Chandigarh

StateCommission

A/37/2021

Sukrita Goyal - Complainant(s)

Versus

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

Navneet Jindal Adv.

06 Dec 2021

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

 

Appeal No.	:	37 of 2021
Date of Institution	:	15.04.2021
Date of Decision	:	06.12.2021

 

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,District Bathinda, Punjab 151301.

…..Appellant/Complainant.

Versus

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. through its Director/Manager.

…Respondent/Opposite Parties.

 

Appeal under Section 41 of the Consumer Protection Act, 2019.

 

BEFORE: JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT.

                MRS. PADMA PANDEY, MEMBER.

                MR. RAJESH K. ARYA, MEMBER.

 

Argued by: (Through Video Conferencing)

 

Sh. Navneet Jindal, Advocate for the appellant.

Ms. Niharika Goel, Advocate for the respondents.   

 

PER  RAJESH  K.  ARYA, MEMBER

                This appeal has been filed by the complainant (appellant herein) for modification of order dated 02.03.2021 passed by District Consumer Disputes Redressal Commission-I, U.T., Chandigarh (in short ‘the District Commission’), vide which, his consumer complaint bearing No.344 of 2019 was partly allowed against the opposite parties (respondents herein) whereby the opposite parties were directed to pay Rs.57,293/- to the complainant along with interest @8% p.a from the date of repudiation i.e. 18.12.2018 till realization besides awarding Rs.15,000/- and Rs.10,000/- towards compensation and costs of litigation. The order was to be complied with within a period of 30 days, failing which, the amounts of Rs.57,293/- and Rs.15,000/- as compensation were to entail interest @12% p.a. from the date of order till realization.

2.             It may be stated here that the complainant had taken a health insurance policy, renewed from time to time, since four years. The said policy covered hospitalization and single claim including pre-hospitalization within 30 days prior to hospitalization and post-hospitalization expenses incurred during next 60 days. The complainant got hospitalized at Bathida for the period from 17.10.2018 to 24.10.2018, where she was diagnosed as Idiopathic Thromocytopenic Purpura (ITP). She filed claim of Rs.57,293/- with the opposite parties for the hospitalization period and Rs.13,153/- for post-hospitalization. However, the claim was rejected by the opposite parties vide letter dated 18.12.2018, Annexure                 C-5/Annexure OP-7. It was the case of the opposite parties that the complainant failed to supply detailed original discharge summary, detailed original final bill, complete indoor case papers & original cash paid receipts against final bill, which led to rejection of her claim.

3.             The District Commission, after minutely going through the material available on record and pleading of the parties, accepted the complaint of the complaint so far as her claim for Rs.57,293/- was concerned.

4.             The only modification in the impugned order, as sought by the appellant/complainant, by filing this appeal, is with regard to post-hospitalization claim of Rs.13,153/- incurred for the period from 01.11.2018 to 08.12.2018, which the District Forum did not award. It has been stated in Para 2 of the appeal that the second claim of Rs.13,153/- is supported by receipts and all the medical record. It was further stated that the above period falls within the period of 60 days post-hospitalization, as such, the respondents are liable to pay the said claim also. 

5.             After hearing the counsel for the parties and having gone through the material available on record and the written arguments very carefully, we are of the considered view that the District Forum rightly allowed the claim of Rs.57,293/- vide the order impugned and further, the respondents are also liable to pay the post-hospitalization expenditure incurred by the complainant for the reasons to be recorded hereinafter. Relevant portion of Schedule of Benefit appended to the Policy, Annexure C-1, reads thus:-

“2.

Pre-hospitalization & Post-hospitalization medical Expenses

Pre-hospitalization up to 30 days before & Post- hospitalization up to 60 days after hospitalization.”

6.             Bare perusal of aforesaid benefit at No.2 of Schedule of Benefits makes it abundantly clear that the complainant could claim medical expenses incurred up to 60 days after hospitalization. As the appellant was hospitalized at Bathida for the period from 17.10.2018 to 24.10.2018, as such, she could have claimed medical expenses incurred up-to 23.12.2018, on which date, period of 60 days post-hospitalization came to an end. Undoubtedly, post-hospitalization, she incurred expenditure of Rs.13,153/- for the period from 01.11.2018 to 08.12.2018, which stands corroborated from the receipts placed on record of the District Commission. In our view, the District Forum erred in not allowing this part of the claim relating to post-hospitalization expenditure incurred by the complainant. Thus, in addition to the relief already given by the District Commission, the appellant is also entitled for Rs.13,153/- towards post-hospitalization expenses incurred by her.

7.             For the reasons recorded above, the appeal is accepted and the impugned order dated 02.03.2021 passed by District Commission-I, U.T., Chandigarh is modified in the following manner:-

                The respondents/opposite parties are directed as under:-

1. to pay an amount of Rs.57,293/-and Rs.13,153/- to the appellant/complainant along with interest @8% per annum from the date of repudiation i.e. 18.12.2018 till realization.
2. to pay an amount of Rs.15,000/- to the appellant/complainant, as awarded by the District Commission, for causing mental agony and harassment to her;
3.  to pay Rs.10,000/- to the appellant/complainant as costs of litigation.

8.             This order be complied with by the respondents/opposite parties within a period of 30 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) and (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.

9.             Certified copies of this order, be sent to the parties, free of charge.

10.           The file be consigned to Record Room, after completion.

Pronounced.

06.12.2021.

[RAJ SHEKHAR ATTRI]

PRESIDENT

 

 

(PADMA PANDEY)

        MEMBER

 

 

(RAJESH  K. ARYA)

MEMBER

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