Delhi

North East

CC/80/2021

Shri Manish Kumar - Complainant(s)

Versus

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

22 Sep 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. 80/21

 

 

 

In the matter of:

		Shri Manish Kumar R/o C 374, Pocket J & K, Dilshad Garden, Delhi-110095		Complainant
		Versus
		Religare Health Insurance Co. Ltd. Through Its Chief Medical Offcer, 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:		02.07.21 25.07.23 22.09.23

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Adarsh Nain, Member

ORDER

Ms. Adarsh Nain, 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 from Opposite Party under the plan CARE vide policy no. 12453361 which was valid for two years i.e. from 12.05.18 to 11.05.20 covering the Complainant, his wife and two sons. The Complainant stated to have paid a sum of Rs. 32,128/- as premium. The Complainant stated that during the currency of the said policy, on 22.05.19, Complainant’s son suffered certain health problems and got admitted in Swasthya hospital. The Complainant stated that during period of treatment/hospitalisation i.e. from 22.05.19 to 27.05.19, son of Complainant was given various medicines as per doctors’ advice and was discharged on 27.05.19.  Thereafter at the time of discharge, hospital raised a bill of Rs. 20,440/- and Complainant also incurred huge amount towards medicines purchased from drug store of said hospital vide various cash memos on different dates. Complainant raised his claim with Opposite Party for reimbursement after the discharge of his son but Opposite Party without any justification refused to reimburse the claim of Complainant on the ground that mother of patient already a diabetic patient, whereas on the one hand, son of the Complainant was not having any such pre-existing disease prior to obtaining the policy. The Complainant stated that vide letter dated 23.06.19 the Opposite Party required  the Complainant to provide all or any documents regarding the previous treatment of the minor and the Complainant categorically informed/ apprised the Opposite Party on phone that his son suffered fever for the first time and there was no previous medical record, but still the Opposite Party again issued another letter dated 30.08.19 declined to pay any amount against the claim of the Complainant. The Complainant stated that despite providing all the details, documents, and relevant information as and when sought for by the Opposite Party including all the bills, invoices and other medical records, the Opposite Party rejected the claim of the Complainant vide rejection letter dated 30.08.19 with vague, evasive and non-existent averments.  Hence, this shows deficiency on the part of Opposite Party. The Complainant has prayed for Rs. 24,706/- with interest @ 18 % p.a. and Rs. 5,00,000/- as compensation for mental harassment. He has also prayed for Rs. 10,000/- as litigation expenses.   

Case of the Opposite Party

2. Upon service, the Opposite Party entered the appearance through their counsel and filed written statement. The Opposite Party while admitting the subject policy covering the Complainant and his family took preliminary objection that the policy was subject to terms and conditions. On merits, it has been contended by the Opposite Party that upon receipt of the Complainant’s claim, a query was raised on 03.09.2019 and the Complainant was asked to provide the first consultation paper related to diabetes and hyper tension as per the query raised in claim no.90949174. It is submitted that the Complainant failed to reply and did not provide necessary documents, in spite of repeated reminders, the present claim was rejected vide letter dated 30.08.2019 on the basis of deficiency not replied. It is submitted that there is no deficiency in service on their part as the claim of the Complainant was rejected in accordance with policy terms and conditions.

Rejoinder to the written statement of Opposite Party

3. The Complainant filed rejoinder to the written statement of Opposite Party wherein the Complainant has denied the pleas raised by the Opposite Party and has reiterated the assertion made in the complaint.

Evidence of the Complainant

4. The Complainant in support of his complaint filed his evidence by way of affidavit wherein he has supported the averments made in the complaint.

Evidence of the Opposite Party

5. In order to prove its case, Opposite Party has filed affidavit of Shri Sahil Chauhan, AR for Opposite Party, wherein the averments made in the written statement of Opposite Party have been supported.

Arguments & Conclusion

6. We have heard the Ld. Counsels for the Complainant and Opposite Party. We have also perused the file and the written arguments filed by the parties.
7. The case of the Complainant is that he and his family was insured with the Opposite Party Insurance Company vide subject floater medi-claim policy and during the subsistence of the said health policy with the Opposite party, the Complainant’s son fell sick and remained under treatment. Complainant raised his claim with Opposite Party for reimbursement after the discharge of his son but Opposite Party without any justification refused to reimburse the claim of Complainant on the non-existent and vague grounds that mother of patient already a diabetic patient and the Complainant had failed to provide necessary documents. It is submitted that the conduct of the Opposite Party shows deficiency in service which needs to be compensated.
8. On the other hand, the case of the Opposite Party is that the Complainant failed to reply and did not provide necessary documents, in spite of repeated reminders, the present claim was rightly rejected on the basis of deficiency not replied. It has been contended by the Opposite Party that upon receipt of the Complainant’s claim, a query was raised and the Complainant was asked to provide the first consultation paper related to diabetes and hyper tension as per the query raised in claim no. 90949174 which the Complainant failed to provide. It is submitted that there is no deficiency in service on their part as the claim of the Complainant was rejected in accordance with policy terms and conditions.
9. From the perusal of the pleadings and evidence led by the parties, it is revealed that it is undisputed that the Complainant’s claim arose during the subsistence of a valid policy issued by the opposite party company.
10. The only issue which is to be decided is that whether the reimbursement claim was rejected validly by Opposite Party. The case of Opposite Party is that upon receipt of the Complainant’s claim for reimbursement, a query was raised on 03.09.2019 and the Complainant was asked to provide the first consultation paper related to diabetes and hyper tension as per the query raised in claim no.90949174. The contention of the Opposite Party is that since, the Complainant failed to reply the query raised in claim no.90949174 and did not provide necessary documents, in spite of repeated reminders, the present claim was rejected vide letter dated 30.08.2019 on the basis of deficiency not replied.
11.  The contention of the Opposite Party is that the claim was rejected on the basis that the query raised in different claim was not satisfied by the complainant. Moreover, Opposite Party has not been able to show anywhere that how that would decide the fate of present claim. The Opposite Party  have failed to explain as to why they raised the query pertaining to another claim at the time of considering present claim and substantiate their case. Thus, the contention of the Opposite Party deserves to be rejected out rightly.
12. Therefore, in view of the above discussion, we are of the considered opinion that the conduct of the Opposite Party has been totally unjustified and unreasonable. We find the Opposite Party deficient in services and guilty of unfair trade practice by rejecting the valid claim of the Complainant on a baseless ground, causing mental agony and torture to the Complainant.
13. Accordingly, we allow the complaint and direct the Opposite Party to pay to the Complainant the claim amount of Rs. 24,706/- with interest @9% per annum from the date of institution of the complaint, Rs.25000/- towards compensation and litigation cost. Opposite Party is liable to pay the same within a period of 4 weeks from the date of receipt of order. In case of delay in the payment beyond 4 weeks Opposite Party will be liable to pay interest @9% p.a. for the delayed period.
14. Order announced on 22.09.23.

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

File be consigned to Record Room.

(Anil Kumar Bamba)           Member

(Adarsh Nain) Member

(Surinder Kumar Sharma) President