Complainant got some chest pain and admitted in Yashoda Hospital, Ghaziabad. Complainant was diagnosed with Acute Coronary Syndrome, Hyperprolactinemia, diabetic mellitus Type 2, Normal Left Ventricular function and Polycystic Ovary disease. Complainant submitted admission request note with complete details about herself that she was not suffering from any kind of diabetic problem prior to that date. Complainant got discharged on 04.05.2019 and at the time of discharge the hospital authorities raised a bill of Rs. 63,622/-. The Opposite Party arbitrarily and without any justification refused to reimburse the Complainant for the said hospital charges on the ground that policyholder was already a diabetic patient whereas on the one hand, the Complainant was not having any such pre-existing disease prior to obtaining the policy.  At the time of taking the said policy the representative of the Opposite Party  assured that taking into consideration the medical history and no ailment and no             pre-existing disease of all the members of the family, they need not to pay any amount towards their medical expenses. It is further submitted by the Complainant that despite providing all the details, documents and relevant information as and when sought by the Opposite Party, the Opposite Party finally rejected the claim of the Complainant vide rejection letter dated 06.06.2019 with vague, evasive and non-existent averments. The Complainant has prayed to direct the Opposite Party to pay a sum of Rs. 63,322/- along with 18 % interest p.a., Rs. 10,00,000/- on account of mental harassment and        Rs. 10,000/- on account of litigation expenses.

Case of the Opposite Party

2. Opposite Party contested the case and filed its written statement. It is stated the present complaint is not maintainable and is liable to be dismissed as the name of the Opposite Party has changed from Religare Health Insurance Co. Ltd. to Care Health Insurance Ltd. Accordingly, there does not exist a company by the name of Religare Health Insurance Co. Ltd. and hence the present complaint is liable to be rejected on this ground.  It is submitted that Opposite Party had issued a health insurance policy “Care Floater” having policy no. 12453361 to the spouse of the Complainant Mr. Manish Kumar covering the Complainant, her spouse and two sons from 1.05.2018 till 11.05.2020 for a sum insured up to Rs. 10,00,000/- subject to policy terms and conditions. It is further submitted that the Opposite Party received a cashless request from Yashoda Super Speciality Hospital, Ghaziabad for the hospitalization of the Complainant on 02.05.2019 with provisional diagnosis of Acute Coronary Syndrome, Hyperglycemia and Ketoacidosis. It is further submitted that upon receipt of the request Opposite Party raised a query vide letter dated 02.05.2019 and asked to provide:

1. Exact duration and past history of present ailment with 1^st consultation paper and all past treatment records. Present ailment and diabetes.
2. Investigation reports supporting diagnosis.
3. It is submitted that after that Opposite Party received a query reply. Thereafter, Opposite Party raised a query vide letter dated 04.05.2019 and asked Complainant to provide: 1^stconsultation paper when Hypertension and Diabetes were first diagnosed with all past treatment records. It is further submitted that the Complainant failed to provide the necessary documents with all past treatment records to the Opposite Party. Thereafter, Opposite Party denied the request on the basis of as per requirement past treatment details not provided so pre-existing nature of ailment could not be ruled out hence cashless facility denied under non-submission of required necessary documents and requested the Complainant to file for reimbursement with all supportive documents.Thereafter, Opposite Party received a reimbursement claim request from the Complainant on 13.05.2019 for the same hospitalization at Yashoda Super Speciality Hospital, Ghaziabad, from 02.05.2019 to 04.05.2019 and was diagnosed with Acute Coronary Syndrome, Hyperprolactinemia, Type II DM, Normal Left Ventricular Function and Polycystic Ovary Disease. It is further submitted that upon receipt of the claim a query was raised vide letter dated 16.05.2019 and asked Complainant to provide: “Exact duration and past history of present ailment with 1^st consultation paper and all past treatment records. For diabetes and hypertension. Including treatment records when diagnosed for the first time. It is submitted that Opposite Party also sent a reminder for the above query but Opposite Party received no reply and no required documents were submitted by the Complainant. Thereafter, Opposite Party rejected the claim vide letter dated 06.06.2019 on the grounds of deficiency not replied, first consultation paper to DM and HTN not submitted. Hence, there is no deficiency on the part of the Opposite Party and the complaint is liable to be dismissed.

Evidence of the Complainant

4. The Complainant in support of her case filed her affidavit wherein she has supported the assertions made in the complaint.

Rejoinder to the written statement of Opposite Party

3. The Complainant filedrejoinder to the written statement of Opposite Partywherein the Complainant has denied the pleas raised by the Opposite Partyand has reiterated the assertions made in the complaint.

 

Evidence of the Opposite Party

4. To support its case Opposite Party has filed affidavit of Shri Sahil Chauhan, wherein, he has supported the case of the Opposite Party as mentioned in the written statement.

Arguments & Conclusion

5. We have heard the Parties. We have also perused the file and written arguments filed by the Complainant and Opposite Party. The case of the Complainant is that her husband has taken a Floater mediclaim policy from the Opposite Party and she is one of the insured by the said policy. The period of the policy was from 12.05.2018 to 11.05.2020. On 02.05.2019 due to some medical complications she admitted to the hospital and discharged on 04.05.20198 after required treatment and at the time of discharge the hospital authorities raised a bill of Rs. 63,622/-. The opposite Party arbitrarily and without any justification refused to reimburse the Complainant for the said hospital charges on the ground that policyholder was already a diabetic patient. At the time of taking the said policy the representative of the Opposite Party assured that taking into consideration the medical history and no ailment and no pre-existing disease of all the members of the family, they need not to pay any amount towards their medical expenses. It is further alleged by the Complainant that despite providing all the details, documents and relevant information as and when sought by the Opposite Party, the Opposite Party finally rejected the claim of the Complainant vide rejection letter dated 06.06.2019 with vague, evasive and non-existent averments. Hence, there is deficiency of service on the part of the Opposite Party.
6.  The case of the Opposite Party is that the present complaint is not maintainable and is liable to be dismissed as the name of the Opposite Party has changed from Religare Health Insurance Co. Ltd. to Care Health Insurance Ltd. Accordingly, there does not exist a company by the name of Religare Health Insurance Co. Ltd. and hence the present complaint is liable to be rejected on this ground.  It is further submitted that Opposite Party had issued a health insurance policy “Care Floater” to the spouse of the Complainant covering the Complainant, her spouse and two sons from 11.05.2018 to 11.05.2020 for a sum insured up to Rs. 10,00,000/- subject to policy terms and conditions. Opposite Party further stated that the Opposite Party received a cashless request from hospital for the hospitalization of the Complainant on 02.05.2019. On receipt of the request, the Opposite Party raised a query on 02.05.2019 and asked to provide:

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

2. Investigation reports supporting diagnosis.

7. It is further submitted by the Opposite Party that they have received a query reply. Thereafter, Opposite Party raised a query on 04.05.2019 and asked Complainant to provide: 1^stconsultation paper when Hypertension and Diabetes were first diagnosed with all past treatment records and Complainant failed to provide the necessary documents. Hence, Opposite Party denied the cashless facility. Thereafter, Opposite Party received a reimbursement claim request from the Complainant on 13.05.2019 for the same hospitalization from 02.05.2019 to 04.05.2019 and on receipt of the claim a query was raised and asked Complainant to provide: “Exact duration and past history of present ailment with 1^st consultation paper and all past treatment records for diabetes and hypertension. Including treatment records when diagnosed for the first time. It is submitted that Opposite Party also sent a reminder for the above query but Opposite Party received no reply and no required documents were submitted by the Complainant. Hence, Opposite Party rejected the claim vide letter dated 06.06.2019 on the grounds of deficiency not replied. So, there is no deficiency on the part of the Opposite Party.
8. It is clear from the above mentioned fact that Opposite Party did not lead any evidence regarding any previous treatment or concealment of the fact by the Complainant. As per Opposite Party, they have raised a query on 02.05.2019, which was duly replied by the treating hospital on 03.05.2019. Their TPA should have checked any concealment or information by the Complainant. There was merely raising technical objection to deny the reimbursement of the medical claim of the Complainant. With regard to the change of the Opposite Party form Religare Health Insurance to Care Health Insurance Ltd., it is clear from the record that at the time of purchase of the policy and also at the time of submission of the reimbursement claim Religare Health Insurance was in existence. The name of the Opposite Party changed from the Religare Health Insurance Co. Ltd. to Care Health Insurance Ltd. on 19.08.2020 which was much later than claim was filed by the Complainant. In view of the above, the complaint is allowed. Opposite Party i.e. Religare Health Insurance Co. Ltd.  now Care Health insurance Ltd. is directed to pay an amount of Rs. 63,622/- to the Complainant along with interest @ 6 % p.a. from the date of filing the complaint till recovery.   Opposite Party i.e. Religare Health Insurance Co. Ltd. now Care Health Insurance Ltd. is also directed to pay an amount of Rs. 25,000/- to the Complainant on account of mental harassment and litigation expenses along with interest @ 6 % p.a. from the date of this order  till recovery.  
9. Order announced on 01.08.2023.

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Anil Kumar Bamba)		(Surinder Kumar Sharma)
(Member)		(President)