Punjab

Sangrur

CC/106/2018

Kamlesh Jain - Complainant(s)

Versus

Religare Health Insurance - Opp.Party(s)

Amit Goyal

07 Sep 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    106

                                                Instituted on:      01.03.2018

                                                Decided on:       07.09.2018

 

Kamlesh Jain wife of Rakesh Kumar Jain C/o M/s. Bhagwant Rai Mohan Lal Jain, Shop No.24, Old Grain Market, Sunam, District Sangrur.

                                                        …Complainant

                                Versus

Religare Health Insurance Company Limited, Regd. Office: 5^th Floor, 19, Chawla House, Nehru Place, New Delhi through its M.D.

                                                        ..Opposite party

 

For the complainant            :       Shri Amit Goyal, Adv.

For Opp.party                    :       Shri Jatinder Verma, Adv.

 

 

Quorum:    Sarita Garg, Presiding Member

                Vinod Kumar Gulati, Member

       

 

Order by : Sarita Garg, Presiding Member.

1.             Smt. Kamlesh Jain, complainant (referred to as complainant in short) has preferred the present complaint against the opposite party (referred to as OP in short) on the ground that the complainant is a consumer of the OP by purchasing an insurance policy bearing number 10375033 under which she was entitled for medi claim insurance to the tune of Rs.5,00,000/- for the period from 29.8.2015 to 28.8.2016.  It is further averred that the policy in question was got renewed further and the policy is still in existence for the period from 29.8.2017 to 28.8.2018.  It is further averred that the policy in question was issued by the OP after thoroughly medically examined the complainant and her husband from their empanelled doctor i.e. Dr. Prabhjot Singh Sibia of Sangrur and after conducting the required medical tests.  In the present case, the grievance of the complainant is that  during the subsistence of the insurance policy, the complainant suffered pain in her knee joints and difficulty in walking, as such, she consulted Max Health Care, Mohali on 10.10.2017, where she was diagnosed for advanced osteoarthritis and was advised total nee replacement, as such, the hospital authorities applied for pre authorisation request, but the same was rejected by the OP vide their email dated 22.10.2017 on the ground that the complainant is a case of hypertension, which is said to be illegal one.  Further case of the complainant is that she was admitted in Max Health Care, Mohali on 29.10.2017 where she underwent knee replacement surgery and was discharged on 5.11.2017, where she spent an amount of Rs.3,50,986/- as per invoice dated 5.11.2017 and apart from that she spent an amount of Rs.17,805/- on follow up treatment. Further case of the complainant is that after discharge from the hospital, the complainant submitted all the bills to the OP and requested for reimbursement of the payment of the claim amount, but the same was rejected vide letters dated 1.12.2017 and 4.12.2017, which is said to be illegal one.  Thus, alleging deficiency in service on the part of the OP, the complainant has prayed that the OP be directed to pay to the complainant the insurance claim of Rs.3,68,791/-  along with interest @ 18% per annum from the date of treatment till realisation and further claimed compensation and litigation expenses.

 

2.             In reply of the complaint filed by the OP, legal objections have been taken up on the grounds that the complaint is not maintainable, that this Forum has no territorial jurisdiction to hear and try the present complaint, that this Forum has no jurisdiction to hear and try the present complaint, that the complainant has suppressed material facts as regards of pre existing disease before purchasing the policy and in the present case, the OP was issued policy on 29.8.2015 to 28.8.2016, 29.8.2016 to 28.8.2017 and 29.9.2017 to 28.8.2018 and on investigation it was revealed that the complainant had concealed this disease of hypertension, that the complaint is not maintainable in the present form, that the complaint is false, frivolous and vexatious in nature.  On merits, it is admitted that the complainant had purchased the policy in question for Rs.5,00,000/-  for the period from 29.8.2015 to 28.8.2016 and got renewed thereafter.  It is further averred that the alleged claim under the policy firstly received from the hospital for cashless treatment for her planned hospitalisation for osteoarthritis bilateral for both knee on 16.10.2017 with estimated cost of Rs.4,20,940/- and upon receipt of the cashless request claim along with the documents, the OP vide letter dated 16.10.2017 sought for exact duration and past history present ailment with 1^st consultation paper and all past treatment records, but the said query was not received from the concerned hospital and as such pre authorisation request was closed. It is further stated that the complainant was suffering from hypertension since April, 2015, so the OP denied the cashless request of the complainant vide letter dated 22.10.2017.  On merits, it is admitted that the complainant is insured under the policy in question for Rs.5,00,000/- with the OP covering herself and spouse. It is admitted that the complainant lodged the CL-90436954 for claim amount of Rs.3,54,170/-, which was rightly denied  on the ground that the complainant had past history of hypertension since April 2015. The other allegations levelled in the complaint have been denied in toto. 

3.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-24 copies of documents and closed evidence. On the other hand, the learned counsel for the OP has produced Ex.OP/1 to Ex.OP/11 copies of documents and affidavit and closed evidence.

 

4.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits  acceptance, for these reasons.

 

5.             It is an admitted fact between the parties that the complainant got medical insurance policy for the period from 29.8.2017 to 28.8.2017 from the OP  for Rs.5,00,000/- on floater basis after paying the requisite premium, as is evident from the copy of insurance policy document, Ex.C-1 on record. It is also not in dispute that the complainant suffered from the problem of knee joints and difficulty in walking and as such she consulted the doctor at Max Health Care, Mohali (which is an empanelled hospital of the OP) on 10.10.2017 and also applied for pre authorisation of the treatment, but the Op rejected the request of the hospital for pre authorisation on the ground that the complainant was suffering from hypertension since April 2015. Further the learned counsel for the complainant has contended that after getting the treatment from Max Hospital, Mohali, she submitted the bills to the OP for reimbursement to the tune of Rs.3,54,170/- as admitted by the OP in their written reply, but the OP rejected the claim of the complainant on the ground that she was suffering from hypertension since April 2015, which is not covered under the terms and conditions of the policy of insurance, as such any liability of the insurance company has been denied.  On the other hand, the learned counsel for the complainant has contended vehemently that the complainant was not suffering from the hypertension at the time of getting the insurance policy, whereas it is an admitted fact of the complainant that she suffered some problem of hypertension in the month of December, 2015 i.e. after getting the medical insurance policy. It is worth mentioning here that the complainant had been taking the policy since the year 2015 regularly and at the time of paying the claim, the OP chose other ways to repudiate the rightful claim of the complainant. Moreover, the hypertension is not a disease and on this ground alone, the OP is not justified to deny the claim to the complainant. In the circumstances, we feel that the OP has wrongly repudiated the claim of the complainant, which is a clear cut deficiency in service on the part of OP. As such, we feel that ends of justice would be met if the OP is directed to pay to the complainant the claim amount of Rs.3,54,170/- as spent by the complainant and paid to the Max Health Care, Mohali vide bill dated 5.11.2017, a copy of which on record is Ex.C-18. 

 

6.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

 

7.             Accordingly, in view of our above discussion, we allow the complaint and direct the OP to pay to the complainant an amount of Rs.3,54,170/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 01.03.2018 till realisation. We also direct the OP to withdraw letter dated 17.2.2018, Ex.C-11 whereby the OP cancelled the policy of the complainant without assigning any cogent reason. We further order the OP to pay to the complainant an amount of Rs.5000/- in lieu of consolidated amount of compensation and litigation expenses.

 

8.             This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        September 7, 2018.

                                       

                                                                (Sarita Garg)

                                                          Presiding   Member

 

 

 

                                                        (Vinod Kumar Gulati)

                                                                     Member