DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .
Complaint No. 163
Instituted on: 22.04.2019
Decided on: 08.03.2021
Jyoti Grover W/o Sh. Ashish Kumar Grover, Resident of #56, Partap Nagar, Outside Sunami Gate, Sangrur.
…. Complainant.
Versus
1. Religare Health Insurance, 3rd Floor, Shanghai Tower, Firoz Gandhi Market, Ludhiana through its Manager 141001.
2. Religare Health Insurance, Vipul Tech Square, Tower C, 3rd Floor, Golf Course Road, Sector 43, Gurgaon-122009 through its Manager.
3. Religare Health Insurance, 5th Floor, 19, Chawla House, Nehru Palace, New Delhi-110019 through its Managing Director.
4. Punjab National Bank, Branch Gaushala Road, Sangrur through its Branch Manager.
….Opposite parties.
For the complainant: :Shri Amit Aggarwal, Adv.
For the OP No.1to3 :Shri Jatinder Verma, Adv.
For the OP No.4. :Shri Sonu Singla, Adv.
Quorum: Shri Jasjit Singh Bhinder, President
Shri V.K.Gulati, Member
ORDER:
Shri Jasjit Singh Bhinder, President
1. Smt. Jyoti Grover, complainant has filed this complaint pleading that the complainant obtained one health insurance policy of Rs.5,00,000/- vide policy number 12299637 from the OPs number 1 to 3 through OP number 4 for the period from 4.4.2018 to 3.4.2019 by paying the requisite premium of Rs.8653/- and the amount of premium was deducted from the account of the complainant. It is further averred that under the policy in question, the complainant herself, her husband Ashish Kumar Grover, sons Mannan Grover and Aarush Grover were insured under the said cashless policy. Further case of the complainant is that husband of the complainant Shri Ashish Kumar Grover suffered with acute pain in the abdomen and he visited to Singla Surgical Hospital, Sangrur for check up on 27.09.2018 and the doctor of above said hospital suggested for Ultrasound and IVP test and found that he was suffering with stones problem in kidney and the doctor suggested for surgery. Further case of the complainant is that Shri Ashish Kumar Grover was admitted in Mayo Healthcare Super Speciality Hospital, Mohali on 29.9.2018 as the said hospital was empanelled under the OPs. The Mayo Health Care Hospital applied for cashless treatment for Mr. Ashish Kumar Grover on 29.9.2018 but after 4-5 hours they informed to the complainant that the cash less treatment has been denied by the OPs and suggested to file for reimbursement with treatment record. Further case of the complainant is that surgery of Mr. Ashish Kumar Grover was conducted by the doctors on 29.9.2018 and was discharged on 30.09.2018 and an amount of Rs.80,372/- was charged by the hospital, which were paid by the complainant. Further case of the complainant is that Ashish Kumar Grover again suffered with high fever and got admitted in Singla Surgical Hospital on 4.10.2018 and was discharged on 9.10.2018, where he spent an amount of Rs.32,597/- and by this way the complainant spent a total amount of Rs.1,12,966/-. Thereafter the complainant lodged the claim with the OPs for reimbursement of the amount of Rs.1,12,966/- but all in vain. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the Opposite parties be directed to pay to the complainant the amount of Rs.1,12,966/- along with interest and further to pay Rs.50,000/- as compensation on account of mental agony, tension and harassment and an amount of Rs.33,000/- on account of litigation expenses.
2. In reply filed by the OPs number 1 to 3, preliminary objections are taken up on the grounds that the complaint is not maintainable, that this Commission has got no jurisdiction, that the present complaint is premature being the complainant did not provide the requisite documents as necessary for adjudicate the claim, that the policy holder shall furnish all the information that is sought from him by the insurer, that intricate questions of law and facts are involved in this case, that the complainant is estopped from filing the present complaint and that the complaint is false, frivolous and vexatious in nature. On merits, it is admitted that the complainant had taken the health insurance policy from the OPs with assured sum of Rs.5,00,000/- covering herself, spouse and children. The policy terms and conditions were also supplied to the complainant. It is further averred that the complainant approached the OPs with the cashless claim vide claim number 80210601 with respect to complainant’s husband hospitalization w.e.f. 29.9.2018 for total amount of Rs.99,000/- and the OPs enquired about the various information such as “exact duration and past history of present ailment with first consultation paper and all past treatment record, but the same was not provided. It is further averred that the Ops sent various letters to the complainant but nothing was done. It is stated that the complainant herself has violated the terms and conditions of the policy. On merits, it is admitted that the complainant got the policy in question from the Ops for Rs.5,00,000/- for the period from 4.5.2018 to 3.5.2019 and the policy conditions were supplied to the complainant. It is stated further that since the complainant did not provide the complete information to the Ops, as such the claim has been rightly repudiated vide letter dated 27.9.2018. Lastly, the Ops number 1 to 3 have prayed that the complaint be dismissed with special costs.
3. In reply filed by OP number 4, preliminary objections are taken up on the grounds that the complainant is not the consumer, that the complaint is not maintainable that the complainant has no cause of action and locus standi to file the present complaint and that this Commission has got no jurisdiction to hear and decide the present complaint. On merits, it is admitted that the complainant has obtained policy number 12299637 from OP number 1 to 3 through OP number 4 for the period 4.4.2018 to 3.4.2019. But the remaining allegations leveled in the complaint have been denied.
4. The learned counsel for the parties produced their respective evidence.
5. The learned counsel for the complainant has argued that the complainant obtained one health insurance policy of Rs.5,00,000/- bearing number 12299637 from the OPs number 1 to 3 by paying the requisite premium of Rs.8653/- and the amount of premium was deducted from the account of the complainant and the policy in question was cashless. The learned counsel for the complainant has further argued that the complainant took the said policy regularly 3rd time through the OP number 4. The learned counsel for the complainant has further argued that Ashish Kumar Grover husband of the complainant suffered pain in the abdomen on 27.9.2018 and visited Singla Surgical Hospital, Sangrur for check up and the doctor of above said hospital suggested for Ultrasound and IVP test and found that he was suffering with stones problem in kidney and the doctor suggested for surgery. Further the learned counsel for the complainant has argued that Shri Ashish Kumar Grover was admitted in Mayo Healthcare Super Speciality Hospital, Mohali on 29.9.2018 as the said hospital was empanelled under the OPs and the Mayo Health Care Hospital applied for cashless treatment for Mr. Ashish Kumar Grover on 29.9.2018 but after 4-5 hours they informed to the complainant that the cash less treatment has been denied by the OPs and suggested to file for reimbursement with treatment record. Further case of the complainant is that surgery of Mr. Ashish Kumar Grover was conducted by the doctors on 29.9.2018 and was discharged on 30.09.2018 and an amount of Rs.80,372/- was charged by the hospital. The learned counsel for the complainant has further argued that Ashish Kumar Grover again suffered with high fever and got admitted in Singla Surgical Hospital on 4.10.2018 and was discharged on 9.10.2018, where he spent an amount of Rs.32,597/- and by this way the complainant spent a total amount of Rs.1,12,966/-. The learned counsel for the complainant has further argued that thereafter the complainant lodged the claim with the OPs for reimbursement of the amount of Rs.1,12,966/- but the claim was rejected and as such, the complainant has prayed for acceptance of the complaint.
6. On the other hand, the learned counsel for the OPs has argued that the complainant has not provided necessary documents for adjudication of the claim and that the complaint is premature and deserves dismissal. The learned counsel has further argued that there is no deficiency in service on the part of the OPs. However, the said policy is admitted. The Ops have thus prayed for dismissal of the complaint with special costs.
7. To prove this case, Smt. Jyoti Grover has tendered affidavit Ex.C-1 and has deposed as per the complaint, Ex.C-2 to Ex.C-4 are the insurance policy of Religare Health Insurance policy, Ex.C-5 is prescription slip of Singla Surgical Hospital, Ex.C-6 is report of Jindal Ultrasound Centre, wherein stone in kidney was detected, Ex.C-7 is the report of Bansal Xray centre. Ex.C-8 is letter written by Religare to Mayo Helthcare whereby denied the cashless hospitalization of Shri Ashish Kumar Grover, Ex.C-9 is the discharge summary, Ex.C-10 is the IPD bill for Rs.75,543/- , Ex.C-12 to Ex.C-19 are the receipts and bills of medicine, Ex.C-20 is letter written by Ashish Kumar Grover to Religare Health Insurance, Ex.C-21 is letter of Mayo Healthcare and Ex.C-22 is the repudiation letter dated 28.12.2018. This letter is totally vague and is meant to defeat the insurance claim of the complainant. There is nothing written in this letter why the claim of the complainant has been rejected. Ex.C-23 is also letter of repudiation.
8. On the other hand, the learned counsel for the OPs has produced Ex.OP1 to 3/1 copy of rules of IRDA, Ex.OP1to3/2 copy of insurance policy, Ex.OP1to3/3 copy of cashless form, Ex.OP1to3/4 and Ex.OP1to3/5 letter of Religare, Ex.OP1to3/6 claim form, Ex.OP1to3/7 to Ex.OP1to3/10 copies of letters, Ex.OP1to3/11 claim form, Ex.OP1to3/12 to Ex.OP1to3/16 are copies of letters of Religare and Ex.OP1to3/17 is affidavit of Tejinder Singh, Manager Law wherein he has stated that the claim has rightly been rejected.
9. Majority of the documents were exhibited by the complainant in her evidence. Ex.OP1to3/7 is the letter written to Smt. Jyoti Grover for certain documents. Admittedly, they have tendered letters written to the complainant and she has given the documents.
10. Admittedly, the documents of the surgery of Shri Ashish Kumar Grover conducted by Mayo Healthcare Speciality Hospital Mohali and Singla Surgical are on the file and all the ultrasound reports are also on the file. Ex.C-20 is the copy of letter sent to Religare Health Insurance by Ashish Kumar Grover, wherein all the details have been explained. All the documents have been supplied to the OPs but despite that the insurance company has repudiated the rightful claim of the complainant, which is clear cut deficiency in service on the part of the Ops number 1 to 3.
11. In view of our above discussion, we allow the complaint and direct OP number 1 to 3 to pay to the complainant the amount of Rs.1,12,966/- along with interest @ 6% per annum from 28.12.2018 i.e. the date of repudiation of the claim till realization in full. We further direct OP number 1 to 3 to pay to the complainant an amount of Rs.20,000/- on account of compensation for mental tension, agony and harassment and an amount of Rs.20,000/- on account of litigation expenses. This order be complied with by the opposite parties within 60 days from the date of receipt of certified copy of this order. A certified copy of this order be issued to the parties free of cost as per rules. File be consigned to records.
Pronounced.
March 8, 2021.
(Vinod Kumar Gulati) (Jasjit Singh Bhinder)
Member President
