Punjab

Ludhiana

CC/19/499

Rajvendra Singh - Complainant(s)

Versus

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

Rahul Kumar Adv.

16 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 499 dated 29.10.2019.                                                        Date of decision: 16.01.2023.

 

Ragvendra Singh S/o. Rajbahadur Singh, R/o. H. No.9784, St. No.5, Kot Mangal Singh, Near ATI Chowk, Janta Nagar, Ludhiana.                                                                                                           ..…Complainant

                                                Versus

1. The Manager/Authorized Person/Concern Officer Religare Health Insurance Company Limited, # Vipul Tech Square, Tower C, 3^rd Floor, Sector-43, Golf Course Road, Gurgaon.
2. The Manager/Authorized Person/Concern Officer Religare Health Insurance Company Limited # Office at San Palaza Building, SCO 13, 3^rd Floor, Feroze Gandhi Market, Ludhiana.                                                                                                                       …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         None.

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

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Succinctly stated, the facts of the complaint are that the authorized agent/representative of the opposite parties approached the complainant and allured him that opposite parties provide valuable health insurance and other policies and under the said allurement, the complainant got  health insurance policy No.13566919 on 05.01.2019 with sum assured of Rs.5,00,000/- from the opposite parties and paid premium of Rs.5907/- to opposite party No.2. The complainant further submitted that on 01.09.2019, he suddenly started some pain in his throat and due to this, he became unconscious and his family members took him to the hospital and admitted in SPS Apollo Hospital, Sherpur Chowk, Ludhiana. Due to critical condition of the complainant, the concerned doctor of SPS Apollo Hospital admitted the complainant in their hospital. The complainant got treatment from the said hospital and was discharged on 05.09.2019. The complainant immediately approached opposite party No.2 for pay the expenses or bill of treatment of Rs.51,139/- and Rs.988/- medicine bills as per terms and conditions of the policy. Opposite party No.2 told the complainant to pay the said bills to the hospital from his own pocket and they assured him that his claim shall be lodged and treatment bills shall be paid by insurance company within one week. The complainant repeatedly approached opposite parties number of times but they kept the matter lingered on one pretext or the other. Till date the opposite parties have not paid the hospital bills and medicine charges to the complainant and refused to pay the above said bills/charges without any reason or justification. The opposite parties are deficient and negligent and have adopted unfair trade practice due to which the complainant has suffered mental, physical pain and harassment. The complainant issued legal notice dated 26.09.2019 through his counsel Sh. Rahul Kumar, Advocate  but to no avail. Hence this complaint whereby the complainant has sought direction o the opposite parties to provide the claim amount of Rs.51,139/- and Rs.988/-, compensation to the tune of Rs.25,000/- and litigation expenses of Rs.22,000/- and cost of Rs.11,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement by taking preliminary objections that the complaint is not maintainable and the allegations made against them are false, frivolous and vexatious. The opposite parties alleged that they had issued policy namely Product Care bearing No.13566919 to the complainant covering the complainant w.e.f. 06.01.2019 to 05.01.2020 for a sum insured of Rs.5,00,000/- subject to policy terms and conditions. The complainant approached the opposite parties with a cashless request with respect to his hospitalization w.e.f. 02.09.2019 and in order to analyze the claim, the opposite parties triggered a claim investigation and raised query letter dated 02.09.2019 seeking information from the complainant which is reproduced as under:-

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

As per the documents received with the pre-authorization form, the opposite parties came to notice that-

• As per the complainant’s statement dated 02.09.2019, blood was oozing out from his mouth for the first time on 02.06.2019 and 03.06.2019.
• As per the OP Discharge Advice, he was advised Tablet Petril MD which is used to treat seizures of different type.

Thereafter the opposite parties company again raised a query letter dated 03.09.2019

1. Documents required

Medical indication for Tan Patril along with doctor’s prescription for same

1. Pre hospitalization OPD treatment record

As patient has complaints of blood in sputum since June 2019.

The opposite parties further averred that the hospital did not provide all the requisite documents as specified in the query letters so the claim was rejected vide Denial Letter dated 04.09.2019 on the ground reproduced as under:-

• As per submitted documents, payability of this case cannot be ascertain at this time, hence liability of insurer cannot be taken at present juncture and cashless facility is being denied. Please file for reimbursement with all supportive documents.
• Documents not received.

On post denial of the cashless request, the complainant again approached them with reimbursement claim with respect to his hospitalization at SPS Hospital, Ludhiana from 02.09.2019 to 05.09.2019. He was diagnosed with Acute Vertigo and Acute Bronchitis. The opposite parties also found that the complainant has paid Rs.10,000/- in cash towards his final bill and in order to properly analyze the claim, opposite parties again raised query letter dated 16.09.2019 seeking documents such as:-

• Documents required

When sputum tinged blood exportation occurred

• Original cash paid receipt against final bill

1000

• Pre hospitalization OPD treatment record
• Complete indoor case papers with admission notes, history sheet, doctor’s notes, nursing notes and vital chart.

The opposite parties again raised query letters dated 23.09.2019, 27.09.2019 and reminder letters dated 07.10.2019, 17.10.2019 seeking documents:-

1. Documents required

Medical indication for Tan Patril along with doctor’s prescription for same

1. Pre hospitalization OPD treatment record

As patient has complaints of blood in sputum since June 2019.

• Complete indoor case papers with admission notes, history sheet, doctor’s notes, nursing notes and vital chart.

The opposite parties further alleged that even after repeated reminders, the complainant did not provide the documents. As such the claim has not been rejected but closed on deficiency not replied. The complainant was advised to provide requisite documents as specified in query in accordance with clause 6.3(a) of the Policy Terms and conditions and the company will process the claim as per the policy terms and conditions on receipt of documents as mentioned in the query. Clause 6(a) is reproduced as under:-

          Clause 6- Claims Procedure and Management

          Clause 6.3- Duties of claimant/insured person in the event of          claim.

1. It is agreed and understood that as a condition precedent for a claim to be considered under this policy:

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.

The claim has not been rejected in toto and the opposite party company is still waiting for requisite documents in order to process the claim. The opposite parties further alleged that they replied the legal notice of the complainant vide reply dated 14.10.2019.

                   On merits, the opposite parties reiterated the facts stated in preliminary objections and denied the deficiency of service on their parties. In the end, a prayer for dismissal of the complaint has been made.

3.                The complainant did not formally tender any evidence despite grant of numerous opportunities nor any one put in appearance on behalf of complainant and as such, evidence of the complainant was closed by order on 10.11.2022. However, at the time of filing the complaint, the complainant submitted his affidavit Ex. CA along with documents i.e. Ex. C1 are the postal receipts, Ex. C2 is the legal notice dated 26.09.2019, Ex. C3 is the welcome kit and insurance policy, Ex. C4 to Ex. C8 are the copies of bills of medicine etc., Ex. C9 is the discharge summary dated 05.09.2019.

4.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Sh. Ravi Boolchandani, Manager (Legal) of the opposite parties along with document Ex. R1 is the copy of insurance policy documents, Ex. R2 is the copy of preauthorization request form, Ex. R3 is the copy of deficiency letters dated 02.09.2019 and 03.09.2019, Ex. R4 is the copy of claim form, Ex. R5 is the copy of OP discharge advice, Ex. R6 is the copy of denial letter dated 04.09.2019, Ex. R7 is the copy of claim form, Ex. R8 is the copy of discharge summary, Ex. R9 is the copy of deficiency letters dated 16.09.2019, 23.09.2019, 27.09.2019, 07.10.2019, 17.10.2019, Ex. R10 is the copy of legal notice dated 26.09.2019 issued by complainant, Ex. R11 is the copy of citation/judgment of Hon’ble Supreme Court of India and closed the evidence.  

5.                None has been appearing on behalf of the complainant since 05.04.2022.  We have heard the arguments of the counsel for the opposite 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 and decided to proceed with the case.   

6.                Perusal of documents shows that the complainant, a subscriber of cashless health insurance policy issued by the opposite parties, got himself admitted with SPS Apollo Hospital, Sherpur Chowk, Ludhiana on 01.09.2019  i.e. during the subsistence of the policy in question and he was discharged on 05.09.2019. During his hospitalization on 02.09.2019, pre-authorization for cashless claim was initiated upon which the opposite parties raised certain queries and vide letter ex. R6 the cashless facility was declined due to non-receipt of the documents from the hospital. The complainant was advised to file the reimbursement claim along with supportive documents.

7.                The complainant lodged reimbursement claim with the opposite parties vide claim form Ex. R7 along with documents. The opposite parties raised queries vide letter dated 16.09.2019 followed by reminder letters dated 23.09.2019, 27.09.2019, 07.10.2019 and 17.10.2019 and ultimately invoked the clause 6.3(a) of the policy and closed the claim of the complainant. Clause 6.3 (a) is reproduced as under:-

Clause 6.3- Duties of claimant/insured person in the event of          claim.

1. It is agreed and understood that as a condition precedent for a claim to be considered under this policy:

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.

However, the claim was not rejected in toto and the opposite parties were open to process the claim in case the desired documents are submitted.

8.                Ex. R9 consists four deficiency letters/reminders issued by the opposite parties and conjoint reading of these letters reveals the requirement of following documents to be submitted by the complainant:-

1. Documents required

     When sputum tinged blood exportation occurred

2. Original cash paid receipt against final bill

     1000

3. Pre hospitalization OPD treatment record
4. Complete indoor case papers with admission notes, history sheet, doctor’s notes, nursing notes and vital chart.

The complainant has staked the claim of Rs.51,139/- and Rs.988/-  on the basis of bills submitted along with his claim. The insurance companies are required to be more liberal in their approach without being too technical.

9.                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 the given set of circumstances, it would be just and appropriate if the complainant is directed to submit the above said documents as per Ex. R9 to opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties shall consider and reimburse claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant. 

10.              As a result of above discussion, the complaint is partly allowed with an order that the complainant is directed to submit the documents as per Ex. R9 to the opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties shall consider and reimburse the claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant.  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:16.01.2023.

Gobind Ram.

 

 

Ragvendra Singh Vs Religare Health Insurance Co. Ltd.           CC/19/499

Present:       None for complainant.

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

 

                   None turned up for the complainant today also. None has been appearing on behalf of the complainant since 05.04.2022.

                   Arguments on behalf of the opposite parties heard. Vide separate detailed order of today, the complaint is partly allowed with an order that the complainant is directed to submit the documents as per Ex. R9 to the opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties shall consider and reimburse the claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant.  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:16.01.2023.

Gobind Ram.