Haryana

Karnal

CC/480/2019

Kamal Madan - Complainant(s)

Versus

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

Manoj Ahuja

04 Aug 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL  COMMISSION, KARNAL.

 

                                                          Complaint No. 480 of 2019

                                                          Date of instt.01.08.2019

                                                          Date of Decision 04.08.2021

 

Kamal Madan son of Late Shri Balbir Madan House no.307 near Karma sweets Chhoti Mangalpur, Kunjpura Road, Karnal.

 

                                                 …….Complainant.

                                              Versus

 

Religare Health Insurance Company Ltd., SCO-214, First Floor, Sector-12, opposite Mini secretariat, Karnal through its Branch Manager.

 

                                                                      …..Opposite Party.

 

Complaint Under section 12 of the Consumer Protection Act, 1986 as amended Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

 

 Argued by: Shri Manoj Ahuja counsel for complainant.

                    Shri Rohit Gupta counsel for opposite party.

 

                (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 party (hereinafter referred to as ‘OP’) on the averments that complainant alongwith his wife namely Rachna Batra and daughter namely Ahana purchased a Care Insurance Plan, bearing policy no.10843197, valid from 21.10.2016 to 20.10.2017 and the sum insured under the policy was Rs.5,00,000/-. Complainant paid the premium of Rs.11010/- for the said policy. Thereafter, the said policy was got renewed by the complainant and his above named family members from the OP by paying a premium of Rs.12926/- and the same was valid from 21.10.2017 to 20.10.2018 and the sum insured under the said policy was Rs.5,00,000/-. The said policy was further got renewed by paying premium of Rs.13465/- and the same was valid from 21.11.2018 to 20.11.2019.

2.             Further, on 04.08.2018 the complainant developed pain in his abdomen and he got examined himself from Dr. Abid Hussain of Sanjiv Bansal Cygnus Hospital, Karnal and he was diagnosed as AFI VIRAL WITH LRTI OSA WITH ACUTE ON CHRONIC CKD and the complainant was admitted in the said hospital from 04.08.2018 to 07.08.2018, however, there was no improvement in the condition of the complainant, so, he was taken to Rama Super Specialty Hospital, Karnal, where he was only examined and tests were conducted upon him, but he was not admitted in the said hospital and thereafter the complainant was taken to Amrit Dhara Hospital, Karnal on 08.08.2018, where he was admitted and his treatment was started for PYREXIA ACUTE KIDNEY INJURY as diagnosed by the doctor of abovesaid hospital after conducting tests upon the complainant and the complainant remained admitted in the said hospital upto 12.08.2018. Since the abovesaid policy purchased by the complainant from the OP was a cashless policy, so all the documents relating to said policy were handed over to the abovesaid hospitals. However, the officials of the abovesaid hospital got deposited an amount of Rs.10,000/- from the family of the complainant by assuring that the same will be refunded after the discharge of complainant. The OP duly intimated regarding the admission of the complainant. The complainant was treated in the said hospital and remained admitted there upto 12.08.2018. At the time of discharge, when the hospital official contacted the OP for making the payment of bills of the treatment of the complainant, the OP asked the complainant to pay the bills of the hospital and they will lateron pay the claim amount to him and the complainant had to pay a sum of Rs.26979/- to the abovesaid hospital. Thereafter, complainant got lodged his claim with the OP and sent all the documents to OP but till today, the claim amount has not been paid by the OP. Thereafter, complainant visited the office of OP so many times and requested for reimbursement of the claim but OPs failed to pay the same. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

3.             Notice of the complaint was given to the OP, who appeared and filed written version raising preliminary objections with regard to maintainability; locus standi; cause of action; territorial jurisdiction and concealment of true and material facts from this Commission. On merits, it is pleaded that the insurance policy bearing no.10843197 for a period from 21.10.2016 to 20.10.2017 and further renewed from 21.10.2017 to 20.10.2018 was issued from Gurgaon and request for Pre-Authorization of Cashless hospitalization were denied from New Delhi/Gurgaon and Reimbursement claims of the complainant was processed and stands closed from New Delhi/Gurgaon by Religare Health Insurance Co. Ltd. where the OP is having its office, as such the present matter is not maintainable before this Commission. During the currency of the said policy a Cashless facility request for first hospitalization of the complainant was received at Sanjiv Bansal Cygnus Hospital, Karnal on 04.08.2018 for AFI Viral with LRTI, OSA with Acute on Chronic Kidney Disease. On intimation for cashless facility, query was sent by the OP company on 04.08.2018, 05.08.2018, 06.08.2018 seeking necessary details. Complainant replied to queries, the complainant was specifically asked about the duration of OSA (Obstructive Sleep apnea) and CKD (Chronic Kidney Disease) alongwith their first consultation record vide Query letter dated 7 Aug, 18. However, the complainant has failed to provide the same for reasons best known to the complainant. The OP company is of the opinion that the complainant must have been possession of the First Consultation Note and treatment record of the said ailments since he was diagnosed but same are not being provided by the complainant. On assessment cashless facility was denied vide letter dated 7 Aug. 18 for non-submission of important documents for proper assessment of the claim with the following wording:-

“ As per requirement past treatment details not provided so pre-existing nature of ailment could not be ruled out. Hence cashless facility denied under non-submission of required necessary documents. Please file for reimbursement with all supportive documents (not providing past treatment records related to CKD, OSA)”

 

Thereafter, the complainant approached to OP company for filing the Reimbursement Claim for the above stated Hospitalization from 04 Aug. 2018 to 7 Aug. 2018 for AFI Viral with LRTI, OSA with Acute on Chronic CKD. On receipt of reimbursement claim, query was sent by the OP company on 27 Aug. 18, 10 September, 2018, 20 September, 2018 and 30 September, 2018 seeking necessary details. Complainant replied to queries. However, the complainant did not submit the necessary documents and the claim was closed vide letter dated 09.10.2018.

4.             Further, again a cashless facility request for second hospitalization of the complainant in Amritdhara hospital, Karnal was received on 08.08.2018 for Prexia Acute Kidney Injury. On intimation for cashless facility, query was sent by the OP company on 09.08.2018 and 10.08.2018 seeking necessary details. Complainant replied to queries but that was insufficient. On assessment cashless claim facility as denied vide letter dated 10.08.2018 for non submission of important documents for proper assessment of the claim with the following wording:-

As per requirement past treatment details not provided so pre-existing nature of ailment could not be ruled out. Hence cashless facility denied under non-submission of required necessary documents. Please file for reimbursement with all supportive documents (Duration of CKD and OSA).

Deficiency not related.

        Thereafter, the complainant approached the OP for filing the Reimbursement Claim for the above stated Hospitalization from 08.08.2018 to 12.08.2018 for Prexia acute Kidney Injury. On receipt of reimbursement claim, Query was sent by the OP on 27.08.2018, 10.09.2018, 20.09.2018 and 30.09.2018 seeking necessary details. Complainant replied to queries. However, the complainant did not submit the necessary documents and the claim was closed vide letter dated 10.10.2018 for deficiency not replied with the following wording:

Case rejected as deficiency not replied for OSA related first document.

Deficiency not replied.

                In the light of the non-receipt of the documents, the OP closed the claim of the complainant, vide letter dated 10.10.2018 due to non-receipt of necessary documents required for assessment of claim in adherence to the policy terms and conditions. It is further pleaded that OP has neither repudiated nor denied/rejected the claim of the complainant and will reconsider the admissibility of the claim on receipt of the necessary documents. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

5.             Complainant tendered into evidence his affidavit Ex.CW1/A, policy certificates Ex.C1 to Ex.C3, detail of final bills Ex.C4, discharge summary Ex.C5, certificate of doctor of  Sanjive Bansal Cygnus Hospital, Karnal Ex.C6, invoice/receipt Ex.C7, medical bills of Rama Super Specialty & Critical Care hospital Ex.C8 and Ex.C9, bill of Amritdhara Hospital, Karnal Ex.C10, discharge summary of Amritdhara Hospital, Karnal Ex.C11, medical certificate Ex.C12 and reply of the letters Ex.C13 and closed the evidence on 16.03.2020 by suffering separate statement.

6.             On the other hand, OP tendered into evidence affidavit of Shreya Chansoria, Manager Ex.OP1/A, Certificate of Incorporation Ex.OP1, policy certificate with policy terms and conditions Ex.OP2, query letter dated 04.08.2018 Ex.OP3, cashless denial letter Ex.OP4, query letters dated 27.08.2018, 10.09.2018, 20.09.2018 and 30.09.2018 closure Ex.OP5 to Ex.OP9, query letters and cashless denial letter Ex.OP10 to Ex.OP12 and query letters and closure letter Ex.OP13 and closed the evidence on 25.03.2021 by suffering separate statement.

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.            Learned counsel for complainant argued that complainant had purchased a health policy from the OP. On 04.08.2018, complainant developed pain in his abdomen and got examined himself from Cygnus Hospital, Karnal and remained admit from 04.08.2018 to 07.08.2018. There being no improvement, complainant was taken to Rama Super Speciality Hospital, Karnl and from there he was taken to Amrit Dhara Hospital, Karnal on 08.08.2018 and where he remained admit for PYREXIA ACUTE KIDNEY INJURY and was discharged on 12.08.2018 after recovering from his illness and was cured. Since, the policy was cashless policy, so all the documents relating to said policy were handed over the concerned hospitals. The OP was duly intimated regarding admission of complainant in the hospital. At the time of discharge, when the hospital official contacted the OP for making the payment of bills, the OP asked the complainant to pay the bills and they will later on pay the claim amount to him and complainant had paid Rs.57,550/- to the hospitals. Thereafter, complainant got lodged his claim with the OP and sent all the documents but till today no claim has been paid by the OP. He further argued that the OP was demanded documents with regard to the previous medical history. Since, there was no previous history, therefore, the complainant could not provide the documents for the same. Finding no other alternative, the complainant has filed the present complaint and prayed for allowing the same.

9.             Per-contra, learned counsel for the OP while reiterating the contents of written version, has vehemently argued that this Commission has got no territorial jurisdiction to try, entertain and adjudicate the present matter as policy in question was issued from Gurgaon and pre-authorization of cashless hospitalization were denied from New Delhi/Gurgaon and reimbursement claims of the complainant was processed and stands closed from New Delhi/Gurgaon by the OP, where the OP is having its office, as such, the present matter is not maintainable for want of territorial jurisdiction and the complaint deserves to be dismissed. He further argued that complainant without sending the requisite documents for proper assessment of claim, has filed the present complaint in a hastily manner and without the documents, the OP cannot take any further action in the matter, therefore, there is no cause of action in the present complaint. The complainant was asked about the duration of OSA and CKD alongwith their first consultation record vide query letter dated 7.8.2018, but the complainant had failed to provide the same and, hence, the OP has declined the cashless facility for non-submission of important documents. The complainant approached the OP for settlement of claim. On receipt, the queries were sent by the OP and complainant replied the queries but did not submit the necessary documents, hence, the claim of the complainant was closed for want of necessary documents. There is no deficiency in service on the part of OP, hence, prayed for dismissal of complaint.

10.           Admittedly, the complainant has purchased a health insurance policy from the OP. During subsistence of policy, the complainant fell ill and remained under treatment in various hospitals. The cashless claim of the complainant was rejected. Thereafter, complainant approached the OP for reimbursement of his claim but the OP closed the same due to insufficient of requisite documents.  

11.           The first plea taken by the OP is that this Commission has no jurisdiction to try and entertain the present complaint. Hence, this Commission, firstly decide the issue whether this Commission has jurisdiction to try and entertain the present complaint or not?

12.           As per the OP, the present policy was issued from Gurgaon and the cashless facility as well as claim for reimbursement was also closed from New Delhi/Gurgaon, therefore, this Commission has no jurisdiction to try and entertain the present complaint. In this regard, we are of the considered opinion that the complainant had purchased the policy in question from Karnal, the payment of premium amount was also made from Karnal and the complainant remained under treatment in various hospitals at Karnal and the claim for reimbursement was also applied from Karnal. Since, the cause of action has arisen at Karnal, therefore, this Commission has territorial jurisdiction to try and entertain the present complaint. Thus, this plea taken by the OP has no force.

13.           The other plea taken by the OP is that the complainant was failed to provide the requisite documents, hence, his cashless facility as well as reimbursement of claim was declined. In order to prove its case, the OP relied upon the document Ex.OP3, according which, they demanded documents from Sanjiv Bansal, Cygnus Hospital, Karnal, failing which, the cashless facility was declined vide letter Ex.OP4 dated 07.08.2018. Vide letter Ex.OP5 dated 27.08.2018, the OP demanded exact duration and past history of present ailment with IST Consultation paper and all past treatment records from the complainant and vide letter Ex.OP6, the OP again demanded first consultation document when OSA was diagnosed.  Vide letter Ex.OP7 the OP sent reminder of the previous letter demanding first consultation document when OSA was diagnosed. Vide letter Ex.OP8, the OP sent reminder of previous letter and vide letter Ex.OP9, the claim was declined due to deficiency not replied. Vide letter Ex.OP10 and Ex.OP11, the OP demanded documents from Amritdhara Hospital, and failing which, the OP vide letter Ex.OP12 declined the cashless claim. Vide letter Ex.OP13, OP again demanded Ist consultation paper and all past treatment records from the complainant and lastly denied the claim on the ground of deficiency not replied. In this regard, we are of the considered opinion that vide letters Ex.OP3 Ex.OP10 & Ex.OP11, the demand of documents were raised from the concerned hospitals and it was the concerned doctors who were required to send the documents to the OP and not the complainant. Furthermore, the onus to prove the fact that the complainant was any previous history was lie upon the OP, but the OP has failed to place on record any document that the complainant was having any previous medical history and he intentionally did not provide the documents of the same despite several demands. Hence, this plea taken by the OP has no force.

 14.          Hence, in view of the above discussion and facts and circumstances of the case, we are of the considered view that act of OP while repudiating the claim of the complainant amounts to deficiency in service and unfair trade practice.

15.           The complainant has placed on record bill Ex.C4 of Sanjeev Bansal Cygnus Hospital, Karnal, amounting to Rs.29,369/-, medicine bill Ex.C7 of Rs.100/-, bill Ex.C8 of Rs.300/- of Rama Superspecialty & Critical Care Hospital, lab bill Ex.C9 of Rs.900/- of Rama Superspeciality & Critical Care Hospital and bill Ex.C10 of Rs.26,979/- of Amritdhara Hospital, Karnal. The total of abovesaid bills come to Rs.57,648/- but the complainant in the prayer para of complaint has prayed for an amount of Rs.57,550/-. Hence, the complainant is entitled for an amount of Rs.57,550/- alongwith compensation and litigation expenses, etc.

16.           In view of the above discussion, we allow the present complaint and direct the OP to pay Rs.57,550/- to the complainant alongwith interest @ 9% per annum from the date of repudiating of the claim till its realization. We further direct the OP to pay Rs.15,000/- to the complainant on account of mental agony and harassment suffered by him and Rs.5500/- for the litigation expense. This order shall be complied within 45 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:04.08.2021

                                                                       

                                                                  President,

                                                       District Consumer Disputes

                                                       Redressal Commission, Karnal.

 

 

 

(Vineet Kaushik)

     Member