Chandigarh

DF-I

CC/344/2019

Sukrita Goyal - Complainant(s)

Versus

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

Navneet Jindal Adv.

02 Mar 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/344/2019
Date of Institution	:	08/05/2019
Date of Decision	:	02/03/2021

 

Sukrita Goyal w/o Sh. Parshant Goyal aged about 34 years currently resident of House No.48, First Floor, Sector 21-A, Chandigarh 160022.

Permanent r/o

Raman Mandi, Tehsil Talwandi Sabo, Distt. Bathinda, Punjab 151301.

… Complainant

V E R S U S

1. Religare Health Insurance Company Limited, Chandigarh, SCO 56-58, Top Floor, Sector 9-D, Chandigarh through its Director/Manager.
2. Religare Health Insurance Company Limited, GYS Global, Plot No.A3, A4, A5, Sector 125, Noida U.P. through its Director/Manager.
3. Director, Religare Health Insurance Company Limited GYS Global, Plot No.A3, A4, A5, Sector 125, Noida U.P.

… Opposite Parties

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                  

ARGUED BY	:	Sh. Navneet Jindal, Counsel for complainant
	:	Sh. Mohit Garg, Vice Counsel for Sh. Paras Money Goyal, Counsel for OPs

Per Rattan Singh Thakur, President

1.      Averments are, first time in December 2015, complainant had taken a health insurance policy from the OPs which was thereafter got renewed and premium is being paid for the last four years.  The policy covers hospitalization and single claim includes pre-hospitalization expenses which are incurred by the patient/ claimant within 30 days prior to the hospitalization and post hospitalization expenses incurred during next 60 days can also be claimed. Her case is, she sustained rashes in her skin in large number for which she consulted a hospital and was hospitalized at Bathinda, being permanent resident of Bathinda, and the disease was diagnosed as Idiopathic Thrombocytopenic Purpura (ITP) which is on account of acute condition of platelets count. She remained hospitalized from 17.10.2018 to 24.10.2018. Firstly she was taken to Bansal Hospital where she underwent various tests.  Later on, she filed a claim i.e. actual expenses paid to the hospital pre and post expenses of the treatment as per the policy document.  The total amount claimed was ₹2,100/- as pre-hospitalization expenses excluding the ambulance charges of ₹2,400/- ₹50,743/- as expenses incurred during hospitalization and ₹2,050 which were incurred till 31.10.2018. In total the claim raised was ₹57,293/-. On being submitted to the OPs for reimbursement, the claim was rejected which according to the complainant amounts to deficiency in service and unfair trade practice on their part. Averred the branch office of the OPs where the bill was submitted falls within the territorial jurisdiction of this Commission.  Hence, the present consumer complaint for directing the OPs to pay the claim of ₹57,293/- alongwith interest plus ₹13,153/- to be raised as post hospitalization claim alongwith compensation of ₹30,000/- and litigation expenses of ₹20,000/-
2.     OPs contested the consumer complaint, filed their joint written reply and admitted the complainant has taken the health insurance policy and the sum assured is ₹5.00 lakh and she has been continuously renewing it from 3.12.2015 till 2.12.2019. Their opposition is hospitalization of the complainant was at Punjab Cancer Care & Research Centre, Bathinda and total amount of ₹57,293/- was claimed including the pre and post hospitalization expenses. However, on queries being raised viz. to supply detailed original discharge summary; detailed original final bill and complete indoor case papers with admission notes, history sheet etc., the same were not supplied.  Averred, as per clause 6 of the policy document, it was agreed the company shall be provided with complete necessary documentation and information which the company has requested to establish its liability for the claim, its circumstances and its quantum.  Maintained, due to non supply of these documents, claim was rightly repudiated.  On these lines, the cause is sought to be defended.
3.     Replication was filed by the complainant and averments made in the consumer complaint were reiterated. She has also reiterated all queries were replied alongwith documents and there is no reason to justify the repudiation of the claim.
4.     Parties led evidence by way of affidavits and documents.
5.     We have heard the learned counsel for the parties and gone through the record of the case, including the written arguments. After scanning of record, our findings are as under:-
6.     The admitted facts are, complainant has taken the policy in question right from the year 2015 and is getting it renewed on payment of premium and lastly it was renewed upto 2.12.2019. There is no denial of these facts as per recitals contained in the joint reply furnished on behalf of the OPs. The sole attack of the OPs is the documents asked for were not supplied, therefore, the claim was not processed.
7.     We shall refer here, on the queries being raised, the same were replied through the medium of email by the complainant. The OPs responded to the documents and time and again as per Annexure C-9 dated 30.11.2018 and 6.12.2018 reiterated the claim was currently under process.  Not only this, at page 6, the OPs had further responded on 14.12.2018 that they had received the reply and the claim No.90759481-00 is currently under process. The email sent by Sh. Parvesh Goyal, is at page 7 and vide Annexure C-10 dated 18.12.2018, the main claim was rejected. Hence, the pre and post hospitalization claim was also rejected.
8.     Now the OPs have not given any clarification how the reply furnished by the complainant to the queries raised by OPs was not found satisfactory by them. No such reasons at all were assigned by the OPs to reject the replies furnished by the complainant to the queries raised by the OPs.
9.     The complainant persistently and consistently for the last four years preceding to the lodgement of the present claim had been paying the premium i.e. a large amount to the OPs and when the first time she made a claim for reimbursement of the treatment expenses, it is being ignored and rejected by the OPs without any rhyme or reason.  The OPs were simply to see and scrutinize the claim was honest and bonafide one and had been preferred genuinely for the expenses incurred on the treatment. Rather by putting in the queries they started examining and questioning what treatment suited to the complainant and what not and assumed the role of a physician or say a doctor which was not their business at all. They were simply to see the genuineness of the claim preferred.
10.     Now we will scrutinize whether the record produced by the complainant makes us to believe the claim being genuine one or not.  If it is so, the claim is liable to be accepted.  We shall refer to Annexure C-3 i.e. detail of bills submitted by the complainant to the OPs.  Total claim which was verified by the Punjab Cancer Care & Research Centre, Bathinda is ₹50,743/- and it was verified by Dr. Anuj Kumar Bansal, MD, Punjab Cancer Care & Research Centre, Bathinda.  It is so made out with the Xerox copy of the medical claim submitted and it was verified by the hospital. Not only this, even there is a prescription slip dated 1.10.2018 (at page 31) issued by Dr. Ramji Das Memorial Bansal Hospital, Bathinda vide which the history of the disease was narrated and again there is a investigation report dated 11.10.2018 (at page 33) by Malwa Lab, Bathinda with regard to investigation conducted regarding the blood urea, S. Creatinine, S. Sodium etc. as per details given there.  Besides it, there is a receipt form issued by Punjab Cancer Care & Research Centre and again there is a patient record book of Punjab Hemathology & Cancer Care Centre and numerous receipts annexed therewith. The OPs have not contended these documents annexed with the record are bogus ones and not genuinely issued documents.  It is not the case of the OPs at all.  Now on what basis and what material same was not found genuine has not been disclosed by the OPs.  Rather a draconian letter was written by the OPs that since the documents were not supplied, therefore, it was rejected. These were the documents of treatment and payment made which were not at all forged one even as per the case of the OPs.  Now we find no reasons to discard the claim of the complainant which seems to be reasonable, just and genuine one and repudiation of the claim by the OPs is totally unjust, unfair and tantamounts to unfair trade practice and deficiency in service on the part of the OPs. Post hospitalization claim of ₹13,153/- appears to be not verified by the doctor concerned. Hence, this part of the relief is liable to be declined. 
11.     In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OPs are directed as under :-

1. to pay ₹57,293/- to the complainant alongwith interest @ 8% per annum from the date of repudiation i.e. 18.12.2018 till realization.
2. to pay an amount of ₹15,000/- to the complainant as compensation for causing mental agony and harassment to her;
3. to pay ₹10,000/- to the complainant as costs of litigation.

12.     This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
13.     Certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
02/03/2021	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	Member	President