Punjab

Fatehgarh Sahib

CC/227/2020

Jagninder Singh - Complainant(s)

Versus

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

Sh Harpreet Singh Bhutta

11 Apr 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL

                            COMMISSION

                      FATEHGARH SAHIB.

                                                             

Consumer  Complaint No.	:	CC/227 of 2020
Date of Institution	:	02.11.2020
Date of Decision	:	11.04.2023

 

 

Jagninder Singh  aged about 64 years son of son of Sh. Rattan Singh resident of House no.68, Sun City colony , Khamanon, District Fatehgarh  Sahib.

 

                                                                                                               …………....Complainant

                                                Versus

 

1. Religare Health Insurance Company Limited, Branch office: GTB Market, Khanna, Tehsil Khanna, District Ludhiana through its branch Manager.
2.  Religare Health Insurance Company Limited, 3^rd Floor, Roa Mother Singh Complex, Vipul Tech Square Tower, Golf Course Road, Sector 43,Gurugram-122009 (Haryana) through  its authorized signatory/M.D
3. Punjab National Bank,  Branch officer : Ludhiana- Chandigarh Road, Khamanon, Tehsil Khamanon, District Fatehgarh Sahib through its Branch Manager

 

..………....... Opposite Parties

 

 

Complaint under Section 35 of Consumer Protection Act 2019

 

 

Quorum

Sh. S.K. Aggarwal, President

Ms. Shivani Bhargava, Member

Sh. Manjit Singh Bhinder, Member

 

Present: Sh.Harpreet Singh Bhutta, counsel for complainant.

              Sh.Amit Gupta, Counsel for OPs no.1 and 2

    OP no.3 Ex-Parte vide order dated 25.2.2021

 

The  complaint has been filed against the OPs (opposite parties)  under Section 34 of Consumer Protection Act-2019 alleging deficiency in service with the prayer for giving direction to the OPs to pay Rs.2,24,279/-  as insurance claim, to pay Rs.1,00,000/- on account of mental agony and litigation expenses.

1. The complainant purchased a health insurance Policy from OPs in 2018 through Punjab National Bank. The  complainant was issued a health insurance Policy  namely  Group Care PNB bearing Policy no.11561922 with certificate Insurance no.12853658 covering the complainant and his spouse  with effect from 12.8.2018 till  11.8.2019 for sum insured  of Rs.5,00,000/- subject to policy terms and conditions.  The Policy was again renewed  from 12.8.2019 till 11.8.2020. On 16.6.2020 , the complainant suffered heaviness, pain in chest and was admitted in Gracian hospital, Mohali and discharged on 18.6.2020.  The complainant paid Rs.2,24,279/- to the said hospital .  Thereafter, the complainant  got lodged  the Medical claim with the OPs for reimbursement. The OPs  repudiated the claim  vide letter dated 28.7.2020. Hence this complaint.
2. Notice of the complaint was given to the OPs through registered Post OPs no.1 and 2 appeared through their Counsel  and filed  written version. OP no.3 did not appear despite service of summons as such OP no.3 was proceeded against Ex-Parte for non appearance vide order dated 25.02.2021.
3.      The complaint has been contested by the OPs and they  filed written version jointly  by raising preliminary and legal objections.   Written version  was filed on behalf of  Care Health Insurance  Ltd  formerly  known as  Religare Health Insurance Co. Ltd. The complainant  approached the OPs no.1 and 2  for reimbursement of claim . The OPs raised a query vide letter dated 16.7.2020 and asked to provide the requisite documents and the complainant provided the same.  Upon perusal of the medical documents as provided by the complainant, it came to the light that the complainant is suffering from Type 2 diabetes (DM). It is specifically mentioned in the policy  that any claim arising out of Hypertension and Diabetes shall not  be  admissible during 24 consecutive months from the cover start date.  Therefore, the OPs  rejected the claim vide letter dated 28.7.2020. Hence,  prayer for dismissal of complaint  with cost has been made.
4. The complainant in support of his complaint tendered in evidence his  affidavit Ex.CW1/1,  and  Photo copies of documents i.e ExC1 certificate of insurance  no.12853658, Ex.C2 Member ID card, ExC3 and Ex.C4 premium acknowledgement , Ex.C5 Discharge slip,   Ex.C6 payment receipts,  Ex.C7 claim denial letter dated 28.7.2020, Ex.C8 legal notice dated 21.9.2020,  Ex.C9 and  Ex.C10 postal receipts. In rebuttal the OPs tendered Ex.OP1/A affidavit  of Sahil Chauhan , Legal Manager, Care Health Insurance, Gurgaon,  Ex.OP1 free lock period letter along with  terms and conditions, Ex.OP2 letter dated 14.8.2019 of renewal of certificate of Insurance no.12853658,  Ex.OP3 letter dated 17.8.2020 ,  Ex.OP4  receipt of hospital ,  Ex.OP5 claim form ,  Ex.OP6 discharge slip of hospital, Ex.OP7 medical bill , Ex.OP8 medical reports of Lab., Ex.OP9 letter dated 16.7.2020, Ex.OP10  letter dated 16.7.2020 along with record,   Ex.OP11 claim denial letter,  Ex.OP12 legal notice,  Ex.OP13 reply of legal notice and closed their evidence.
5.   Heard. Entire record has been perused.
6.   From  the perusal of the record on file, we find that complainant spent Rs.2,24,279/ on his treatment vide Ex.C6. The Ops repudiated the claim on the ground that complainant is  suffering from Type 2 diabetes (DM) and there is  2 years  waiting period for DM ,  HTN and  its  related complication vide Ex.OP11.   Complainant suffered all of sudden chest pain  and  pain in both  shoulders. Complainant got admitted in hospital on 16.6.2020. Cardiologist performed angioplasty on same day and stent was  inserted to remove the blockage from the heart vessels vide Ex.C5. It is not a hard and fast rule that every person having Mellitus-II diabetes would  necessarily suffer from a cardiac disease. There was no evidence let in by the Ops to show that Diabetes Mellitus  type-II was the cause of the heart surgery . There was no proximity between  heaviness in chest & Diabetes. If the insured suffers a sudden sickness or ailment which is not expressly excluded  under the  Policy , a duty is cast on the insurer to indemnify the insured there under . Insurance Company rejected his claim on the ground that any claim arising out of hypertension and  diabetes  shall not be  admissible  during 24 consecutive months from  the cover start date. On 16 June , 2020, complainant  got done his heart surgery and waiting  period of 2 years  as  mentioned in Policy completed on 11 August, 2020.  Insurance Companies should not be  hyper technical  while deciding the claim. Insurance Company rejected his claim just before one & half month of completion of 2 years of his Policy. Rejection of claim purely on technical ground will  result in Policy holder’ loosing confidence in Insurance Companies and giving rise the excessive litigation. Insurance companies should not  reject genuine claims . Repudiation of claim  was wholly unwarranted  and devoid of any merit. Therefore, OPs no.1 and 2 are held  liable  for deficiency in service. OP no.3 is Proforma OP.
7.   As  a corollary of our above discussion, the present complaint is partly allowed. Therefore,   OPs no.1 and 2  i.e care Health Insurance  Co. Ltd.  formerly known as Religare Health Insurance Co. Ltd. are  directed as under:-

[a] To pay jointly and severally Rs.2,24,279/- to the complainant along with interest@ 6% P.A from the date of filing of complaint within 30 days, failing which interest @ 9% P.A. shall be payable.    

[b] ComplianceTo pay Rs.15,000/-compensation for harassment and litigation charges to the complainant.

Compliance of the order be made by the OPs no.1and 2 within 30 days from the date of receipt of certified copy of this order. Failing which the complainant shall be entitled to recover the above said amount through legal process. The complaint could not be decided within the statutory period due to pandemic of Covid-19 and paucity of staff. Copy of this order be sent to the complainant and the OPs as per rules. File be consigned to record Room.

       Pronounced 11 April 2023

                                                           

                                                                      (S.K. Aggarwal)

                                                                              President

                                                                    

    

                                                                             (Shivani Bhargava)

                                                                              Member

 

                                                                             ( Manjit Singh Bhinder )

                                                                                   Member