DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi- 110016

Case No.377/2018

Virender Prabhakar

S/o Late Sh. V. K. Prabhakar

R/o A-285 Shivalik

New Delhi- 110017

                                                                                                                        ….Complainant

Versus

Religare Health Ins. Co. Ltd.

D3, P3B, District Centre,

Saket, New Delhi - 110017

        ….Opposite Party

       Date of Institution    :         18.12.2018  

       Date of Order            :         02.03.2022

Coram:

Ms. Monika A Srivastava, President

Ms. Kiran Kaushal, Member

Sh. U.K. Tyagi, Member

ORDER

Member:  Sh. U. K. Tyagi

The Complainant has put in a claim for an amount of Rs.66,418/- towards hospitalization and medical expenses alongwith interest @18% p.a. from the date of payment till realisation; compensation of Rs.1,00,000/- towards harassment, mental pain and sufferings and sum of Rs.35,000/- towards cost of litigation.

                The Complainant obtained a Floater Health Insurance Plan for an annual sum of Rs.5,00,000/- covering the insured as Member and his wife for the period 04.01.2016 to 03.01.2017 from Religare Health Insurance Company Ltd. (hereinafter referred as OP). On 20.07.2016, the Complainant’s wife i.e.
Ms. Neha Kala was admitted in emergency at Fortis Hospital, Vasant Kunj, New Delhi where she was diagnosed with Tetany, Hypocalcaemia with acute Febrile Illness and Hypovitaminosis. The patient remained in hospital for 7 days and was discharged on 27.07.2016. The discharge summary is exhibited as Annexure ‘C-2’.

            The Complainant had approached the OP for cashless claim towards health insurance vide Pre-authorization on 20.07.2016. The OP had rejected the pre-authorization for cashless claim but instead suggested the Complainant for reimbursement post discharge of patient from hospital. Total hospitalisation medical bill of the aforesaid hospital came to Rs.1,49,565/- which was paid by the complainant from his own pocket. The same is exhibited as Annexure ‘C-5’. She was also prescribed some medication and test which rose the total bill to Rs.1,51,124/-. The Complainant put in claim to OP for the reimbursement of said expense of Rs.1,51,124/- and wrote many e-mails which are exhibited at Annexures-7,8 & 9. The OP kept on insisting the submission of some set of information.

            The OP sent a letter 24.01.2017 and e-mail dated 27.01.2017 to the Complainant and treating doctor seeking explanation for the treatment of Ms. Kala. Accordingly, a reply was sent on 15.03.2017 by the treating doctor and Complainant. The said reply was acknowledged by the OP vide e-mail 27.03.2017 sating that “TAT to process reimbursement claim after receipt of query reply in 7 days” which was not adhered to, as maintained by complainant. The true copies of the e-mail are exhibited as Annexure-‘10’.

            The OP made a part payment of Rs.84,705.97/- on 25.07.2017 against the claim of Rs.1,51,124/-. That short payment was not accompanied with any explanation on enquiry in August, 2017 from customer care of the OP, it was informed that the payment of Rs.84,705.97/- was full and final payment and letter regarding deficit payment with reasons shall be sent by the OP. The Complainant, on the conduct of OP has lost faith for the deficit claim of Rs.66,418/-. Hence, the Complaint is before this Commission.

            The Complainant has filed the evidence by way of affidavit alongwith written submission whereas the OP was proceeded exparte vide order of this Commission on 25.04.2019 as  the OP had refused to receive the notice. The same notice was received back in the Commission with the remark “refused”.

This Commission has gone into the entire record made available by the Complainant. The OP has been found lackadaisical and indifferent to some extent in its approach towards the e-mail/letters and matter regarding deficit payment. No reason for short payment was put forth by the OP. Moreover, the OP refused to take the notice of this Commission. It goes to show that the OP has scant regard to the proceedings of this Commission. Further, no explanation/reason was put forth for the deficit payment. This all reflects on the part of OP that he is totally unconcerned for the adherence to the terms and conditions of the contract made between the Complainant and the OP in the form of insurance policy provided to the Complainant. The evidence advanced by the Complainant has acquired the status of incontrovertible evidence in the absence of any counter evidence of the OP.

            Keeping in view of the facts and circumstances of the case as mentioned above, this Commission is of the conscious view that the OP is grossly negligent resulting in deficiency in service. Accordingly, OP is directed to make payment of the deficit amount of Rs.66,418/- within two months from the date of receipt of this order alongwith interest @6% p.a.; Rs10,000/- as compensation towards harassment, mental pain and suffering; Rs.5,000/- as litigation  charges failing which rate of interest shall be levied @9% p.a. till realization of this entire amount.

File be consigned to the record room after giving a copy of the order to the parties. Order be uploaded on the website.