Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 19
Instituted on : 10.01.2019.
Decided on : 06.10.2022.
Dr. Ramesh Jain s/o Sh. J.M.D.Jain R/o Kath Mandi, District Rohtak.
………..Complainant.
Vs.
- Yogender Chauhan, The Branch Manager Religare Health Insurance Company Limited/Religare Securities Ltd. Ground Floor, Ashoka Plaza, Delhi Road, Rohtak.
- The Manager Religare Health Insurance Company Limited 5th Floor, 19 Chawla House, Nehru Place New Delhi-110019.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR. VIJENDER SINGH, MEMBER
Present: Sh. Abhishek Chaudhary, Advocate for the complainant.
Sh. Puneet Chahal, Advocate for opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case as per complainant are that he had obtained a health insurance policy no. 10422834 dated 29.10.2015 from opposite parties and the same is continuing till date. Complainant has been paying yearly installment of about Rs.23,000/- since 2015 and has paid an amount of Rs.24000/- for the year 2018-19. On 16.10.2018 complainant all of a sudden, developed chest pain so he firstly consulted a local doctor, who gave some medicines but the complainant could not get any relief. Thereafter he reported to Nobel Heart & Super Specialty Hospital where after investigation, doctor told him that there is blockage in 3 major vessels in the heart and advised stent for the remedy of this disease and he followed the advised of the concerned doctor. It is further submitted that complainant remain admitted in Noble Heart & Super Specialty Hospital for more than 24 hrs. where he came to know that this hospital is on panel of opposite party so complainant submitted card of opposite party which was issued by them. On 17.10.2018, one person from opposite party came and taken all relevant original documents from complainant as well as from the hospital. After some time complainant came to know that opposite parties declined the claim of cashless facility for complainant vide their letter dated 18.10.2018 on the ground that : “As per requirement past treatment details not provided so pre existing nature of ailment could not be ruled out. Hence cashless facility denied under non-submission of required necessary documents”. The complainant came to know that this decline was made by the company on the ground that the concerned hospital at one place mentioned that there is history of hypertension in the past where at many places it has been mentioned that there is no history of hypertension or diabetes. In this regard a separate letter was also issued by Dr. Manoop Mittal declaring that in the treatment papers of my client, the reference at one place of past history of hypertension has been wrongly mentioned and the same be ignored. The opposite party had given several times assurance that when the right information will reach to their concerned office they will release the payment qua complainant bill. The complainant approached opposite party many times but all in vain. Hence this complaint and it is prayed that opposite party may kindly be directed to reimbursement the claim amount of Rs.1,55,875/- alongwith interest and also to pay Rs.1,00,000/- as compensation and litigation expenses to the complainant as prayed in relief clause.
2. Notice of the present complaint was issued to the opposite parties. Opposite parties appeared and filed their written reply submitting therein that on receipt of Cashless facility request form alongwith Medical documents opposite party came up-front with the following facts regarding the health status of the complainant i.e. “As per the Patient History and Physical Record dated 16.10.2018 of Noble Heart & Super Specialty Hospital the complainant was specified to be a known case of Hypertension”. Basis above made observation, opposite party sent its Query letters dated 16.10.2018 and 17.10.2018 to the complainant to get the past information pertaining to Hypertension but due to non-receipt of necessary documents for the claim assessment, they were unable to rule out the past history of Hypertension of the complainant. Accordingly, the cashless facility request filed by the complainant was denied for the reasons queries not replied and the same was intimated to the complainant vide letter dated 17.10.2018. It is further submitted that in the event of cashless denial, it is the duty of the complainant to file for the reimbursement claim as the denial of the cashless facility request is not the rejection of the claim. The complainant was required to submit the original documents for the proper assessment of claim in accordance to the policy terms and conditions but the complainant failed to do so. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with costs.
3. Ld. Counsel for the complainant in his evidence has tendered affidavits Ex.CW1/A and Ex. CW2/A and documents Ex.C1 to Ex.C19 and closed his evidence on dated 24.02.2020. On the other hand, ld. counsel for opposite party has tendered affidavits Ex.RW1/A, documents Ex.R1 to Ex.R17 and closed his evidence on dated 12.03.2021.
4. We have heard ld. counsel for the parties and gone through the material aspects of the case very carefully.
5. As per the complainant, he was admitted in the Nobel heart and Super Specialty Hospital Delhi Byepass Rohtak for his treatment on 16.10.2018 under the supervision of Dr. Manoop Mittal. After investigation it was found that 3 major vessels found blocked in the heart and stents were advised for this disease. The complainant followed the advise of the doctor and got further treatment from the above mentioned hospital. An intimation was also given to the respondents officials from where the complainant was insured. The pre authorization of the complainant has been denied by the respondent insurance company vide letter Ex.C17 dated 18.10.2018 on the ground that : “As per required past treatment detail not provided so pre existing nature of ailment could not be ruled out. Hence cashless facility denied under non-submission of required necessary documents. Please file for reimbursement with all supportive documents(not providing exact history and very first consultation letter related to hypertension) rejection remain same”. After receiving this denial of pre authorization, the treating doctor issued a certificate Ex.C6 submitting therein that : “Complainant/Dr. Ramesh Jain was non hypertensive. No past H/O hypertension was there. But in case record file at one place we wrongly mentioned that k/c/o HTN. So please correct the information on year side and please approve the claim”. This certificate has been issued by the treating doctor on 29.10.2018. Thereafter one another certificate was also issued by the treating doctor which is Ex.C7. As per complainant, after receiving this certification, respondent officials have not released the claim of the complainant till date. We have minutely perused the documents placed on record by both the parties. As per discharge summary(C5) the history of present ailment is mentioned as : This patient is non diabetic & non hypertensive. He presented with complaint of ongoing chest pain with sweating since last few hrs. His ECG was suggestive of ST depression in posterior leads and he was admitted for coronary angiography followed by possible PCI”. Moreover under head of past history, “ No significant” is mentioned. The patient was admitted in the hospital on 16.10.2018at 08:23AM and discharged on 17.10.2018 at 04:05 PM and stayed in the hospital for more than 24 hours. The discharge summary has been issued by the treating doctor on 17.10.2018. After perusal of the discharge summary and other documents we came into the conclusion that patient was not suffering from hypertension and there is no history of his ailment regarding HTN or any other ailment. So no any previous treatment record is available with the complainant as he was never treated for any other ailment. So complainant was unable to submit any such document with the insurance company. Moreover the treating doctor filed his affidavit as Ex.CW2/A mentioning therein that : “Complainant had no past history of CAD, Hypertension and Diabetes”. As such the repudiation of the claim by the opposite parties is on baseless grounds and there is deficiency in service on their part. Hence opposite parties are liable to pay the claim amount to the complainant as spent by the complainant on his treatment. As per hospital bill Ex.C13 complainant has spent an amount of Rs.155875/- on his treatment
7. In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite parties to pay the claim amount of Rs.155875/-(Rupees one lac fifty five thousand eight hundred and seventy five only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 10.01.2019 till its realization to the complainant, also to pay Rs.10000/-(Rupees ten thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
06.10.2022.
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Nagender Singh Kadian, President
…………………………………
Tripti Pannu, Member.
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Vijender Singh, Member
