BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.165 of 2019
Date of Instt. 17.05.2019
Date of Decision: 03.09.2024
1. Kiran Bala aged about 58 years W/o Ashok Kumar
2. Ashok Kumar aged about 65 years S/o Sh. Ram Chand
Both residents of Ward No.7, Bhogpur, Tehsil & Distt. Jalandhar.
..........Complainants
Versus
1. Religare Health Insurance, 5th Floor, 19 Chawla House, Nehru Place, New Delhi-116019, through its Chairman/CEO.
2. Religare Health Insurance, Near LIC Building, PUDA Complex, Opp. District Administrative Complex, Jalandhar, through its Incharge.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. H. K. Chopra, Adv. Counsel for Complainants.
Sh. R. K. Sharma, Adv. Counsel for OPs.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainants, wherein it is alleged that the complainant No.2 had purchased health insurance policy No.13072735 from OP No.2 on 26.09.2018, which was valid from 27.09.2018 to 26.09.2019, for himself and for complainant No.1. At the time of issuance of the policy, the blank form were got signed and premium of Rs.33,466/- was accepted by the OP. The complainant No.1 fell ill and was admitted to the Fortis Hospital Ludhiana and she remained admitted from 19.01.2019n to 26.01.2019, where she was treated for ARDS, H1N1 positive and other ailments. The complainant No.1 was treated by the doctors of the above said hospital and now is hale and hearty. The complainant No.1’s treatment bill amounted to Rs.2,41,000/-. The policy cover purchased by the complainant was on the terms of the cashless policy subject to 20% copayment, as insured complainant No.2 above 61 years of age as main applicant of policy. The OPs were under obligation to make the direct payment of the medical bill to the concerned hospital. However, when the hospital bill was conveyed to the OPs No.1 and 2, the same has been declined by the OPs on flimsy grounds i.e. non disclosure of material facts/pre-existing disease at the time of proposal etc. The OPs have rejected the claim of the complainant No.1 illegally and capriciously has cancelled the policy in toto. Though, no document has been supplied to the complainants. Due to the act and conduct of the OPs, the complainant has suffered harassment and as such,necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse Rs.2,41,000/- as bill of the treatment that has been paid by the complainants to the hospital and Rs.2,00,000/- as compensation for causing mental tension and harassment to the complainant and Rs.20,000/- as litigation expenses.
2. Notice of the complaint was given to the OPs, who filed reply and contested the complaint by taking preliminary objections that the complaint is not maintainable against the OPs as the complainant cannot take advantage of his own wrongs. The complainant No.2 himself is guilty of non-disclosure of material facts at the time of taking policy as such, the complaint is liable to be dismissed. It is further averred that there is neither any deficiency in service nor any negligence in service nor any unfair trade practice on the part of the OPs. The cashless claim of the complainant was repudiated as per terms and conditions of the insurance policy after due application in mind vide denial letter dated 20.01.2019 on the ground of material facts/pre-existing ailment at the time of proposal. On merits, the factum with regard to taking health insurance policy by the complainant is admitted and it is also admitted that the complainant No.1 admitted in Fortis Hospital, Ludhiana and it is also admitted that complainant lodged claim and the same was repudiated, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
6. It is proved that the complainant has purchased the insurance policy from the OP. The insurance policy has been proved Ex.C-1. Schedule of benefits has been proved as Ex.C-2 and premium acknowledgement has been proved Ex.C-3. The receipt of premium by the OP has also been admitted. The complainant has proved that she fell ill and was admitted to Fortis Hospital, Ludhiana on 19.01.2019, where she remained admitted till 26.01.2019. She was treated for ARDS (Viral Pneumonia), H1N1 positive and other ailments. Her treatment bill was of Rs.2,41,000/-. She applied for cashless which was declined and repudiated by the OP. She has challenged the repudiation of the claim of the complainant which was repudiated on the ground of non-disclosure of material facts/pre-existing ailments at the time of proposal. She has proved on record, the record of the hospital which included discharge summary, medical bills and other medical record Ex.C-4, Ex.C-5, Ex.C-7 and Ex.O-12.
7. On the other hand the OPs have alleged that the cashless claim was rejected rightly as in the proposal form she has never disclosed about her pre-existing ailments. The claim is to be given as per the terms and conditions of the policy. The complainant was asked number of times to supply the document, but she never provided the documents. The OP has proved on record Deficiency Letter Ex.O-5 to Ex.O-7. They have also produced on record the medical record of the complainant to show that she was having pre-existing ailments for which she was treated in the Fortis Hospital. However, it has been alleged that no reimbursement was ever sought by the complainant. Perusal of Ex.C-6 shows that it is denial of pre-authorization, meaning thereby that the request of the complainant for cashless hospitalization was denied. This is not the case of the complainant that she applied for reimbursement of the claim. Even in Para No.11 of the written statement on merits, the OP has categorically mentioned that the complainants have not submitted any medical bills or lodged reimbursement claim after the denial of cashless facility. Since, the amount for treatment was paid by the complainant to the hospital authorities and the cashless claim was denied, therefore, the complainant was to lodge the claim for reimbursement. In such circumstances, the complainant is directed to file reimbursement claim with the insurance company alongwith all the documents, within 15 days from the date of receipt of the copy of the order and then the OPs will settle the claim of the complainant within 15 days from the date of receipt of the claim alongwith necessary documents/information, failing which the OPs will be liable to pay compensation of Rs.20,000/- to the complainant. It is further ordered that if the complainant is not satisfied with the settlement of the claim made by the OPs, then he is at liberty to file a fresh complaint. Thus, the complaint of the complainant is disposed of. This complaint could not be decided within stipulated time frame due to rush of work.
8. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
03.09.2024 Member Member President
