Haryana

Karnal

CC/253/2020

Harvinder Singh - Complainant(s)

Versus

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

Jagjit Kumar

12 Apr 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 253 of 2020

                                                        Date of instt.16.07.2020

                                                        Date of Decision:12.04.2023

 

Harvinder Singh aged about 47 years son of Sardar Piara Singh, resident of house no.469, sector-6, Urban Estate, Karnal. Aadhar card no.5697-7397-1728.

                                               …….Complainant.

                                              Versus

 

1.     Religare Health Insurance Company Ltd. registered office D-3, District Center, Saket, New Delhi-110017.

 

2.     Religare Health Insurance Company Ltd., Branch office situated at 354, Mugal Canal, Karnal.

                                                                      …..Opposite Parties.

 

Complaint Under Section 12 of the Consumer Protection Act, 1986 and after amendment Under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.

              Dr. Rekha Chaudhary…..Member

                   

Argued by: Shri J.K. Malhotra, counsel for complainant

                   Shri Ashwani Popli, counsel for the OPs.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint Under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant had purchased a Health Insurance Policy from OPs, vide policy no.10778971, Plan Name ‘CARE’, cover type ‘Floater’ valid from 02.09.2016 to 01.09.2018 and the complainant has paid Rs.33,700/- as one time premium amount. In the said policy the complainant is insured with other three family members complainant’s spouse namely shefali, daughter of complainant namely Punya and son of complainant namely Sukhmeet. After the expiry of tenure of said policy, complainant has renewed the same for further two years i.e. from 02.09.2018 to 01.09.2020 and paid the premium amount to the OPs. The said policy is a cashless policy. At the time of purchasing the policy, the OPs medico legally examined the complainant and his wife through S.R.L. Laboratories. The wife of complainant was suffering from cataract (Phacomorphic Glaucoma) and on the advice of doctor, the complainant decided to operate the right eye of his wife. To operate the eye of his wife, complainant contacted to the Arora Eye and Lasic Laser , # 650, Sector-7, Urban Estate, Karnal and the doctor concerned stated that the said hospital is on the penal of OPs and the hospital will provide cashless facility to the complainant. On the assurance of hospital, the complainant got operated the right eye of his wife on 11.05.2020 and discharged on 12.05.2020 and the total expenses was Rs.41,209/-. But at the time of providing cashless policy, the OPs have refused to provide cashless facility and on refusal of OP, complainant had paid the abovesaid amount. Thereafter, after discharge from the hospital, complainant visited the office of the OPs and submitted all the required documents and completed all the formalities for reimbursement of his claim but OPs have passed the claim of  Rs.29159/-only. After that complainant visited the office of OP so many times and requested to pay the remaining amount of Rs.12,050/- to the complainant but OPs did not pay any heed to the request of complainant. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that OPs have issued a policy bearing no.10778971 with the insurance coverage to the complainant, his wife, his daughter and son w.e.f. 02.09.2016 till 01.09.2018 and subsequently renewed for a period from 02.09.2018 till 01.09.2020 for a sum insured of Rs.5,00,000/- subject to the policy terms and conditions. Complainant filed a cashless claim for the treatment of her spouse in day care at Arora Eye and Lasik Laser Centre on 10.05.2020. As per pre-authorization form, complainant was mentioned to be diagnosed with “Cataract in Right Eye’ and was advised for MICS Phoco with IOL IN Right Eye” As per claim Tele-verification patient/insured clearly mentioned that she was diabetic from 4-5 years. On receipt of the abovesaid cashless claim the OP company sought following additional documents, vide query letter dated 08.05.2020 and 09.05.2020.

1.     Exact duration and all past treatment records for “Diabetes”.

It is further pleaded that even after receiving the query letters to provide the exact duration and history of diabetes with all past treatment records the complainant has failed to provide any such document to the OPs. Post scrutinizing the documents, the OPs rejected the cashless claim, vide claim denial letter dated 10.05.2020 and made the following observation:

“Discrepancy in medical documents (history of diabetic) please file for reimbursement with all supportive documents”.

Post rejection of the above cashless claim, complainant filed a reimbursement claim for the treatment of her spouse in Day Care at Arora Eye and Lasik Laser Centre on 10.05.2020. As per discharge summary, complainant was mentioned to be operated for “Phacomorphic Glaucoma in ‘Right Eye’ and was underwent “MICS Phoco with IOL in right eye’. It is further pleaded that above reimbursement claim of the complainant was duly approved by OPs, vide settlement letter dated 17.06.2020 for an amount of Rs.29,159/- paid vide NEFT no.N168201161631888 dated 16.06.2020. The claimed amount was Rs.41,209/- out of which Rs.29159/- was duly approved by OPs after deducting Rs.12,050/- as per policy terms and conditions. The details of the deductions are as follows:-

Particulars                                                         Amount deducted

Extra Lens Charges                                            Rs.10,550/-

(Reasonable & customary charge)

 

Room holding charges (not admissible                 Rs.  1500/-

in day care treatment)

                Total                                                 Rs.12,050/-

 

The deduction of Rs.10550/- was made towards the reasonable and customary charges for extra lens charges. The said deduction is made as per terms and conditions of the policy. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Complainant has tendered into evidence his affidavit  Ex.CW1/A, copy of policy certificate Ex.C1, copy of acknowledgment of policy Ex.C2, copy of claim approval and settlement letter Ex.C3, claim form Ex.C4, copy of OPD slip Ex.C5, copy of discharge summary Ex.C6 and Ex.C9, copy of bill-cum-receipt Ex.C7, copy of medicines bills Ex.C8, copy of medication sheet Ex.C10, copy of pre-operative check list Ex.C11 and closed the evidence on 15.02.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Pratyush Prakash, Manager Ex.OP1/A, copy of policy certificate Ex.OP1, copy of policy renewal Ex.OP2, copy of terms and conditions of the policy Ex.OP3, copy of cashless form Ex.OP4, copy of query letters dated 08.05.2020 and 09.05.2020 Ex.OP5 and E.OP6, copy of denial letter dated 10.05.2020 Ex.OP7, copy of discharge summary Ex.OP8, copy of settlement letter dated 17.06.2020 Ex.OP9, copy of judgment Ex.OP10 and closed the evidence on 20.10.2022 by suffering separate statement.

6.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant

purchased a Health Insurance Policy from OPs. The said policy is a cashless policy. The wife of complainant was suffering from cataract (Phacomorphic Glaucoma). An operation was conducted to her right eye in Arora Eye and Lasic Laser Centre, Karnal and spent Rs.41,209/-. The OPs have refused to provide the cashless facility and on refusal of OP, complainant had paid the abovesaid amount. After discharge from the hospital, complainant visited the office of the OPs and submitted all the required documents and completed all the formalities for reimbursement of his claim but OPs have passed the claim of Rs.29159/-only. Complainant requested the OPs to pay the remaining amount of Rs.12,050/-  but OPs did not pay any heed to the request of complainant and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that complainant filed a cashless claim for the treatment of her spouse in day care at Arora Eye and Lasik Laser Centre on 10.05.2020. As per pre-authorization form, complainant was mentioned to be diagnosed with “Cataract in Right Eye’. The patient/insured clearly is suffering from diabetic since 4-5 years and OPs rejected the cashless claim, vide claim denial letter dated 10.05.2020. The reimbursement claim of the complainant was duly approved by OPs and paid an amount of Rs.29,159/-  after deducting Rs.12,050/- as per policy terms and conditions and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant purchased a Health insurance policy from the OPs. It is also admitted that during the subsistence of the insurance policy complainant’s wife was hospitalized in Arora Eye and Lasik Laser Centre, Karnal and diagnosed with “Cataract in Right Eye’. It is also admitted that the policy in question is a cashless policy. It is also admitted that OPs have not provided the cashless facility to the complainant. It is also admitted that OPs have passed the claim of Rs. 29,159/- and the said amount was paid to the complainant.

11.           Complainant has spent an amount of Rs.41,209/- on the treatment of his wife. He filed the claim with the OPs for reimbursement of the said amount but OPs have passed only Rs.29,159/-.

12.           On the post rejection of the cashless claim, complainant approached to the OPs for reimbursement of the claim. The claim of the complainant was duly approved by the OPs for an amount of Rs.29,159/- and same was paid on 16.06.2020 to the complainant. The OPs have made deduction of Rs.12,050/- as per terms and conditions of the insurance policy. An amount of Rs.10,550/- has been deducted as extra Lens charges and Rs.1500/- for room holding charges. Lenses are vary greatly in rate and quality.  Complainant has failed to prove on record that the Lens which was fitted in the eye of his wife, were as per norms of general schedule.  Thus, the OP has rightly reimbursed the claim amount to the complainant. Hence, we are of the considered view that there is no deficiency in service on the part of the OP.

13.          Thus, as a sequel to abovesaid discussion, the present complaint is devoid of any merits and same deserves to be dismissed and same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated:12.04.2023     

                                                               

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 

(Dr. Rekha Chaudhary)

                           Member