Punjab

Ludhiana

CC/19/515

Baldev Krishan - Complainant(s)

Versus

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

Ankur Ghai Adv.

07 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:515 dated 05.11.2019.                                                        Date of decision: 07.03.2023.

 

Baldev Krishan son of Sh. Daryai Lal, resident of 105, Kartar Nagar, Model Gram, Ludhiana.                                     

……Complainant

                                                Versus

1. Religare Health Insurance Company Limited, Vipul Tech Square, Tower-C, 3rd Floor, Sector 43, Golf Course Road, Gurgaon-122009 through its General Manager

2. Religare Health Insurance Company Limited, SCO 16-17, 4th Floor, Fortune Chambers Ferozgandhi Market, Ludhiana-141001 through its General Manager.

2nd Address:- SCO 13, Shangai Tower, 4^th Floor, Feroz Gandhi Market, Ludhiana

                                                                             …….Opposite parties.

Complaint Under Section 12 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant            :         Sh. Shiv Kumar, Advocate for and on behalf of                                        Sh. Ankur Ghai, Advocate.

For OPs                         :         Sh. G.S. Kalyan, Advocate.

 

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that the complainant is a senior citizen of 83 years old and was desirous to take health insurance policy and representatives of the opposite parties approached him and offered to provide health insurance services and claimed that the opposite parties are the best health insurance company in the market and provide cashless, hassle free facility to their customers in the time of medical treatment. The complainant submitted that on the representations of the representatives of the opposite parties, he took policy bearing No.13459192 for the period from 22.12.2018 to 21.12.2019 with sum insured of Rs.5 Lac bay paying premium of Rs.37006/-.  The complainant further submitted that he  complained chest pain in the second week of March 2019 and with the directions of a qualified doctor he had undergone various blood and other health test done. The reports of the said test were normal and the complainant was any problem and he was reported free of any problem. Again after a little time the complainant had for which uneasiness advised test and even thereafter the ECG report was normal. He did not face any difficulty. The complainant further submitted that in the month of May 2019, he again faced discomfort for which he got admitted to Fortis Hospital Ludhiana and he was subjected tests related to the pain/discomfort. The concerned doctors had subjected the complainant to the procedure to the process of diagnosis and he was discharged on 11.5.2019 and advised optimal Medical Management to continue. The complainant over a period since March 2019 had to spend a sum of Rs.75,000/- approximately up to 11.5.2019. The deficiency in service of the opposite parties started with the complainant getting admitted in the hospital as at the time of admission to Fortis hospital, the complainant requested for cashless treatment by making necessary representation and  vide mail dated 08.05.2019  the opposite party acknowledged their report of pre authorization request No. PPC0805201901380. However, vide mail dated 11.05.2019 denied cashless facility without any reason. The opposite parties on false flimsy grounds rejected the cashless hospitalization facility by claiming that past treatment details are not provided and that pre-existing nature of ailment cannot be ruled out. All these grounds were false and frivolous to the knowledge of the opposite parties as even during the issuance of policy the complainant had rightly mentioned that there was no pre-existing disease. The denial of cashless hospitalization facility on the part of the opposite parties was not only illegal but also caused acute mental, physical and economic harassment to the complainant. Due to denial of cashless claim, the complainant has to arrange cash for payment to the hospital. Thereafter, he submitted claim form along with documents through email dated 26.08.2019 but the opposite parties started evading the matter despite receipt of mail. The complainant made several inquiries to know the status of his claim, he was asked to provide all the documents of his medical treatment. The opposite parties vide mail dated 26.06.2019 sought bills, past history of ailments, past treatment record, indoor case paper, history sheet etc. to which the complainant sent reply through his grandson vide letter dated 26.06.2019 that he has already supplied the documents. Thereafter, the opposite parties sought documentation of November 2016 of DMC Hospital etc. and due reply was sent by the opposite parties that the said consultation of DMC OPD was for minor purpose and in fact the said documentation were not available. Even t he document of 2018 as sought was duly supplied which was available with the complainant concerning OPD relating to eye. The opposite parties further demanded documents vide letter dated 18.08.2019 including all the treatment record of 2016. Through email dated 19.08.2019 the complainant replied that the record prior to 2019 were of minor issues like fever, cough, cold and the same were not at all related to cardiac problem faced by him. However, vide email dated 02.09.2019, the opposite parties denied the claim of the complainant on the ground that deficiency not replied which is illegal on the part of the opposite parties. The complainant served legal notice dated 14.10.2019 to the opposite parties to pay the amount of Rs.75,000/- along with compensation of Rs.50,000/- and litigation expenses of Rs.10,000/- but to no effect. Hence this complaint whereby the complainant has sought direction to the opposite parties to pay treatment expenses of Rs.75,000/- along with compensation of Rs.50,000/- and litigation expenses of Rs.20,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement and assailed the complaint on the ground of maintainability of complaint,  lack of cause of action, the complaint being abuse of process of law etc. The opposite parties alleged that they had issued a policy namely "Care" under Policy bearing number 13459192 wherein the complainant was covered for a total sum insured of Rs. 5,00,000/- having validity from 22.12.2018 to 21.12.2019. The policy was later renewed from 22-Dec-2019 till 21-Dec-2020.  The opposite parties further alleged that as per bills received, the amount of Rs. 46,393/- paid to the complainant in accordance with policy terms & conditions vide NEFT no. N330190991052072. However, as per the policy certificate and policy terms and conditions, co- payment is applicable in this case. Therefore, the amount of Rs. 15,398 was deducted by the company for co-pay and other non-payable items as per policy terms & conditions. Co-pay is applicable where age of member at time of inception of policy is 61 years or above and the rest of the amount was deducted as the same being non-payable items as per policy terms and conditions. The opposite parties alleged that in earlier settlement letter, there was a typo error in claimed and deducted amount and later the error was rectified vide another settlement letter. On receipt of cashless request through Fortis Hospital where insured was to be admitted from 07.05.2019, the opposite party company sent a Deficiency Letter dated 08.05.2019 and asked the complainant to provide the following documents: -

• Complete indoor case papers with admission notes, history sheet, Doctor's notes, nursing notes and Vital Chart.

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

Thereafter an investigation was also triggered by the opposite party cmpany in order to check the veracity of the claim and the company again sent a Deficiency Letter dated 09.05.2019 and asked the complainant to provide following documents:

• Doctor Prescription of Dr. Akashdeep

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

Treatment records from MYO Lab required.

As the required documents were not sent by the complainant, therefore, the opposite party company asked the complainant to file for reimbursement along with all supportive documents. The cashless request was denied vide denial letter dated 11.05. 2019, operative part of which is reproduced as under:-

• 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 please file for reimbursement with all supportive documents.
• Deficiency not replied.

Thereafter, the complainant filed a reimbursement claim with them. As per the medical documents, the Insured was admitted at Fortis Hospital from 07.05.2019 till 11.05.2019. The claim form was received to the company on 22.05.2019 and they sent a Query Letter dated 26.06.2019 and asked to provide the following documents:

• Final Bill- Consolidated
• Detailed original final bill
•  Exact duration and past history of present ailment with is consultation paper and all past treatment records.
•  Complete indoor case papers with admission notes, history sheet, doctor's notes, nursing notes and vital chart.

Thereafter, Later Query Letter dated 15.07.2019 and Query Letter dated 23.07.2019 was also sent to the complainant and asked him to provide certain documents. A reminder letter dated 12.08.2019 was also sent to the complainant as no document was sent to the opposite party company. As no documents were received, therefore, claim was denied vide Denial Letter dated 02.09.2019 on ground of Deficiency Not Replied.

Reason for seeking documents: During investigation it came to knowledge of the Company that the Complainant had consultation at DMC Hospital Therefore, repeated query letters and remind letters were sent to the Complainant to provide documents related to such consultation. Thereafter a legal notice was received from the complainant. The company again reviewed claim after the receipt of notice and thereafter approved the claim vide Settlement letter dated Nov-2019. The opposite parties further alleged that the deductions made by them as per policy terms and conditions, which is reproduced as under:-

90990637-00	Krishan Baldev MR
Descriptions	Amount	Deductions
Total Claimed Amount               Total Deductions	612791               -15398	RMO charges 1100 Registration100 Dietician 300 Patient Diet 1200 Admission 800 Medical Record Charges 300 Co-pay 11598.2 Total deductions 15398.2
Total payable	46393

 

The relevant clause is reproduced as under:-

2. Benefits

General Conditions applicable to all benefits and Optional Covers

g. The Co-payment......….….….….….….…...... Air Ambulance Cover)

(i) At the time of issue of the first policy with the Company, if age of Insured Person (in case of Floater) is 61 years or above, such Insured Person or all Insured Persons (in case of Floater) shall bear a co-payment of 20% per claim (over & above any other co- payment, if any)

Clause 6- Claims Procedure and Management

Clause 6.2- Claim Settlement- Facilities

Cashless Facility

vi) If the Company does not authorize the Cashless Facility due to insufficient Sum Insured or if insufficient information provided to the Company to determine the admissibility of the Claim, then payment for such treatment will have to be made by the Policy holder/ Insured Person to the Network Provider, following which a Claim for reimbursement may be made to the Company which shall be considered subject to the Insured Person's Policy limits and relevant conditions. Please note that rejection of a Pre-authorization request is no way construed as rejection of coverage or treatment. The Insured Person can proceed with the treatment, settle the hospital bills and submit the claim for a possible reimbursement.

Clause 6.3- Duties of a Claimant/ Insured Person in the event of Claim

a. It is agreed and understood that as a condition precedent for a Claim to be considered under this Policy:

vi) The Company shall be provided with complete necessary documentation and information which the Company has requested to establish its liability for the Claim, its circumstances and its quantum.

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections and factual submissions. The opposite parties has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of insurance policy w.e.f. 22.12.2018 to 21.12.2019, Ex. C2 is the copy of premium acknowledgement, Ex. C3 is the copy of advice of doctor of Dhaliwal Clinic dated 12.03.2019,  Ex. C4 is the copy of test report, Ex. C5 and Ex. C6 are the copies of treatment record of the complainant, Ex. C7 is the copy of discharger summary, Ex. C8 is the copy of bill, Ex. C9, Ex. C10, Ex. C13, Ex. C14, Ex. C17, Ex. C18 are the copies of emails, Ex. C11 is the copy of claim form, Ex. C12 is the copy of deficiency letter dated 26.06.2019, Ex. C15 is the copy of deficiency letter dated 15.07.2019, Ex.  16 is the copy of deficiency letter dated 18.08.2019, Ex. C19 is the copy of legal notice dated 14.10.2019,  Ex. C20 and Ex. C21 are the copies of postal receipts, Ex. C22 is the copy of reply of legal notice and closed the evidence.

4.                On the other hand, counsel for opposite parties tendered affidavit Ex. RA of Sh. Tejinder Singh, Manager Legal of the opposite parties along with documents Ex. R1 is the copy of policy documents, Ex. R2 is the copy of renewal of policy, Ex. R3 is the copy of policy terms and conditions, Ex. R4 is the copy of request for cashless hospitalization, Ex. R5 is the copy of deficiency letter dated 08.05.2019, Ex. R6 is the copy of deficiency letter dated 09.05.2019, Ex. R7 is the copy of denial letter dated 11.05.2019, Ex. R8 is the copy of claim form, Ex. R9 is the copy of deficiency letter dated 26.06.2019, Ex. R10 is the copy of deficiency letter dated 15.07.2019, Ex. R11 is the copy of deficiency letter dated 23.07.2019, Ex. R12 is the copy of reminder-2 dated 12.08.2019, Ex. R13 is the copy of claim denial letter dated 02.09.2019, Ex. R14 and Ex. R15 are the copies of judgments, Ex. R16 is the copy of letter dated 27.11.2019 of opposite parties written to the complainant, Ex. R17 is the copy of claim approval and settlement letter, Ex. R18 is the copy of legal notice of complainant dated 14.10.2019, Ex. R19 is the copy of reply to legal notice and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.

6.                Complainant Baldev Krishan, a senior citizen of about 83 years old and holder of valid and renewed medi-claim policy issued by the opposite parties, was admitted in the Fortis Hospital, Ludhiana on 07.05.2019 and was discharged on 11.05.2019. He sent a request for pre-authorization upon which the opposite parties vide deficiency letter dated 08.05.2019 Ex. R5 and 09.05.2019 Ex. R6 requisitioned certain past medical and treatment record from the complainant but those were not submitted. Due to the non-submission of the required necessary documents, cashless facility was denied on 11.05.2019 vide letter Ex. R7    . The complainant was further advised to submit reimbursement claim with all supported documents.

7.                On 22.06.2019, the reimbursement claim of the complainant was received by the opposite parties and on 26.06.2019 the deficiency letter Ex. R9 was sent and the complainant was asked to provide the following documents:-

• Final Bill- Consolidated
• Detailed original final bill
•  Exact duration and past history of present ailment with is consultation paper and all past treatment records.
•  Complete indoor case papers with admission notes, history sheet, doctor's notes, nursing notes and vital chart.

Later on, on 15.07.2019 Ex. R10, 23.07.2019 Ex. R11 and 12.08.2019 Ex. R12, the complainant was again requested to supply those documents but those documents were not submitted. Finally on 02.09.2019, the reimbursement claim of the complainant was denied vide rejection letter Ex. R13.

8.                It is the case of the complainant as well that in the second week of March 2019, he experienced chest pain and availed medical consultations. The queries sought by the opposite parties at the time of pre-authorization of cashless policy and thereafter, at the time of settling the reimbursement claim pertained to past history and record of present ailment as well but the complainant did not meet their requirements to its fullest. However, on receipt of legal notice Ex. C19 = Ex. R18, the claim of the complainant was reviewed and after making deduction of Rs.15,398.25 out of the total claim of Rs.61,791/-, a claim amount of Rs.46,393/- was settled and paid to the complainant on 26.11.2019. This fact is also evident from the letter Ex. R17 and Ex. R19. From the sequel of above said events, it is clear that the opposite parties had been approaching the complainant again and again for settlement of the documents and as such, there is no deficiency in settling the claim on their part.

9.                With regard to justification of deductions, the counsel for the opposite parties has drawn the attention of this Commission towards the relevant clauses of the policy i.e. Clause 6, 6.2 and 6.3 of the policy. The closure scrutiny of these conditions shows that the complainant being more than 61 years of age was required to bear as co-payment of 20% of the claim over and above any other co-payment. So the policy documents being vital documents are required to be construed strictly without affecting the interest of the parties. So the deduction of amount of Rs.15,398.25 is justified.  

10.               As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                       President         

 

Announced in Open Commission.

Dated:07.03.2023.

Gobind Ram.

 

 

Baldev Krishan Vs Religare Health Insurance                         CC/19/515

Present:       Sh. Shiv Kumar, Advocate for and on behalf of Sh. Ankur Ghai,              Advocate for complainant.

                   Sh. G.S. Kalyan, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                       Member                     Member                                       President         

 

Announced in Open Commission.

Dated:07.03.2023.

Gobind Ram.