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.173/2018
SH. ANANT RAM SHARMA S/O RISHI RAM
R/O HOUSE NO. 572/33, RAM NAGAR MOHALLA,
KATHMANDI ROHTAK…..COMPLAINANT
Vs.
RELIGARE HEALTH INSRANCE
REGD. OFFICE: 5TH FLOOR, 19 CHAWLA HOUSE
NEHRU PLACE, NEW DELHI-110019 ..….RESPONDENT
Date of Institution-09/08/2018
Date of Order-18/05/2022
O R D E R
MONIKA SRIVASTAVA– President
The complainant has filed the present complaint seeking a direction for OP to pay Rs. 3,56,000/- along with interest at the rate of 18% per annum and Rs. 50,000/- in favour of the complainant and Rs.1,00,000/- towards damages and mental harassment caused to the complainant.
It is the case of the complainant that he had taken a one year family floater health insurance policy from the OP which provided a health cover of Rs.4,00,000/- to the complainant and his family members and it was valid from
23.05.2015 to 22.05.2016. The complainant states that on 22.07.2015 he felt severe pain in his leg, he tried some home treatment for the next few days but since he did not get any relief he approached Sir Ganga Ram hospital on 29.07.2015. The doctor at the said hospital gave some treatment to the complainant and advised him to come again for further examination. The complainant again approached the said hospital after two months. After examination, the doctors this time advised the complainant to get himself admitted for surgery as he was suffering from AortoIliac Occulsive Disease. The complainant was admitted to the same hospital on 13.10.2015 and since the complainant was having cashless facility from OP, Ganga Ram hospital informed the OP about the admission of the complainant in the said hospital. The complainant further states that even after receiving the information and after the visit of some executives of the insurance company, the complainant was told that he could continue treatment in the hospital as the OP would take some time to approve the claim of the complainant. It is stated complainant had to foot the entire bill of the hospital, the bills are annexed with the complaint.
Thereafter, the complainant preferred his claim before the OP along with all the necessary details and was told by the OP to submit consultation slip prior to 29.07.2015. It is stated by the complainant that he kept telling the OP that he had not consulted any doctor prior to 29.07.2015. It is stated by the complainant that the OP ignored the legitimate claim of the complainant theory even though Dr. V S. Bediwho treated the complainant had provided observation and discharge summary. It is stated that inspite of giving the discharge summary and the answer to the query of the complainant, the OP did not process the claim of the complainant.
The complainant had to approach Ombudsman Chandigarh on 22.04.2016 and vide order 16.09.2016 it was observed by the Ombudsman that the insurance
company had arbitrarily closed the claim and the insurance company was directed to process the settlement claim as per the terms and conditions of the policy within 30 days of the receipt of the award. It is the case of the complainant that as the OP Company had agreed before the Ombudsman to depute official investigator to seek necessary clarification from doctor but they did not do so and also did not settle the claim of the complainant within 30 days as per the said order. It is the case of the complainant that OP is indulging in unfair trade practice and has avoided their responsibility of not settling the claim preferred by the complainant.
Per Contra, the OP has stated that the complaint is totally vexatious, misconceived, based on misrepresentation of facts and is not maintainable in law as there is no cause of action which has arisen in favour of the complainant. The OP has not denied the facts leading to this case. It is stated that when they received the documents, a query was raised vide letter dated 13.10.2015 for seeking documents confirming the duration and etiology of the present ailment. It is stated that since they did not receive any response from the complainant they rejected the cashless facility request of the complainant vide letter dated 15.10.2015. When the complainant filed the reimbursement claim bearing number CL No. 90146084 the OP raised a query to Dr. V.S Bedi, no response was received and reminder letters were sent dated 20.12.2015 and 29.12.2015.
The OP has further relied on judgment passed by the Hon’ble Supreme Court in Satwant Kaur Sandhu vs New India Assurance and of the Hon’ble National Commission in ShnyniValsanPombally vs State Bank of India where in these judgments deal with the consequences non-disclosure of material facts.
In the rejoinder, the complainant has mostly denied all the allegations of the OP and has stated that the complainant has provided each and every document which was available with a complainant to the OP at the time of seeking cashless facility.
It is observed from the from the letter of the OP which is exhibit R-6 that the reason for denial was As per submitted documents pre-existing nature of ailment could not be ruled out hence liability of insurer could not be taken at the juncture have and cashless facility is being denied. File for reimbursement with all supportive documents.
The claim of the complainant was rejected vide letter dated 27.04.2016 where in it was stated Query to doctor not received hence closed.
Both the parties have filed their respective reply, rejoinder, evidence affidavits as well as written arguments. Having carefully gone through all the material on record this Commission is of the view that the OP is guilty of unfair trade practice and deficiency in service. It is apparent from the record that the OP does not wish to honour its contractual obligation with the complainant and therefore is looking for a reason to repudiate the claim of the complainant. It is clear from the record of the case that the complainant did not suffer from any co-morbidity and the query which was put to the treating doctor was answered in spite of which the OP has chosen to be ignorant and unfair in its dealing with the complainant. Even the order of the Ombudsman was clear and the undertaking given by the OP before the Ombudsman was also not honoured by them. Therefore, we think it is a fit case where OP should be penalised for causing mental harassment to the complainant for reason which is non-existent.
Therefore, in the facts stated above this Commission directs the OP to reimburse the complainant for a sum of Rs. 3,56,000/- along with interest at the rate of 7%p.afrom the date of closing the claim till realization and further pay sum of Rs. 50,000 towards mental harassment and Rs.25,000/- as litigation
expenses within a period of three months from the date of this order failing which the OP would be liable to pay the entire sum at the rate of 10% p.a from the date of filing of the complaint till realization.
File be consigned to the record room after giving a copy of the order to the parties. Order be uploaded on the website.
(Dr. RAJENDER DHAR) (RASHMI BANSAL) (MONIKA SRIVASTAVA)
MEMBER MEMBER PRESIDENT
