Haryana

Karnal

CC/256/2018

Balinder Singh - Complainant(s)

Versus

Religare Health Insurance Company Limited - Opp.Party(s)

Shadi Ram Chauhan

01 Aug 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                                             Complaint no.256 of 2018

                                                                             Date of instt. 01.10.2018

                                                                             Date of Decision 01.08.2019

 

                                                    

Balinder Singh aged about 46 years son of Shri Ram Singh resident of village Manglora Kadim Tehsil and District Karnal (Aadhar no.2265 5458 4331)                                                                   

…….Complainant

                                        Versus

 

1. Religare Health Insurance Company Limited, Vipul Tech Square, Tower-C, 3^rd floor, Golf Course Road, Sector 43, Gurgaon-122009 through its Managing Director.

2. Indusind Bank Ltd. Branch at Nagla Chowk, Karnal through its Branch Manager.

3. Sanjiv Bansal Cygnus Hospital, Railway Road, opposite Khalsa college, Karnal through its Managing Director.

                                                                        …..Opposite Parties.

                

           Complaint u/s 12 of the Consumer Protection Act. 

         

Before    Sh. Jaswant Singh……President. 

                Sh. Vineet Kaushik………Member

                Dr. Rekha Chaudhary……Member

 

 Present:  Shri Shadi Ram Chauhan Advocate for complainant.

                   Shri Ashwani Kumar Popli Advocate for OP no.1.

                   Shri Suraj Kanwar Advocate for OP no.2.

                   OP no.3 exparte.

 

                   (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant purchased a Group Care Plan Policy from the OP no.1, vide policy no.10087119 and certificate no.10457513 which is having sum assured Rs.2,50,000/-. Complainant is consumer of the OPs since the year 2015 as he has regularly purchased the medi-claim insurance policy vide policy no.11749698, valid from 24.11.2017 to 23.11.2018 from the OP no.1. Complainant was suffering from Gastritis Sinus Bradycardia problem, hence on 19.05.2018 he was taken to the Sanjeev Bansal Cygnus Hospital, Karnal after check up Doctor gave medicine to the complainant and sent back to his home. The illness of the complainant could not be cured with the medicines given to him by Doctor, hence on 21.05.2018 was again taken to the said hospital and as his condition was abnormal, hence he was submitted in the said hospital. He remained admitted there uptill 24.05.2018. On 21.05.2018 the complainant gave information to the OP no.1 about his illness and his pre-authorization request was accepted by OP no.1, vide approval no.CW-12105201802157. The OP no.1 has intimated the hospital to provide further detail, vide request no.8017845500. When complainant was discharged from hospital, he was asked to deposit Rs.18683/- and same was deposited by the complainant because official of the OP no.1 assured for reimbursement of the treatment amount. Again complainant remained admitted in the hospital from 31.05.2018 and discharged on 1.6.2018. Complainant informed the OP no.1 in this regard. At this time complainant spent Rs.13172/- on his treatment. After discharge from the hospital complainant lodged the claim with the OP no.1 for reimbursement of the amount but OP no.1 did not pay the amount and postponed the matter on one pretext or the other. Thereafter, complainant received a  letter dated 23.05.2018 and 31.05.2018 in both letters, the both claim of the complainant has been repudiated on the ground of “condition caused by suicide or substance abuse/intoxication CLD (Alcoholic lever). The said plea taken by the OP no.1 is totally illegal, null and void because the complainant never tried to commit suicide nor he used to consume liquor. The treating doctor of the complainant in his opinion that the complainant admitted with us on 21.05.2018 as a case of palpitations with generalized body weakness with the history of chronic liver disease, hepatitis B related. Patient has no past history of alcohol intake, neither the CLD is due to alcohol. Previous admission might have shown history of alcohol but that was a printing error. Thus, certified and cleared by the head of the department, kindly be sure that patient is non-alcoholic and approve his case on wards. Hence there is deficiency in service on the part of the OPs in repudiating the claim of the complainant. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, OP no.1 appeared and filed written statement raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the complainant was insured, vide health insurance policy Group Care (Scheme 2-IIB) bearing Group Policy no.10087119 and certificate of insurance no.10457513 alongwith his Spouse for a period of 25.11.2015 to 23.11.2016 for a sum insured of Rs.2,50,000/- subject to the Policy Terms and Conditions. Thereafter, the said policy was further renewed on a yearly basis from 24.11.2016 till 23.11.2017. The complainant was further insured, vide Health Insurance Policy Plan Care Floater bearing Policy no.11749698 alongwith his Spouse and 2 sons for a period from 24.11.2017 to 23.11.2018, for a sum insured of Rs.2,50,000/-. It is further pleaded that the complainant was admitted on 21.05.2018 at Sanjiv Bansal Cygnus Hospital for the treatment of Pain in abdomen with Vomiting, BP Low and General Weakness. The complainant was diagnosed with Chronic Liver Disease and was subsequently discharged on 24.05.2018. The complainant approached the OP no.1 by filing a Cashless Facility Request. However, the said cashless facility Request was denied on 23.05.2018 under Permanent Exclusion condition caused by suicide or substance abuse/intoxication of Alcoholic Liver. It is further pleaded that the complainant was admitted on 31.05.2018 at Sanjiv Bansal Cygnus hospital for the treatment of Pain in abdomen with Vomiting, BP Low and General Weakness. The complainant was diagnosed with Chronic Hepatitis B and Gastroenteritis and was given Conservative treatment. The complainant in respect to the same approached the OP by filling cashless facility request. However, the said cashless facility request was denied on 23.05.2018 under Permanent Exclusion condition caused by suicide or substance abuse/intoxication of Alcoholic liver.  It is further pleaded that the cashless request of the complainant was denied on the ground that “As per the Progress Sheet of Sanjiv Bansal Cygnus Hospital, dated 21.05.2018, the complainant was marked as Alcoholic Liver by treating Doctor.” It is further pleaded that o n scrutiny of documents submitted by the complainant or investigation it was found that the complainant has suffering from alcoholic liver which is one of the reasons for ailment of Chronic Liver Disease and as per permanent exclusion clause of terms and conditions of the policy, the OP no.1 has rightly repudiated the claim of the complainant.  There is no deficiency in service on the part of the OP no.1. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             OP no.2 in his reply stated that officials of OP no.2 never persuaded the complainant to purchase Group Care Plan Policy, vide policy no.10087119. Complainant himself approached the OP no.2 for purchase of said policy after going through with the terms and conditions of the Group Care Plan Policy issued by OP no.1. Post issuance of policy, there is separate contract between the complainant and insurance company/OP no.1 and in case of any dispute relating to insurance company including rejection of insurance claim, this has to be dealt by OP no.1 only. It is further stated that the settlement of the insurance claim is within the preview of OP no.1 only who being the sole responsible for issuing the policy to the complainant. There is no deficiency in service on the part of the OP no.2. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

4.             OP no.3 did not appear and proceeded against exparte, vide order dated 26.11.2018.

5.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C10 and closed the evidence on 14.02.2019.

6.             On the other hand, OP no.1 tendered into evidence affidavit of Arvind Singh Ex.RW1/A and documents Ex.R1 to Ex.R7 and closed the evidence on 16.07.2019. OP no.2 led no evidence.

evidence on 15.07.2019.

7.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

8.             Admittedly, the complainant had taken the treatment during subsistence of medical policy. The complainant was diagnosed with chronic liver disease and was approached the OP by filling a cashless facility request. The said cashless facility request was denied by the OP. The complainant was again admitted on 23.05.2018 at Sanjiv Bansal Cygnus Hospital for the treatment of pain in abdomen with Vomiting. The complainant made request for cashless facility to the OP. But this request for cashless facility again denied by OP.

9.             The cashless facility request of the complainant were denied by the OP on the ground that “As per the progress sheet of Sanjv Bansal Cygnus Hospital, dated 21.05.2018 the complainant was marked as Alcoholic Liver by the treatment Doctor and as per exclusion clause of terms and conditions of the policy, the claim of the complainant was repudiated.

10.            The claim of the complainant was repudiated by OP, on the basis of progress sheet of Sanjiv Bansal Cygnus Hospital, Ex.R3. As per said report, complainant was marked as Alcoholic Liver by the treating doctor. But on the other hand, said doctor has issued a letter Ex.C10 same reproduced as under:-

        “The patient namely Mr. Balvinder Singh, age 46 years/M was admitted with us on 21.05.2018 as a case of palpitations with generalized body weakness with history of chronic liver disease, hepatitis B related. Patient has no past history of alcoholic intake, neither the CLD is due to alcohol, previous admission might have shown history of alcohol but that was a printing error. Thus, certified and cleared by the head of the department. Kindly be sure that patient is non-alcoholic and approve his case onwards.”

Thus, treating doctor has clarified in the Ex.C10 that patient was no past history of alcohol intake, neither the CLD is due to alcohol, previous admission might have shown history of alcohol but that was a printing error. OP failed to rebut the Ex.C10. Medical expenses incurred by complainant proved from the bills Ex.C7 & Ex.C9. Thus, in view of above discussion, we are of the confirmed view that act of the OP no.1 amounts to deficiency in service in repudiating the claim of the complainant.

11.            The claim of the complainant was rejected by OP no.1 on the basis of report prepared by the OP no.3. Lateron, said report was rectified by the concern doctor. If the treated doctor had not observed that complainant as alcoholic and his claim would not have been rejected by OP no.1.  As per version of the doctor i.e. OP no.3 in  Ex.C10 is a printing error. We have seen the Ex.R3 but same is hand written instead of printing. Thus, OP no.3 has casually observed that patient is alcoholic. To rebut the said plea OP no.3 did not appear and opted to be proceeded against exparte. Thus, we are of the view that the act of the OP no.3 also amounts to negligent in service.

12.            Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP no.1 to pay Rs.31,855/- to the complainant with interest @ 9% per annum from the date of repudiation till its realization to the complainant. We further direct the OP no.3 to pay Rs.25,000/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:01.08.2019                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

 

       

                (Vineet Kaushik)     (Dr. Rekha Chaudhary)

                    Member                         Member