Haryana

Fatehabad

CC/432/2019

Jagdish - Complainant(s)

Versus

Religare Health Insurance - Opp.Party(s)

Manjeet Kajla

17 Apr 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION FATEHABAD.

                                         Sh.Rajbir Singh, President.                                                      Sh.K.S.Nirania and Smt.Harisha Mehta, Members

 

                                                                    C.C.No.432 of 2019.                                                                                            Date of Instt.: 24.10.2019.                                                                                   Date of Decision: 17.04.2023.

Jagdish son of Mahavir resident of village Khabra Kalan Tehsil & District Fatehabad.

                                                                             ..Complainant

                              Versus

1.Religare Health Insurance Company Limited. 5^th Floor, 19, Chawla House, Nehru Place, New Delhi-110019 through its Chairman-cum-Managing Director/ Managing Director.

2.Religare Health Insurance Company Limited Service Branch, Vipul Tech Square Tower-C, Third Floor, Sector- 4, Gold Course Road, Gurugram-122009 through its Divisional Manager/ Authorized person.

3. Religare Health Insurance Company Limited, Branch Office, Shop No.25, Jaat Dharmshala, Fatehabad through its agent Gobind Ram.

                                                                   ..Opposite Parties.

Complaint U/S 35 of the Consumer Protection Act, 2019                                

Present:                 Sh.Manjeet Kajla, Advocate for complainant.                                                        Sh.Sudhir Kumar, Advocate for Ops.                                                                                                                                                                   

ORDER

SH.RAJBIR SINGH, PRESIDENT

1.                                 Brief facts of the present complaint are that the complainant had obtained an insurance policy bearing No.12466695 having validity from 17.05.2018 to 16.05.2021 under care & cover type Floater plan; that he made insurance premium amounting to Rs.67,726/- to Ops for sum assured of Rs.10,00,000/- with ID No.60436977; that the policy in question has been continuing since 17.05.2018; that on 30.08.2019, Yatharath, son of the complainant fell ill and was taken to Balaji Bachon kaa Hospital and then he was taken to Medanta, The Medicity Hospita, Gurgram on 02.09.2019; that son of the complainant was given medicines there with a direction to visit again for conducting operation as well as for needed treatment; that the estimate for operation and further treatment was given to the Ops, but they refused to pay the same; tha operation on the person of Yatharath was conducted and he remained admitted  there as an indoor patient from 16.09.2019 to 20.09.2019; that an amount of Rs.2,69,582/- was spent on the treatment of son of the complainant; that the complainant had submitted all the requisite documents with the Ops for reimbursement of the total amount of Rs.2,69,582/- but despite that the amount has not been released till date. In the end, Rs.25,000/- has been claimed as damages for harassment, mental agony besides cost of treatment in sum of Rs.2,69,582/- alongwith interest @ 18 % per annum.

2.                          On notice, Ops appeared and filed their joint written statement wherein several preliminary objections such as cause of action, locus standi, concealment of material facts from this Commission, maintainability, estopal and jurisdiction etc. have been taken. It has been further submitted that an insurance policy bearing No.12466695 was issued to the complainant covering his spouse and two sons Yatharath and Aditya;  that the complainant had applied for cashless facility for planned hospitalization of Yatharath  at Medanta Hospital, Gurgaon for Left Robotic/ Laparoscopic Pyeloplasty; that after scrutiny of the documents, the claim was rejected vide letter dated 06.09.2019 on the ground, which is reproduced as under:

                             Permanent Exclusion - Robotic Surgery.

2 Year waiting period: Surgery of Genito Urinary System Unless Necessitated by Malignancy.

It has been further submitted that the claim of the complainant has rightly rejected keeping in view the clause 4.1 and 4.2 of the terms and conditions of the policy in question.  Other contentions have been controverted and in the end, a submission was made for dismissal of the complaint.

3.                          In evidence, learned counsel for the complainant has tendered affidavit of complainant Annexure CW1/A and documents Annexure 1 to Annexure 8 and then closed the evidence. On the other hand, learned counsel for the Ops tendered affidavit of Ms.Shreya Chansoria as Ex.RW1/A and documents Annexure OP1 to Annexure OP4.

4.                          We have heard oral final arguments from both sides. We have also perused the case file minutely.

5.                          It is not disputed that the complainant had obtained Care  Cover Floater policy bearing No.12466695 (Annexure 2) having validity for the period from 17.05.2018 to 16.05.2021 for as sum  assured of Rs.10 lacs from the Ops and also paid the premium thereof.  As per the complainant a sum of Rs.2,69,582/- was spent on his treatment/operation of insured Yatharath and as per the terms and conditions of the policy, so obtained, the insurance company had to reimburse the amount spent on the treatment/operation because he was hospitalized during the subsistence of the policy in question but instead of reimbursing the incurred amount, the Ops have repudiated the claim wrongly and illegally. On the other hand, learned counsel for the Ops has argued that keeping in view the exclusion clauses 4.1 & 4.2 of the terms and conditions of the policy; the claim has rightly been rejected.

6.                          The material question which this Commission has to decide is as to whether the OPs have legally repudiated the claim of the complainant or not and as to whether there was any deficiency in service on the part of Ops.

7.                          Before proceeding further, it is desirable to mention here that the health insurance is a type of insurance that financially protects the insured during medical emergencies. It covers medical expenses related to an accident or illness that leads to hospitalization. A health plan covers doctor consultation fees, surgery costs, hospitalization expenses, cost of medicines, ambulance charges, day care procedures, and mental healthcare, thereby, protecting the insured from financial strain.

8.                          In the present complaint, the Ops have rejected the claim of the complainant keeping in view the clauses 4.1 & 4.2 of the terms and conditions of the policy but there is nothing on the record to show that the terms and conditions of the policy were ever supplied or communicated to the complainant and even learned counsel for the Ops has failed to produce any receipt or acknowledgement on the case, therefore, at this stage, the plea of repudiation on the ground of so called terms and conditions are not sustainable in the eyes of law.

9.                          The Ops have rejected the claim of the complainant mainly on two grounds i.e. Permanent Exclusion - Robotic Surgery and 2 Year waiting period: Surgery of Genito Urinary System Unless Necessitated by Malignancy. In support of both these pleas learned counsel for the Ops has drawn the attention of this Commission towards Annexure OP1.

10.                        In order to reach at any conclusion with regard to first objection of Ops qua Robotic Surgery, the discharge summary, placed on the case file as Annexure 4, of Master Yatharth, is very important and vital document. In this document, it has been clearly mentioned that the procedure of surgery was a Laparoscopic pyeloplastuy (Trans Mesocolic), therefore, the Ops are ceased to raise this plea because laparoscopic operation, cannot be said to be a Robotic Surgery, in any manner. Hence, this plea is hereby rejected.

11.                        Now, we discuss the second point i.e. waiting period of two years.  The point No.7 of Section (ii) of exclusion clause 4.1 of the terms and conditions depicts that Surgery of Genito - Urinary system unless necessitated by malignancy.  Perusal of the case file reveals that the Ops have not led any evidence on the case file, in the shape of expert report, affidavit of any doctor or treating doctor, to prove this plea that Master Yatharh was having any kind of malignancy, therefore, at this stage, the Ops cannot take the shelter of this plea to repudiate the genuine claim of the complainant which is otherwise proved to be genuine.

12.                        It is worthwhile to mention here that the insurance companies are not supposed to obtain only premium but it shows that as and when any genuine claim is raised then it bent upon to reject the same on technical grounds.  In this case, the act and conduct of the Ops is not different because on one hand, it has obtained huge premium of Rs.67726/- from the complainant and on the other hand, repudiated the genuine claim of the complainant by relying on the terms and conditions which were neither communicated nor supplied/intimated before obtaining the policy in question.

13.                         Keeping in view the above facts and circumstances of the case, this Commission is of the considered view that the present complaint deserves acceptance because the Ops have indulged in the unfair trade practice as well as dis-service to the complainant, as discussed above. Accordingly, we allow the present complaint with a direction to the appearing Ops to pay Rs.2,69,582/- (Rs. Two lakhs sixty nine five hundred eight two only) alongwith interest @ 6 % per annum from the date of filing of the complaint till its realisation. We further allow Rs.11,000/-, (Rs. Eleven Thousand) in lump sum, towards mental harassment and agony suffered by the complainant and also towards litigation expenses. The liability of the appearing Ops is joint as well as several.  The compliance of the order be made by the appearing Ops within 45 days from today, failing which the above mentioned relief amount would carry interest @ 12 % per annum from date of filing of the present complaint till actual realization. Copy of this order be supplied to the parties concerned, free of costs, as per rules and thereafter, the case file be consigned to record room, as per rules, after necessary compliance. This order be also uploaded on website of this Commission accordingly, as per rules.

Announced in open Commission.                                                            Dated:17.04.2023

                                                                                                        

                       (K.S.Nirania)              (Harisha Mehta)                   (Rajbir Singh)                                                  Member                       Member                                President