Haryana

Karnal

CC/846/2019

Kaushalya Devi - Complainant(s)

Versus

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

Vinay Bansal

28 Oct 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 846 of 2019

                                                        Date of instt.31.12.2019

                                                        Date of Decision:28.10.2022

 

1.     Kaushalya Devi wife of Shri Kharaiti Lal,

2.     Kharaiti Lal son of Shri Bal Kishan, both residents of F-516, Bank Colony, Karnal.

                                               …….Complainants.

                                              Versus

 

Religare Health Insurance Company Ltd. through its authorized signatory, 354, Mughal Canal, Karnal.

Second Address:- Claims Department Unit no.604-607, 6^th floor, Tower C, Unitech Cyber Park, Sector-39, Gurgaon-122001.

 

                                                                      …..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

      Dr. Rekha Chaudhary……Member

          

 Argued by: Shri Ashok Kapoor, counsel for complainants.

                    Shri Ashwani Popli, counsel for the OP.

 

                    (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 complainants got their health insurance in the year 2016 from the OP, vide policy no.10658975, effective from 20.05.2016 till 19.05.2019.  The complainants paid a sum of Rs.1,18,816/- to the OPs, while getting the policy, complainants completed all the necessary formalities, as per the directions and requirements of the OP. In the month of May, 2019 complainants got their policy renewed by paying a sum of Rs.87,300/-, vide receipt dated 14.06.2019 and the policy was renewed for one year commencing from May, 2019 to May, 2020. There is no claim from the complainant during the previous three years and provided No Claim Bonus, while renewing the policy. In the month of July, 2019 complainant no.1 fell ill and she was vomiting and was feeling stomach paid and thus she was hospitalized with Dr. Sachin Pruthi of S.S.Hospital, Sector-14, Urban Estate, Karnal. Complainant sent information to the OP and on receiving the information the representative of the OP visited the hospital and checked and verified the necessary documents. He also obtained signatures of the complainants on various printed papers for processing the claim. Complainant no.1 was suffering from Jaundice, pain and hypertension. After ultrasound, patient was found having stones in her gallbladder and as such, complainant no.1 was admitted in the hospital and she remained hospitalized on 17.07.2019 and discharged on 23.07.2019 and complainants submitted the claim with the OP, who told that the claim of the complainant is under process. Since complainant no.1 was not getting proper relief, she was hospitalized with Dr. K.C. Sachdeva hospital, Sector-12, Urban Estate, Karnal. The necessary information was sent to the OP, upon which the OP had issued a letter wherein they sought some documentation to the effect that necessary Doctor-prescription regarding first consultation, wherein hypertension was diagnosed for first time and other prescriptions for hyper tension and all other prescriptions for the hypertension. The complainant being unaware about the medical terms, intimated about the same to the Doctor, who provided complete discharge summary etc. which was again sent to the OP, who sent letter dated 29.08.2019 to the complainant by saying that the claim is rejected, as there is discrepancy in the submitted record and discrepancy in the medical documents. The rejection of the claim by OP was/is totally wrong and illegal as all the medical records were submitted to the OP, which were provided by the doctors concerned. It is further averred that complainant no.1 was not getting proper relief as such she was again hospitalized in September, 2019 with Dr. K.C. Sachdeva Hospital, Karnal after necessary medical examination was opined that the complainant is suffering from gallbladder stones, for which, surgical operation is required and the surgery was conducted upon the complainant no.1, for the abovesaid problem and after discharge from the hospital, complainant again intimated to the OP and submitted her medical claim. The complainants spent Rs.36,229/- at the time of first hospitalization of Dr. S.S. Pruthi, in the month of July, 2019. The complainants spent Rs.44620/- at the time of second hospitalization in August,2019 with Dr. K.C. Sachdeva Hospital. Complainants also spent Rs.88,688/- at the time of 3^rd hospitalization in September, 2019 when she was operated for her gallbladder stones, as such complainant has spent a total sum of Rs.1,69,537/-.  Thereafter, complainants visited the office of OP so many times and requested to settle their claim but OP did not pay any heed to the request of the complainant and lingered the matter on one pretext or the other and lastly refused to pay the claim of complainant. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence this complaint.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action and concealment of true and material facts. On merits, it is pleaded that OP issued a policy namely  “Care (For Indusind Bank) Floater” bearing policy no.10658975 in favour of the complainants. The said policy was issued w.e.f.20.05.2016 till 19.05.2019 for a sum insured of Rs. ten lakhs subject to Policy Terms and Conditions. The said policy was renewed w.e.f.13.06.2019 till 12.06.2020. The complainant no.1 approached the OPs for reimbursement of the claim for her hospitalization due to Viral Hepatitis & Joundice with pain in abdomen at SS hospital, Karnal.  The insured was admitted to the hospital w.e.f. 17.07.2019 till 23.07.2019. The said claim form was received with the OP company on 14.08.2019. Upon receipt of reimbursement claim, an investigation was triggered by the OP to ensure the veracity of the claim. Upon perusal of the documents received with the claim form, the OP raised a query vide query letter dated 17.08.2019 and asked for following documents:-

Doctor Prescription

 

Provided first consultation paper wherein hypertension was diagnosed for the first time (Mandatory) and all other prescriptions for the hypertension.

A reply was received from the complainant to the above mentioned query which was based on false facts. Considering the request of the complainant, OP rejected the reimbursement claim, vide denial letter dated 29.08.2019 on the ground that as there is discrepancy in the submitted documents.

Proof

.       That Dr. Sachin Pruthi himself in the OPD dated 17.07.2019 has stated that insured is K/C/O HTN on Rx. On the other hand, he has stated on his letter head under query reply that the insured has no previous history of hypertension, which is self contradictory.

.       As per OPD dated 17.07.2019 of Dr. Sachin Pruthi at SS Hospital, insured is K/C/O HTN on Rx. However, as per insured spouse’s statement, insured has no P/H/O any chronic ailments. This shows misrepresentation of facts.

.       As per the insured spouse’s statement, insured was suffering with Fever/vomiting since 2 days before admission in the SS Hospital on 17.07.2019. However, as per the TPR chart, it can be clearly seen that the insured was afebrile since admission.

.       As per Nursing Note dated 17.07.2019, it has been clearly stated that the patient had no fresh complaints and was stable. This prolonged hospitalization is not justified.

.       That no MD Pathologist is available and only a Lab technician is working under Dr. Sachin Pruthi at SS Hospital. The same has duly stamped by Dr. Sachin Pruthi.

It is further pleaded that OP received a cashless request from the hospital on behalf of the insured. The insured was to be admitted at Dr. K.C. Sachdeva hospital, Karnal w.e.f.17.08.2019 for AFI with Hepatitis and Cholelithiasis. However, since the previous reimbursement claim was still pending at that time, the OP rejected the cashless claim of the insured, vide denial letter dated 17.08.2019 on the following grounds:

Claim pending in reimbursement AL-91051274, hence cashless denied. Kindly file for reimbursement.

 

Reimbursement Claim no.91194142:

Note- This claim is premature as the same is still pending with the OP under deficiency not replied.

The complainant again approached the OP for reimbursement of the claim for her hospitalization due to Cholelithiasis (Multiple) with Emphyema of GB with Extensive Intra-Abdominal Adhesions Dr. K.C.Sachdeva Hospital, Karnal. The insured was admitted to the hospital w.e.f. 05.09.2019 till 10.09.2019. The said claim form was received with the OP on 07.12.2019. Upon receipt of reimbursement claim, an investigation was triggered by the OP to ensure the veracity of the claim. The OP raised queries vide query letter dated 13.12.2019 and 26.12.2019 and asked for following documents;

1.     Detail original discharge summary.

2.     Exact duration and past history of present ailment with 1^st Consultation Paper and all pat treatment records.

        Hypertension (As per one Doctor Prescription which were submitted by you, Doctor written known case of Hypertension on medicines. So need Hypertension Duration).

Since no reply was received from the complainant, the OP sent two reminders vide reminder letter dated 05.01.2020 and 15.01.2020. The reply is still awaited from the complainant and the claim is still pending in process. There is no deficiency in service on the part of the OP. 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 no.2 has tendered into evidence his affidavit Ex.CW1/A, copy of insurance policy Ex.C1, copy of bill of S.S. Hospital Ex.C2, copy of admission file Ex.C3, copy of bill of S.S. Hospital dated 17.07.2019 Ex.C4, copy of documents handed to patients i.e. discharge summary, bills and invoice, investigation report Ex.C5, copy of lab receipts Ex.C6 and Ex.C7, copy of Sai Pharmacy bill Ex.C8, copy of consent letter Ex.C9, copy of cancelled cheque Ex.C10, copy of claim details Ex.C11, copy of discharge summary Ex.C12, copy of service detailed receipt Ex.C13, copy of impatient bills (details) Ex.C14, copy of bill dated 17.08.2019 Ex.C15, copy of progress chart Ex.C16, copy of bill of Dr. Nishtha Khera dated  17.08.2019 Ex.C17, copy of bill of Kay Pharmacy dated 17.08.2019 Ex.C18, copy of treatment chart dated 17.08.2019 Ex.C19, copy of Aadhar card of complainant Ex.C20, copy of cancelled cheque Ex.C21, copy of details of insurance history Ex.C22 and Ex.C24, copy of ultrasound report Ex.C23, copy of discharge summary Ex.C25, copy of impatient bill dated 10.09.2019 Ex.C26, copy of health insurance form Ex.C27, copy of bill of Ajay Sethi dated 07.09.2019 Ex.C28, copy of USG WHOLE ABDOMEN (TAS) Ex.C29, copy of report of CT scan dated 04.09.2019 Ex.C30, cop of OPD card Ex.C31, copy of bill invoice dated 05.09.2019 Ex.C32, copy of bill dated 08.09.2019 Ex.C33 and Ex.C35, copy of test report dated 04.09.2019 Ex.C34, OPD card dated 04.09.2019 Ex.C36, copy of final report dated 13.09.2019 Ex.C37, copy of receipt Ex.C38, copy of shipment tracking history Ex.C39 and closed the evidence on 20.08.2021 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Lakshay Juneja 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, cop of claim form Ex.OP4, copy of query letter dated 17.08.2019 Ex.OP5, copy of query reply E.OP6, copy of claim denial letter dated 29.08.2019 Ex.OP7, copy of pre-authorization form Ex.OP8, copy of denial letter dated 17.08.2019 Ex.OP9, copy of query letters dated 13.12.2019 and 26.12.2019 Ex.OP10 and Ex.OP11, copy of reminder 1^st dated 05.01.2020 Ex.OP12, copy of 2^nd reminder dated 15.01.2020 Ex.OP13, copy of investigation report Ex.OP14, copy of OPD slip of Dr. Sachin Pruthi dated 17.07.2019 Ex.OP15, copy of insured spouse’s statement Ex.OP16, copy of Analysis value sheet Ex.OP17, copy of Nursing Note dated 17.07.2019 Ex.OP18, copy of TPR chart Ex.OP19, copy of judgment dated 17.01.2013 Ex.OP20, copy of claim form Ex.OP21 and closed the evidence on 07.02.2022 by suffering separate statement.

6.             We have heard the learned counsel of 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 complainants had purchased a health insurance in the year 2016 from the OP, valid from 20.05.2016 till 19.05.2019 and the same was got renewed from May, 2019 to May, 2020. In the month of July, 2019 complainant no.1 fell ill and she was hospitalized with Dr. Sachin Pruthi of S.S. Hospital, Sector-14, Urban Estate, Karnal. Complainant sent information to the OP and  remained hospitalized from 17.07.2019 to 23.07.2019 and complainants submitted the claim with the OP. Since complainant no.1 was not getting proper relief, she was again hospitalized with Dr. K.C. Sachdeva hospital, Sector-12, Urban Estate, Karnal. The necessary information was sent to the OP. The complainants requested the OP for claim but OP did not pay the same and rejected the same on 29.08.2019 on flimsy ground. He further argued that complainant no.1 was not getting proper relief as such she was again hospitalized in September, 2019 with Dr. K.C. Sachdeva Hospital, Karnal after necessary medical examination was opined that the complainant is suffering from gallbladder stones, for which, surgical operation is required and the surgery was conducted upon the complainant no.1, for the abovesaid problem and after getting discharge from the hospital, complainant again intimated to the OP and submitted her medical claim. The complainants have spent a total sum of Rs.1,69,537/- on her treatment.  Thereafter, complainants visited the office of OP so many times and requested to settle their claim but OP failed to do so and lastly refused to pay the claim of complainant and hence prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that the complainant no.1 approached the OP for reimbursement of the claim for her hospitalization due to Viral Hepatitis & Joundice with pain in abdomen at SS hospital, Karnal.  OP rejected the reimbursement claim, vide denial letter dated 29.08.2019 because there was discrepancy in the submitted documents.  He further argued that OP received a cashless request from the hospital on behalf of the insured. The insured was again admitted and submitted the claim with the OP and same was also rejected, vide denial letter dated 17.08.2019 The complainant again approached the OP for reimbursement of the claim for her hospitalization. Upon receipt of reimbursement claim, an investigation was conducted to ensure the veracity of the claim. The OP raised queries vide query letter dated 13.12.2019 and 26.12.2019 but no reply was received from the complainant, thus the claim of the complainants has rightly been repudiated and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, complainants have availed the health insurance policy from the OPs. It is also admitted that during the subsistence of the insurance policy complainant no.1 was hospitalized in Dr. Sachin Pruthi of S.S. Hospital, Sector-14, Urban Estate, Karnal and in the Sachdeva hospital, Sector-12, Urban Estate, Karnal twice.

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.OP7 dated 29.08.2019 on the ground, which reproduced as under:-

.      Claim is rejected as there is discrepancy in the submitted records.

.      Discrepancy in the medical documents.

Request for pre-authorization of cashless hospitalization of the complainant was also denied by the OP, vide denial letter Ex.OP9 dated 17.08.2019 on the ground, which reproduced as under:-

.       Claim pending in reimbursement AL-91051274, hence

cashless declined, kindly file for reimbursement

        .       Wrong entry.

 

12.           In deficiency letters Ex.OP10, dated 13.12.2019, Ex.OP11 dated 26.12.2019, reminders Ex.OP12 dated 05.01.2020,  Ex.OP13 dated 15.01.2020 OP has sought the past history of the complainant no.1 relating to hypertension. For non submission of the past history of hypertension, OP has rejected all the claim of the complainant. The policy in question was obtained by the complainants in the year 2016. Complainant no.1 was not suffering from hypertension. The complainant has taken the treatment of gallbladder stones.

13.           The onus to prove its case lies upon the OPs, but OP has miserably failed to prove the same by leading any cogent and convincing evidence. The case of the OP is based upon the prescription slip Ex.OP15, dated 17.07.2019 issued by Dr. Sachin Pruthi, S.S. hospital, Karnal. Neither the said doctor was examined nor his affidavit was tendered into evidence by the OP to prove its version. Moreover, said prescription slip is a photocopy and same is not admissible in the eyes of law. Furthermore, there is no nexus between the treatment taken by the complainant no.1 and hypertension as alleged by the OP.

14.           Further, for the sake of arguments, if it is presumed that the complainant no.1 was suffering from Hypertension at the time of obtaining the insurance policy, in that case also the claim of the complainants cannot be repudiated on the said ground, because  Hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension. In this regard, we are also fortified from the observations of the Hon’ble State Commission, New Delhi, titled as Life Insurance Corporation of India Versus Sudha Jain 2007 (2) CLT 423, in which Hon’ble State Commission has drawn conclusion in para 9 of the order and the relevant clause is 9 (iii), is reproduced as under:-

“9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.” Taking into consideration the facts of the present case and law laid down by the Hon’ble Superior Fora in the above referred cases, we are of the view that OPs were not justified in repudiating the claim of the complainant and are thus liable to pay the amount which the complainant had incurred on his treatment”.

 

Further in United India Insurance Co. Ltd. & Anr. Versus S.K. Gandhi, 2015 (2) CLT 71 (NC)  the insurance company had not placed on record either the discharge summery of the complainant or any medical document signed by the doctors who treated him in Bhatnagar Eye Centre, Karnal and Arpana Hospital, Madhuban to show that the complainant when he was admitted to the said hospital, had himself stated that he was suffering from hypertension from last 8 years. In that case it was held that it is quite possible that the complainant, despite suffering from diabetes was not actually aware of the same and he cannot be accused of mis-statement or concealment. Onus was upon the insurance company to prove that he had made a mis-representation while obtaining the insurance policy and since the insurance policy failed, it was held that it was liable to pay to the complainant to the extent a sum insured by it.

15.  

                It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.

 16.          Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OPs while denying the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

17.           The complainants have spent Rs.1,69,537/- on her treatment and in this regard they has placed on file medical bills and receipts Ex.C2, Ex.C4, Ex.C6 to Ex.C8, Ex.C11, Ex.C13, Ex.C17, Ex.C18, Ex.C26, Ex.C28, Ex.C32 and Ex.C33/-. The said bills have not been rebutted by the OPs. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

18.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.1,69,537/- (Rs.one lakhs sixty nine thousand five hundred thirty seven only)) to the complainant alongwith interest @ 9% per annum from the date of filing the complaint till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.5500/- towards the litigation expenses.  This order shall be complied with 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:28.10.2022.                                                                 

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)

                          Member                           Member