CONSUMER DISPUTES REDRESSAL COMMISSION – X

GOVERNMENT OF N.C.T. OF DELHI

Udyog Sadan, C – 22 & 23, Institutional Area

(Behind Qutub Hotel)

New Delhi – 110016

             Case No.116/2019

Jitender Singh

S/o Ramesh Chandra

R/o Village Gijhore Sector 53 Noida

Gautam Budh Nagar, U.P.201301         . ...COMPLAINANT

Vs.

Religare Health Insurance

R/o 5^th Floor, 19 Chawla House

Nehru Place, New Delhi-110019                                         .…..RESPONDENTS

                           Date of Institution-31.05.2019

   Date of Order-13.09.2024

           O R D E R

RITU GARODIA-MEMBER

1.  The complaint pertains to deficiency in service in rejecting the insurance claim of the complainant.

2. The facts as stated in complaint are that the complainant was insured with OP vide policy No.12418959 valid for a period from 01.05.2018 to 30.04.2019.  The complainant suffered from fever, chills and weakness for 5 days and was admitted in ARTI Hospital and Trauma Centre, Noida from 30.09.2018 to 04.10.2018.

3. The hospital raised a bill of Rs.36,900/-  for which a claim for re-imbursement was lodged with OP.  The OP, then, raised a deficiency letter dated 21.10.2018 asking for admission notes and history sheet.  OP has not paid the claim till date. 

4. The complainant prays for refund of Rs.36,900/- alongwith interest @ 18%, Rs.25,000/- towards mental agony and harassment and Rs.15,000/- towards litigation.

5. OP in its reply submits that a policy namely Care (Floater) was issued to the complainant for a sum insured of Rs.5,00,000/-.

6. OP submits that as per discharge summery, the complainant was diagnosed with Sepsis, Malaria and AGE.  OP started a claim investigation and found some discrepancies.  OP raised query letters dated 21.10.2018, 24.11.2018, 29.11.018 and reminder dated 09.12.2018 seeking documents.

7. Query letters dated 24.11.2018 were also sent to Dr. Ashish Kumar Jaiswal (M.D. Chest) and Dr. Chakshu Bansal (MD Path) seeking reply to various discrepancies and clarifications. It is alleged that the discrepancies were noted in the line of treatment of the doctor, diagnosis, injections, medicines prescribed, indoor case papers and inflation of bill.  OP didn’t receive any reply from the above doctors despite a reminder, hence the claim was denied for deficiency not replied.

8. The complainant has filed evidence by way of affidavit and exhibited the following documents

1. Copy of policy is exhibited as Ex CW-1/A.
2. Copy of Aadhar card is exhibited as Ex CW-1/B.
3. Copy of discharge summery is exhibited as Ex CW-1/C.
4. Copy of receipt is exhibited as Ex CW-1/D.
5. Copy of reports is exhibited as Ex CW-1/E.
6. Copy of deficiency letter is exhibited as Ex CW-1/F.
7. Copy of courier receipt is exhibited as Ex CW-1/G.

9. OP has filed evidence by way of affidavit and exhibited the following documents

1. Copy of online proposal form is exhibited as Ex.R1.
2. Copy of policy terms and conditions is exhibited as Ex.R2.
3. Copy of claim form is exhibited as Ex.R3.
4. Copy of letters are exhibited as Ex. R4, 5,6, & 7.
5. Copy of query reply is exhibited as Ex.R8.
6. Copy of letters are exhibited as Ex.R9, 10 & 11.
7. Copy of hospitalization papers are exhibited as Ex.R12.

10. The Commission has considered the documents and material available on record.  It is admitted by both the parties that the complainant was insured with OP.  It is also admitted that the complainant was hospitalized from 30.09.2018 to 04.10.2018 and a claim was filed with OP.

11. OP has sent a deficiency letter dated 21.10.2018 asking for following documents:

“Complete indoor case papers with admission notes, history sheet, doctors notes, nursing notes and vital chart with vital and treatment chart.”

12. The complainant has annexed bills/receipts by ARTI Hospital and Trauma Centre indicating that Rs.36,900/- has been paid by the complainant.  The complainant also filed discharge card, investigation reports, indoor case papers and the breakup of hospital bills.

13. OP sent deficiency letters dated 24.11.2018, 29.11.2018 and 09.12.2018 asking the complainant to reply to enclosed “queries to the doctor”. The complainant responded to this letter vide letter dated 11.12.2018 stating that he had taken the “Query to doctor” to the hospital who refused to give any reply. 

14. OP repudiated the claim vide letter dated 30.12.2018 stating that “reply of query to doctor not provided”.

15. The query sent to the doctor is a detailed five-page document, inquiring about the treatment administered prior to admission, the treatment plan, reasons for not taking alternate treatment plan, diagnosis, reasons for prescribing medicines and investigations, costs incurred, stationery used, doctors employed and the dates of their employment. Thus, it is evident that the OP sent extensive queries to the hospital, which the hospital has not responded to. The complainant has stated that he is not responsible for the hospital's failure to reply to the insurance company's queries.

16. Hon’ble Supreme Court of India in Gurmel Singh vs Branch Manager, National Insurance Co Ltd. AIR 2022 SC 2486 has observed-

4.1 In the present case, the insurance company has become too technical while settling the claim and has acted arbitrarily. The appellant has been asked to furnish the documents which were beyond the control of the appellant to procure and furnish. Once, there was a valid insurance on payment of huge sum by way of premium and the truck was stolen, the insurance company ought not to have become too technical and ought not to have refused to settle the claim on non­-submission of the duplicate certified copy of certificate of registration, which the appellant could not produce due to the circumstances beyond his control. In many cases, it is found that the insurance companies are refusing the claim on flimsy grounds and/or technical grounds. While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control.

17. In the present case, OP is requesting the complainant to obtain replies to its queries from the treating doctor. The complainant has clarified that the treating hospital and doctors have refused to answer the query. It is evident that the OP is asking the complainant to provide documents that are beyond his control. As discussed by the Hon'ble Supreme Court in Gurmel Singh (supra), the OP should not have refused the claim based on the non-submission of documents that are beyond the complainant's control.

18. Hence we find OP guilty of deficiency in service in repudiating the claim of complainant and direct him to pay-

1. Rs.36,900/- with 9% interest from date of rejection i.e.30.12.2018.
2. Rs.10,000/- as compensation for mental harassment and physical inconveniences.
3. Rs.50,000/- towards litigation cost.

19.  Order be uploaded within 30 days and file be consigned to record room.