Punjab

Ludhiana

CC/19/50

Parminder Singh Kapoor - Complainant(s)

Versus

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

Nitin Jain Adv.

29 Apr 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 50 dated 24.01.2019                  

                               Date of decision: 29.04.2022. 

Parminder Singh Kapoor r/o 6837/3A, St. No.8, Mohar Singh Nagar, CMC Chowk, Ludhiana.                                                                                                                                                                                       ..…Complainant

                                                Versus

1.Religare Health Insurance Co.Ltd., Gys.Global, Plot No.A3, A4, A5 Sector-125, Noida-UP-201301 through its Manager/Executive Officer.

2.Religare Health Insurance Co.Ltd., SCO-13, Shanghai Tower, Feroze Gandhi Market, Ludhiana through its Manager/Executive Officer.                                                                                                                   …..Opposite parties

              Complaint under Section 12 of Consumer Protection Act.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH.JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant            :         Sh.Nitin Jain, Advocate

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

 

ORDER

PER K.K. KAREER, PRESIDENT

1.                In brief, the case of the complainant is that he is the holder of medi claim health insurance policy No.10371029 which is valid till 28.08.2019. The complainant got himself checked from Fortis Hospital, Ludhiana on 05.12.2017 where it was found that he was suffering from left inguinal hernia and was advised to be operated upon. Thereafter, on 16.05.2018, the complainant went to SPS Hospital, Ludhiana where the doctor of said hospital found that the complainant was suffering from left inguinal hernia for the last 10 months and was advised to get himself operated. Accordingly, pre-authorized request for cashless treatment was sent to the OP2 but the staff of the hospital mistakenly mentioned the duration of disease as 10 years instead of 10 months. The cashless request was rejected by the OP2 on the ground of non-disclosure of the disease of Hernia. Thereafter, Dr.Prafull K.Arya, Medical Superintendent of SPS Hospital, Ludhiana issued a certificate dated 17.05.2018 stating that the disease was only 10 months old and it was wrongly mentioned by the staff as 10 years. The complainant again got himself checked from RG Stone, Ludhiana on 25.06.2018. The cashless request for hospitalization was sent through RG Stones which was rejected on 26.06.2018. The complainant got himself operated upon from R.G.Stone, Ludhiana on 29.06.2018 and himself paid all the expenses. He was discharged on 30.06.2018. After discharge, the complainant submitted the bills along with documents with the OP2 but the claim was rejected by the OP2 vide letter dated 19.07.2018. On 27.08.2018, the complainant protested in front of the office of OP2 following which the claim was passed. The complainant suffered physical and mental harassment from 16.05.2018 to 29.06.2018 as he could not get himself operated in time for the disease. On 09.10.2018, the complainant issued a legal notice asking the OPs to pay compensation of Rs.80,000/- for not passing the claim. Instead of paying the amount mentioned in the notice, the OPs deprived the complainant for getting reimbursement for treatment of Hernia as per the terms and conditions of the policy. This amounts to deficiency of service and unfair trade practice on the part of the OPs. Hence the complaint whereby it has been requested that the OPs be directed to pay a sum of Rs.80,000/- to the complainant for causing mental agony and harassment along with litigation expenses of Rs.10,000/- and additional compensation of Rs.50,000/-.

2.                The complaint has been resisted by the OPs. In the written statement filed on behalf of OPs, it has been, interalia, pleaded that the complaint is not maintainable. According to the OPs, the cashless facility request for hospitalization from 07.12.2017 was received through Fortis Hospital, Ludhiana for an amount of Rs.1,86,540/-. The OPs initially approved the claim and sanctioned the authorization letter dated 06.12.2017 for total sanctioned amount of Rs.95,000/-. However, later on the cashless request was cancelled. The complainant again applied for cashless facility for his hospitalization from 25.05.2018 through Satguru Partap Singh Hospital, Ludhiana for an amount of Rs.1,37,593/-. The OPs reviewed the claim and rightly rejected the cashless request vide letter dated 16.05.2018 on the ground of non-disclosure of Hernia which existed even prior to the inception of the policy. The complainant asked the OPs to reconsider the claim and after reconsideration, the claim was again denied vide letter dated 07.05.2018 on the same ground. Thereafter, the complainant applied for cashless request for his hospitalization w.e.f. 29.06.2018 through RG Stone and Super Speciality Hospital, Ludhiana for total amount of Rs.76,589/-. The said request was also rejected vide letter dated 26.06.2018 on the ground of non-disclosure of material facts/pre-existing ailment at the time of proposal. Thereafter, the complainant applied for reimbursement of sum of Rs.90,747/- in respect of his hospitalization from 29.06.2018 to 30.06.2018 but OPs considered and rejected the claim vide claim denial letter dated 19.07.2018 with an observation that the insured was suffering from inguinal hernia prior to the policy inception which was not disclosed. Later on, the complainant provided a certificate from RG Stone and Super Speciality Hospital, Ludhiana wherein it was mentioned that the complainant was a known case of hernia from the last 11 months. The OPs investigated the case and found that the complainant had hernia only from the past 10 months. Accordingly, the claim was approved along with pre-post hospitalization expenses. Thus, there has been no deficiency of service on the part of the OPs and the complaint is liable to be dismissed on this ground alone. The rest of the averments made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

3.                In evidence, complainant submitted his affidavit Ex.CA along with documents Ex.C1 to Ex.C20 and closed the evidence.

4.                 On the other hand, OPs submitted affidavit Ex.RA of Sh.Tejinder Singh, Manager (Legal) of OPs along with documents Ex.R1 to Ex.R12 and closed the evidence.

5.                We have heard the counsel for the parties and have also gone through records.

6.                It is the admitted case of the parties that initially the request for cashless treatment sent through Fortis Hospital, Ludhiana was declined by the OPs. Thereafter, the cashless request from Ex.C5 was sent through SPS Hospital, Ludhiana wherein inadvertently the duration of disease was mentioned as 10 years. As a result, the cashless request was rejected vide letter Ex.C6 dated 16.05.2018. Subsequently, a certificate Ex.C7 dated 17.05.2018 was submitted by the complainant wherein the doctor concerned stated that the duration of disease was inadvertently mentioned as 10 years whereas in fact it was 10 monthly. The complainant further sent a pre-authorization request through RG Stone and Super Speciality Hospital, Ludhiana which was also rejected by the OPs vide letter Ex.C8. The complainant got himself operated upon for the problem of hernia as is evident from discharge summary Ex.C9. The complainant remained admitted in RG Stone and Speciality Hospital, Ludhiana from 29.06.2018 to 30.06.2018 and the claim in respect of the said hospitalization was also declined by the OPs vide letter Ex.C10 dated 19.07.2018. However, it has been claimed by the counsel for the complainant that the complainant lodged a protest and the OPs passed the claim on 27.08.2018. By way of this complaint, the complainant has sought compensation and damages for the delayed payment of the claim. Initially the claim was denied vide letter dated 29.07.2018 on the ground that the insured has been suffering from Hernia prior to the inception of the policy which was not disclosed. However, subsequently vide letter Ex.R12 dated 29.08.2018, the claim was settled for an amount of Rs.85,164/-. Therefore, it appears that in the letter Ex.R12, no reasons have been mentioned as to what made the OPs to change their stand. It is also worth mentioning here that at least on as many as three occasions, pre-authorization request for cashless treatment was denied on the same ground that the complainant was suffering from hernia for the last 10 years whereas in fact it was not so and the certificate Ex.C7 dated 17.05.2018 was issued by SPS Hospital, Ludhiana mentioning that the term of 10 years was mistakenly mentioned in the record though the complainant had been suffering from hernia only for the last 10 months. In this manner, it is evident that the complainant has been unduly harassed by the OPs. Even though eventually the claim was passed and reimbursed, yet in our considered view, it would be just and proper if the OPs are made to pay compensation of Rs.10,000/- to the complainant.

7.             As a result of above discussion, the complaint is partly allowed with an order that the OPs shall pay a sum of Rs.10,000/- (Rupees Ten Thousand only) as compensation to the complainant within a period of 30 days from the date of the receipt of the copy of this order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.         

8.                Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:29.04.2022.

Gurpreet Sharma