BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.79 of 2017

Date of Instt. 28.03.2017

Date of Decision: 28.05.2019

Satnam Singh Age 37 years S/o Makhan Singh R/o 269-B, Surya Enclave, PO Chugitti, Jalandhar-144009 Mob. No.9464975717

..........Complainant

Versus

1. Religare Health Insurance Co. Ltd., Near PUDA Office, Ladowali Road, Jalandhar Through its Branch Manager/Director/Authorized Representative.

2. Religare Health Insurance Co. Ltd., GYS Global, Plot No.A3, A4, A5, Sector-125, Noida, U. P.-201301 Through its Managing Director/Authorized Representative.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Smt. Jyotsna (Member)

Present: None for the Complainant.

Sh. R. K. Sharma, Adv Counsel for the OPs No.1 & 2.

Order

Karnail Singh (President)

1. This complaint has been filed by the complainant, wherein alleged that the complainant is subscriber of Health Insurance Policy No.10664565 insured by OPs. As per this policy, the OPs assured and promised the complainant that the mission of the OPs is to provide highest quality of health care to the customer and accordingly, the complainant purchased the said policy, which was valid for the period 15.07.2016 to 14.07.2017, after paying the premium of Rs.6821/- and the total insured value of the said policy is Rs.4,00,000/-.

2. That the OPs issued Health Cards in the name of the complainant and his wife Dalbir Kaur Maan to be presented at the time of an emergency or a planned hospitalization to access cashless treatment at the network over 4500 + hospitals. Within validity of insurance policy, unfortunately Smt. Dalbir Kaur Maan wife of complainant Satnam Singh suffered with High Grade Fever, Severe Joint Pains, Reddishness on whole body. Due to above disease, she was admitted on 05.11.2016 in Johal Multispeciality Hospital, Hoshiarpur Road, Rama Mandi, Jalandhar and remained admitted there upto 08.11.2016. The hospital authority prepared claim form and gave the same to the OPs for recovery of the amount incurred on the treatment of the complainant i.e. Rs.26,565/-. On 07.11.2016. an authorized representative of OPs came to hospital and prepared the report. Dr. B. S. Johal prepared the patient's history and gave the same to the authorized representative of OPs, who came to hospital to check the status of patient. On 08.11.2016, the complainant was to discharge from hospital and accordingly, the complainant requested the OP on phone continuously upto 04:00 PM to give the above said amount to hospital, but the OPs put the complainant on one pretext or other and at about 04:30 PM, the OPs told the complainant that the claim has been rejected, so, the payment should be paid by the complainant to said hospital. Then the complainant paid the above said amount of Rs.26,565/- from his own pocket to hospital.

3. That the complainant himself gave the reimbursement and other required documents to the OPs at the office of OP No.1 for getting claim of above said amount. The OPs told the complainant to wait for 15 days to obtain the result from their head office but neither reply nor claim was given by the OPs to the complainant and then complainant served a legal notice to the OP with request to pay the insurance claim, but on 07.03.2017, the OP rejected the claim of the complainant without any ground, which is clear cut negligence, deficiency in service on the part of the OPs and accordingly, a cause of action accrued to the complainant to file the instant complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse the insurance claim amount of Rs.26,565/- along with interest @ 12% per annum from the date of admission in the hospital and further OPs be directed to pay compensation to the complainant, to the tune of Rs.70,000/- for mental tension and harassment and further OPs be directed to pay litigation expenses of Rs.3300/-.

4. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared through its counsel and filed joint reply, whereby contested the complaint by taking preliminary objections that the complaint is not maintainable against the answering OPs/Religare Health Insurance Co. Ltd., as such, the same is liable to be dismissed and further submitted that the complainant alongwith his wife were insured, vide policy number 10664565 under Plan 'Care' with a coverage upto Rs.4,00,000/- from 15 July 2016 till 14 July 2017, subject to Policy Terms and Conditions and further alleged that the wife of the complainant was admitted at Johal Multispeciality Hospital, Jalandhar from 05.11.2016 to 08.11.2016, but as per Vital Charts prepared and maintained by Hospital Authorities, the complainant's wife is recorded to be stable with all body vitals including blood pressure, pulse rate and respiration rate to be normal within limits. That as per the Progress Notes dated 06.11.2016 and 07.11.2016, the complainant's wife got stable and Vitals were noted to be normal. In the light of above physical condition of the complainant's wife, the claim of the complainant's wife was rejected, vide letter dated 11.01.2017 under Clause 4.3 (a) (1) read with Annexure C (71) of the Policy Terms and Conditions as the complainant's wife was primarily admitted for investigation and evaluation purpose, which is not payable under the policy. On merits, it is admitted that the policy was obtained by the complainant alongwith his wife and it is also admitted that a claim was lodged by the wife of the complainant, but the same was rejected as per terms and conditions of the policy, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

5. In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA alongwith some documents Ex.C-1 to Ex.C-24 and closed the evidence.

6. Similarly, counsel for the OPs No.1 and 2 tendered into evidence affidavit of Sh. Ankit Shanker Bhardwaj as Ex.OA alongwith some documents Ex.OP-1 to Ex.OP-11 and Ex.OP11/A and closed the evidence.

7. We have heard the learned counsel for the OPs and also gone through the case file very minutely.

8. Before imparting with the main dispute between the parties, we preferred to take a legal issue raised by the OPs in its written reply, in Para No.1 on Preliminary Objection, that the instant complaint is not maintainable against the answering OPs No.1 and 2, the plea taken by the counsel for the OPs for not maintaining the instant complaint is only that the complainant alongwith his wife were insured with the insurance company i.e. OPs No.1 and 2 and wife of the complainant was remained admitted in the hospital from 05.11.2016 till 08.11.2016 and further alleged that the claim of the complainant's wife was rejected, vide letter dated 11.01.2017 and further alleged that the wife of the complainant is individual insured alongwith her husband i.e. complainant with the OPs, if so, then the wife of the complainant has independent right to file a complaint, if her insurance claim has been rejected by the OPs, but the instant complaint filed by the husband of the complainant, who is not a consumer and therefore, complaint is not maintainable and make a request the same may be dismissed.

9. We have sympathetically considered the plea taken by the OPs and same is not meeted out by counsel for the complainant in any manner because the version of the OPs is supported by documentary evidence. For reference sake, we like to refer Para No.4 of the complaint, where complainant himself described that the OP issued health cards in the name of complainant and his wife Dalbir Kaur Maan, the said cards are available on the file Ex.C-4 and both the cards having separate number and separate identity by their names, it means both i.e. complainant and his wife are individually insured with the OP and further, the treatment was taken by the wife of the complainant as per bills available on the file i.e. Ex.C-5 to Ex.C-15, not so, the claim of the complainant's wife Dalbir Kaur Maan was rejected by the OPs, vide claim rejection letter dated 07.03.2017 Ex.C-22.

10. From the above documents as well as pleadings, it is clearly established that the complainant is not a consumer qua the instant insurance claim because the same is related to his wife Dalbir Kaur Maan, who is also one of the insured with the OPs and treatment was also obtained by the wife of the complainant. So, with these observations, we came to conclusion that the complainant is not a consumer qua the relief claimed in this complaint rather the consumer is the wife of the complainant namely Dalbir Kaur Maan and as such, we find that the instant complaint is not maintainable. However, Dalbir Kaur Maan has right to file a fresh complaint, if she so desired and the period consumed in this complaint will be condoned for limitation purpose according to law of limitation.

11. In view of the above detailed discussion, the complaint of the complainant is not maintainable, therefore, the same is dismissed with no order of cost. Parties will bear their own costs. This complaint could not be decided within stipulated time frame due to rush of work.

12. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Jyotsna Karnail Singh

28.05.2019 Member President