Punjab

Ludhiana

CC/19/218

Paramjit Singh - Complainant(s)

Versus

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

sunil Kapoor Adv.

25 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:218 dated09.05.2019.                                                Date of decision:25.01.2023.

 

Paramjit Singh Gill aged 66 years son of Sh. Hazara Singh, resident of House No.40, Plot No.84, Ward No.3, Sandhu  Nagar, Ludhiana now residing at # 108, Ward No.6, Basti Gobindgarh, Moga.                                                                                                                                                         .…Complainant

                                                Versus

1. Religare Health Insurance Company Ltd., B-XIX-133/3/1, Golden Plaza Mal, 1^st Floor, Mall Road, Ludhiana, Punjab through its Branch Manager.
2. Religare Health Insurance Company Ltd., Vipul Tech Square, Tower-C, 3^rd Floor, Sector 43, Gold Corse Road, Gurgaon through its Branch Manager.                                                                                                                                                                     …..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. Sunil Kapoor, Advocate.

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

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the complaint are that on the allurement of the opposite parties, the complainant has taken a travel health insurance policy bearing No.11606136 having validity from 22.09.2017 to 20.03.2018 which was further renewed from 21.03.2018 to 18.09.2018. The complainant stated that prior to it, he has been regularly purchased the medical policy from the opposite parties and as per allurement of the opposite parties the said policy covers any treatment of the complainant and they received the requisite premium. The policy was cashless and the complainant was not to pay any charges to any hospital. The complainant further stated that during the policy period, he has sustained an injury on his left shoulder due to which he remained admitted on 27.02.2018 in the hospital at Medical Practice Sans Souci NSW Australia and got his treatment from there by spending 1174.64 AUS$ which includes hospitalization.  The complainant provided full detail of health problem and medical insurance policy along with medical bills to the opposite parties but they refused to clear the medical claim of the complainant without any reason. However, the complainant time and again approached the opposite parties with request to sanction the claim but initially they postponed the matter on one pretext or the other. A few days back the complainant was astonished to know that instead of giving the claim, the opposite parties flatly refused to pay anything to the complainant. However, at the time of issuance of the policy, the opposite parties assured that in case of any health problem to the complainant, they will pay the requisite claim to him but the opposite parties have repudiated the claim despite the fact that the complainant is their regular customer. On account of non-settlement of claim of the complainant, he has suffered mental torture, mental pain, agony and harassment which amounts to deficiency in service and unfair trade practice on the part of the opposite parties for which they are liable to pay compensation of Rs.2,50,000/- to the complainant. The opposite parties have rejected the claim on illegal and baseless ground without giving any opportunity of being heard to the complainant. The complainant also served a legal notice dated 28.01.2019 upon the opposite parties but no reply was given by the opposite parties. Hence this complaint, whereby the complainant has prayed for issuing direction to the opposite parties to pay the claim amount of Rs,57,320/- along with compensation of Rs.2,00,000/- besides litigation expenses of Rs.33,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement. In the written statement, the opposite parties have assailed the complaint on the ground of maintainability, concealment of material facts, lack of cause of action etc. The opposite parties have further alleged that the complainant approached them for a Travel Policy No.11606136 for the period from 22.09.2017 to 20.03.2018 which was extended from 21.03.2018 to 18.09.2018 subject to policy terms and conditions. Thereafter, the complainant lodged claim for reimbursement vide Reimbursement Claim No.90697159 w.r.t. treatment undergone for Diabetes Mellitus and Frozen Shoulder. On receipt of the documents, the opposite parties could ascertain the fact that his left shoulder got struck in pathway and consulted doctor for the treatment of the same. He took multiple consultations prior to his treatment undergone for current ailment for which the opposite parties raised query vide letter dated 28.09.2018 to sought for various documents for assessment of eh claim which are reproduced as under:-

          a. Detailed narration of incident of injury.

b. Original doctor consultation notes from treating doctor or hospital (mentioning the reason or consultation, treatment advice, investigation repots, prescription) for the all the different date.

c. Provide past medical records related to treatment taken for diabetes in the country of residence.

The opposite parties alleged that they received no response from the complainant then query reminder letters were also sent to the complainant vide letter dated 2.10.2018 and 20.11.2018. The opposite parties received consultation notes related to treatment undergone by the patient for diabetes in the country of residence but no medical records/consultation notes pertaining to current ailment i.e. Shoulder injury was provided by the complainant and due to non-receipt of the said documents, the opposite parties sent final reminder and closure letter dated 20.12.2018 to the complainant. 2.1.5 documents to be submitted for any claim under benefit 1

1. It is a condition precedent to the Company’s liability under this benefit that the following information and documents shall be submitted to the company or the Assistance Service Provider immediately and in any event within 30 days of the event giving rise to the claim under this benefit:

1. Duly filled and signed claim form
2. Duly filled and signed ‘Release of Medical Information Form’
3. Original pathological and diagnostic reports, discharge summary, indoor case papers and prescriptions issued by the treating Medical Practitioner or Network Provider.
4. Copy of passport with entry and exit stamp of the country of treatment.
5. Original bills and receipts for:

• Charges  paid towards hospital accommodation, nursing facilities and other medical services rendered.
• Fees paid to the Medical Practitioner and for special nursing charges.
• Charges incurred towards any and all test and/or examinations rendered in connection with the treatment.
• Charges incurred towards medicines or drugs purchased from a registered pharmacy other than the Network Provider duly supported by the prescriptions of the Medical Practitioner attending to the insured person.
• Any other document as required by the Company to assess the claim.

The opposite parties further alleged that their official applied their mind and send a final reminder/closure letter vide mail/letter dated 20.12.2018, operative part of which is reproduced as under:-

          “Dear Sir/Madam,

In reference to our mail dated 28-Sep.2018, 10/27/2018 and 12/5/2018, we haven’t received the following documents required to process your claim (Claim No.90697159-00) pertaining to Explore Policy (#11606136).

Kindly provide:

1. Original doctor consultation notes from treating doctor or hospital (mentioning the reason or consultation, treatment advice, investigation repots, prescription) for the all the different date service/consultation.”

 

The opposite parties further alleged that the complainant was required to submit all the said documents in original for the assessment of claim but instead of providing documents, the complainant sent legal notice which was duly replied vide letter dated 22.02.2019. Post denial of the claim was due to nonreceipt of documents.

                   On merits, opposite parties reiterated the crux of averments made in the preliminary objections and have denied that there is any deficiency of service and have 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. P1 is the copy of policy certificate-Explore w.e.f. 21.03.2018 to 18.09.2018, Ex. P2 is the legal notice dated 28.01.2019 and closed the evidence.

4.                On the other hand, counsel for opposite parties tendered affidavit Ex. RA of Mr. Kashif Nazki, Manager (Legal) of the opposite parties along with documents Ex. R1 is the copy of  Datasheet- Explore w.e.f. 22.09.2017 to 20.03.2018, Ex. R2 is the copy of police terms and conditions, Ex. R3 is the copy of claim form, Ex. R4 is the copy of query letter dated 28.09.2018, Ex. R5 is the copy of account/receipt of Sans Souci Medical Practice dated 27.02.2018, Ex. R6 is the copy of final reminder and closure letter dated 20.12.2018 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.                The complainant is a senior citizen availed travel health insurance policy and sustained injury on his left shoulder and remained under treatment in the hospital of Medical Practice Sans Souci NSW Australia. He spent an amount of 1174.64AUS$ on his treatment and during the course of settlement of the claim, the opposite parties sought certain documents vide letter dated 28.09.2018 and reminder letters dated 27.10.2018 and 20.11.2018 were also sent to the complainant and finally closed the case on 20.12.2018. The opposite parties have also admitted the receipt of legal notice. In the present case, the claim was disallowed on the basis of non-submission of documents. It is the consistent stand of the complainant that all the available documents with regard to his treatment were duly submitted at the time of filing of the complaint. Moreover, non-submission of the documents cannot be made a sole ground to close the claim of the complainant. The insurance companies are required to be more liberal in their approach without being too technical.

7.                In this regard, reference can be made to 2022(2) Apex Court Judgment 281 (SC) in case title Gurmel Singh Vs Branch Manager National Insurance Company Ltd. whereby it has been held by the Hon’ble Supreme Court of India that the insurance company has become too technical while settling the claim and has acted arbitrarily. The appellant has been asked to furnish the documents which were beyond the control of the appellant to procure and furnish. Once, there was a valid insurance on payment of huge sum by way of premium and the Truck was stolen, the insurance company ought not to have become too technical and ought not to have refused to settle the claim on non­submission of the duplicate certified copy of certificate of registration, which the appellant could not produce due to the circumstances beyond his control. In many cases, it is found that the insurance companies are refusing the claim on flimsy grounds and/or technical grounds. While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control. In view of the aforesaid facts and circumstances, it would be just and appropriate if the opposite parties are directed to consider and reimburse the claim of the complainant strictly as per terms and conditions along with composite costs of Rs.10,000/-.

8.                As a result of above discussion, the complaint is allowed with an order that the opposite parties shall consider and reimburse the claim of the complainant strictly as per terms and conditions of the policy within 30 days from the date of receipt of copy of order. The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

9.                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:25.01.2023.

Gobind Ram.

 

 

Paramjit Singh Gill Vs Religare Health Ins.                     CC/19/218

Present:       Sh. Sunil Kapoor, Advocate for complainant.

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

 

                   Arguments heard. Vide separate detailed order of today, the complaint is allowed with an order that the opposite parties shall consider and reimburse the claim of the complainant strictly as per terms and conditions of the policy within 30 days from the date of receipt of copy of order. The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. 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:25.01.2023.

Gobind Ram.