Haryana

Karnal

CC/554/2019

Rajesh Singla - Complainant(s)

Versus

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

Bhaskar Bhalla

13 Oct 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                   Complaint Case No.554 of 2019.

                                                   Date of institution:29.08.2019.

                                                   Date of decision:13.10.2021.

 

Rajesh Singla son of Sh. Sat Parkash Singla, resident of House No.A-350, Gandhi Chowk, Sadar Bazar, Karnal.

                                        ……Complainant.

                        Versus

1. Religare Health Insurance Co. Ltd., near Gurudwara Pehli Patshahi, G.T.Road, Panipat, through its Branch Manager.

2. Sanjeev Bansal Cygnus Hospital, Railway Road, Karnal through its Managing Director.           

..….opposite parties.

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 Bhaskar Bhalla, counsel for the complainant.

                    Shri Ashwani Popli, counsel for the OP.No.1.

                    Shri Vishal Goel, counsel for OP No.2.

               

   (Jaswant Singh President)

ORDER:                    

       This complaint has been filed by the complainant 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 the complainant purchased a medical health care policy from the OP No.1 bearing No.12585662 valid for the period w.e.f. 14.06.2018 to 13.06.2021 for an amount of Rs.5,00,000/-.  In the month of May, 2019 the complainant suffered from continuous headache, dizziness and other problems due to which he visited the Sanjeev Bansal, Cygnus Hospital, Karnal i.e. OP No.2.  After thorough check-up, the complainant was got admitted on 10.05.2019 in the hospital of OP No.2 as advised by the above-said doctor and the complainant was discharged on 13.05.2019.  The complainant had paid an amount of Rs.35,000/- for his treatment to the OP No.2. The complainant lodged the claim with the OP No.1 and submitted all the necessary documents and requested for reimbursement of the claim but OP did not pay any heed to the request of complainant. On 30.05.2019, the complainant received a letter from the OP No.1, vide which claim of the complainant has been repudiated, without any cogent reason. In this way there was deficiency in service on the part of the OP no.1. Hence this complaint.

2.         On notice, OPs appeared. OP no.1 filed its separate written version raising preliminary objections with regard to locus-standi; maintainability; cause of action and concealment of true and material facts. On merits, it is pleaded that the OP no.1 had issued a health insurance policy in question to the complainant for a sum insured of Rs.5,00,000/- subject to policy terms and conditions.  A cashless request was received from the OP No.2 with reference to complainant’s hospitalization w.e.f. 10.05.2018.  As per pre-auth form, complainant was diagnosed with Pre-syncope and Headache.  Alongwith Pre-auth form, hospital also sent medical documents and reports of complainant.  As per the documents received, the complainant is a case of hypertension.  Therefore, company sent a Query letter dt. 11.05.2019 to the hospital and asked for certain documents.  As no required documents were received from the hospital/complainant, therefore, company rejected request vide Denial letter dt. 12.05.2019 and asked the complainant to file for reimbursement alongwith supported documents.  Another query reply was received from the hospital.  Company again reviewed the reply received and asked the complainant to file for reimbursement vide Denial letter dated 13.05.2019.  After perusal of the documents sent by the complainant, the OP company denied the Reimbursement claim vide Claim Denial Letter dated. 30.05.2019 with the following observation as admission for Investigation and Evaluation is not covered under Policy benefit under Clause 34.2(1) read with Annexure-II (71) and the insured could have been managed on OPD basis.

“As per the submitted documents need for the hospitalization was not justified as the treatment could have been taken on OPD basis and admission is only for investigation and evaluation purpose only.  Hence, we regret to inform you that your claim is rejected”. 

There is no deficiency in service on the part of OPs.  The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             OP No.2 filed the written version raising preliminary objections with regard to locus-standi; maintainability; there is no cause of action with respect to “SANJEEV BANSAL CYGNUS HOSPITAL (Op No.2).  There is no allegation with respect to OP No.2 in the whole complaint.  The patient Mr. Rajesh Singla was admitted to rule out the possibility of Cerebro Vascular Accident as per the symptoms of bifrontal headache since 15 days with dizziness with vertigo with feeling of fall.  Patient had history of hypertension.  Patient was initially treated with pantoprazole, tramadol, pregabalin.  Investigations done were CBC/RFT/LFT/Echo/Cardiology consultation.  On systematic examination neurological N was revealed.  Tentative diagnosis was made of CVA.  Final diagnoses was Headache.  Patient was treated as per symptoms by Dr. Vardan-Consultant Neurosurgeon & Dr. Ranvish-Cardiologist.  There is no deficiency in service on the part of answering OP no.2 and prayed for dismissal of complaint.

4.             Parties then led their respective evidence.

5.             Complainant tendered into evidence his affidavit Ex.C1, copy of health card Ex.C2, copy of bill Ex.C3, copy of discharge summary E.C4, copy of discharge card Ex.C5, copy of letter Ex.C6, copy of claim denial letter dt. 30.05.2019 Ex.C7 and thereafter, closed the evidence on 05.02.2021 by suffering separate statement.

6.             On the other hand, OP no.1 tendered into evidence affidavit of Tejinder Singh Ex.OP1/A, policy certificate Ex.OP1, proposal form Ex.OP2, policy terms and conditions Ex.OP3, cashless from Ex.OP4, query letter Ex.OP5, reminder letters dated 07.03.2019 and 08.03.2019 Ex.OP6 and Ex.OP7, denial letter dated 13.03.2019 Ex.OP8, cashless form II Ex.OP9, query letter dated 11.03.2019 Ex.OP10, Denial letter dated 12.05.2019 and 13.05.2019 Ex.OP11 and Ex.OP12, claim form Ex.OP13, Doctor prescription Ex.OP14, discharge summary Ex.OP15, final bill Ex.OP16, investigation report Ex.OP17, repudiation letter dated 30.05.2019 Ex.OP18 and closed the evidence on 25.03.2021 by suffering separate statement.

7.             OP no.2 tendered into evidence affidavit of Dr. Vardan Kulshreshtha Ex.OP2/A and closed the evidence on 25.08.2021 by suffering separate statement.

8.             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.

9.             Learned counsel for complainant, while reiterating the contents of the complaint has argued that complainant purchased a health insurance policy from OP no.1. In the month of May, 2019 the complainant suffered from continuous headache, dizziness and other problems due to which he visited the Sanjeev Bansal, Cygnus Hospital, Karnal i.e. OP No.2.  After thorough check-up, the complainant was got admitted on 10.05.2019 and discharged on 13.05.2019. Complainant spent Rs.35,000/- on his treatment. After discharge from the hospital complainant applied for reimbursement of the claim with the OP but OP did not pay any claim and repudiated the same on the false and frivolous ground. Hence, prayed for allowing the complaint.

10.           Per contra, learned counsel for OP no.1 while reiterating the contents of the written version, has vehemently argued that complainant is a case of hypertension.  Therefore, OP sent a Query letters dt. 11.05.2019 to the hospital and asked for certain documents.  As no required documents were received from the hospital/complainant, therefore, company rejected request vide Denial letter dt. 12.05.2019 and asked the complainant to file for reimbursement alongwith supportive documents. Company again reviewed the reply received and asked the complainant to file for reimbursement vide Denial letter dated 13.05.2019.  After perusal of the documents sent by the complainant, the OP company denied the Reimbursement claim, vide Claim Denial Letter dated. 30.05.2019 with the observation that the insured could have been managed on OPD basis. Hence, prayed for dismissal of the complaint.

11.           Learned counsel for OP no.2, while reiterating the contents of the written version, has argued that there is no allegation with respect to OP No.2 in the whole complaint. Hence, prayed for dismissal of the complaint against him.

12.           Admittedly, the complainant has obtained a Health insurance policy. It is also admittedly complainant was admitted in Sanjeev Bansal, Cygnus Hospital, Karnal, during the subsistence of the insurance policy. It is also admitted that OP no.2 i.e. Doctor of Sanjeev Bansal Cygnus Hospital, Karnal has charged Rs.37,626/- from the complainant for his treatment. After discharge from the hospital complainant applied for reimbursement of the claim with the OP no.1 but OP no.1 did not pay the claim and repudiated the same, vide repudiation letter Ex.OP18 dated 30.05.2019 on the ground that:-

        “As per the submitted documents need for the hospitalization was not justified as the treatment could have been taken on OPD basis and admission is only for investigation and evaluation purpose only. Hence, we regret to inform you that your claim is rejected.

Benefit not covered in policy”.

13.           The rejection of claim of complainant on the abovesaid ground taken by the OP no.1 is not at all justified and reasonable because the treating doctor considered for admission of the complainant in the hospital for treatment. The OP has taken almost arbitrarily ground in letter dated 30.05.2019, as on one hand it is saying that hospitalization was not justified as the treatment could have been taken on OPD Basis and at the same time, it is saying that admission is only for investigation and evaluation purpose only. The treating doctor considered it necessary to get admitted the complainant in the hospital for treatment of complainant and the OP cannot say that hospitalization was not justified. The treating doctor as per standard medical protocol considered it necessary for admission of complainant in the hospital and thereafter to actually diagnose the disease got conducted investigation and therefore, OP is not justified in denying the genuine claim of the complainant. In this regard we can rely upon the observation of the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) III in which it has been held as under:-

        “It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff nowadays, but are not keen and are found to be evasive to discharge their liability. In large number of cases the Insurance companies made 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 doted 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 clause of the policy, but would adopt methods which would not be governed by the strict condition contained in the policy.

14.           The perusal of the evidence of the OP no.1 reveals that OP no.1 furnished the affidavit of Tejinder Singh working in the capacity of Manager-Legal at Religare Health Insurance Co. Ltd., who has deposed in terms of pleas taken in the written statement but he has not uttered a single word that how he found the opinion that no hospitalization was required for the insured. The OP no.1 has also neither placed on file any record of the TPA nor any opinion of the expert doctor, who examined the reports of insured. It was need of the patient, who was suffering at the time when he got admission in the hospital and he remained there for such a period and it was not the observer who has to observe that whether any admission is required or not. Since, the OP no.1 has failed to place on record any opinion of the expert nor has furnished affidavit of any such expert, who has examined and investigated the reports of the insured, therefore, the plea of the OP no.1 appears to be devoid of merits and OP no.1 has arbitrarily and illegally rejected the claim of the complainant.

15.           Hence, in view of the above discussion and facts and circumstances of the case, we are of the considered view that act of OP no.1 while repudiating the claim of the complainant amounts to deficiency in service and unfair trade practice, which is otherwise proved genuine.

16.           As per detailed final bill Ex.OP16, complainant has spent Rs.37636/- on his treatment. This fact is also admitted by OP no.2 Hence, the complainant is entitled for the said amount alongwith compensation and litigation expenses.

17.           The complaint qua the OP no.2 stands dismissed.

18.           In view of the above discussion, we allow the present complaint and direct the OP no.1 to pay Rs.37,636/- to the complainant alongwith interest @ 9% per annum from the date of repudiating of the claim till its realization. We further direct the OP no.1 to pay Rs.10,000/- 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:13.10.2021

                                                                       

                                                                    President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

       

                         (Vineet Kaushik)              

                            Member