| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA CC.No.515 of 19-10-2016 Decided on 14-05-2018 1.Rohit Aggarwal @ Rohit Kumar aged about 40 years S/o Surinder Kumar; 2.Subhankar Aggarwal aged about 19 years S/o Rohit Aggarwal Both R/o # 32, New Suraj Giri Mandir, New Shakti Nagar, Bathinda. ........Complainants Versus 1.Religare Health Insurance Co. Limited, GYS Global, Plot No.A-3, A-4, A-5, Sector 125, Noida, (UP), 201301, through its Chairman/MD/Director/Manager. 2.lndusind Bank Limited, G.T. Road, Bathinda its Branch Manager. .......Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh.M.P Singh Pahwa, President. Sh.Jarnail Singh, Member. Smt.Sukhwinder Kaur Member Present:- For the complainants: Sh.Vinod Garg, Advocate. For opposite party No.1: Sh.Sanjay Goyal, Advocate. Opposite party No.2: Ex-parte. ORDER M.P Singh Pahwa, President The complainants Rohit Aggarwal @ Rohit Kumar and Subhankar Aggarwal (here-in-after referred to as complainants) have filed complaint U/s 12 of Consumer Protection Act, 1986 against opposite parties Religare Health Insurance Co. Limited and Other (here-in-after referred to as opposite parties). Briefly stated, the case of the complainants is that the complainant No.1 has taken health insurance policy from Max Bupa Health Insurance Company for complainant No.2 as well as for his wife Meenu Aggarwal and daughter Tiya Aggarwal. The policy was valid for the period from 11.3.2014 to 10.3.2015 for a sum of Rs.5,00,000/-. During the validity of the insurance, opposite parties through their agents opposite party No.2 approached the complainants to sell insurance policy of opposite party No.1 on the pretext that this policy is comprehensive policy, which covers all types of ailments and treatments. Accordingly, the complainants purchased the insurance policy by making the total payment of Rs.22,586/- as premium. This policy was for the period from 11.3.2015 to 10.3.2016. It is alleged that opposite party No.2 got various blank papers and forms signed from the complainants. Opposite parties only issued policy bearing No.10234200. The separate policy alongwith terms and conditions was never supplied, even after demand raised by the complainants from time to time. As such, opposite parties cannot take any benefit of the terms and conditions. The policy was renewed against the same number i.e. 10234200 from 11.3.2016 to 10.3.2017 against premium of Rs.25,318/-. It is revealed that during the validity of the insurance policy, the complainant No.2 suffered from high enteric fever, abdomen pain, throat pain and headache etc. The complainant No.2 was taken to Chandigarh Clinic and Nursing Home, Bathinda where he was admitted for the period from 6.4.2016 to 8.4.2016. The various tests were conducted. The complainants spent more than Rs.12,000/- on admission, treatment and medicines therein, but the condition did not improve. The hospital referred the complainant No.2 to Fortis Hospital Mohali. Thereafter he was taken to Fortis Hospital, Mohali. He remained admitted there for the period from 9.4.2016 to 12.4.2016 and a sum of Rs.81,000/- approximately were spent. It is further alleged that the complainants lodged the claim with opposite parties and deposited all the original medical bills and other record. They were intimated that claim No.90209001 for an amount of Rs.80,258/- for treatment in Fortis Hospital, Mohali and claim No.90208932 for Rs.11,696/- for treatment in Chandigarh Clinic and Nursing Home, Bathinda have been registered and payment will be made shortly. The complainants kept on requesting opposite parties time and again for payment of claim, but they instead of making the payment, kept on writing letters dated 16.5.2016 and 25.5.2016 and demanding more and more documents, although all the documents have already been supplied to them on 27.4.2016. It is also alleged that at the time of admission in Chandigarh Clinic and Nursing Home on 6.4.2016 and in Fortis Hospital, Mohali on 9.4.2016, the complainants intimated opposite parties and hospital about the insurance cover and entitlement to get the treatment against the insurance policy. It is also alleged that the insurance company is supposed to decide and pay the claim at the earliest and not later than two months in any case whereas in this case, opposite parties received the claim alongwith all original documents on 27.4.2016, but they have not paid the claim and have unnecessarily withheld the payment even after regular reminders and calls. Due to non settlement of claim and making the payment to the complainants, they have suffered from mental tension, agony, botheration, harassment and financial loss. For these sufferings, complainants have claimed Rs.50,000/- as compensation alongwith Rs.91,954/- as hospitalization charges and medical expenses with interest @ 18% per annum and Rs.20,000/- as litigation expenses. Hence, this complaint. Upon notice, none appeared on behalf of opposite party No.2. As such, ex-parte proceedings are taken against it whereas opposite party No.1 appeared through its counsel and contested the complaint by filing its written version. In the written version, opposite party No.1 has raised the legal objections that the complainants have no locus-standi or cause-of-action to file the complaint. They have not approached to this Forum with clean hands and have not placed true and correct facts before this Forum. They are estopped by their act and conduct from filing the complaint. The complaint against opposite party No.1 is thoroughly frivolous and without any merit. The allegations of deficiency in service levelled against opposite party No.1 are false and baseless. There is no deficiency in service on the part of opposite party No.1. On merits, issuance of policy and renewal from time to time is not denied. However, it is asserted that the policy was issued to the complainants and subject to terms and conditions mentioned in the policy. Opposite party No.1 has sent the complete kit containing policy documents and terms and conditions of the policy to the complainants. It is further mentioned that as per Clause 6.11 of the policy terms and conditions, opposite party No.1 as per the rules of the IRDA, gives 15 days notice period, in case, the complainants are unsatisfied with the terms and conditions of the policy. The complainants never approached opposite party No.1 post receipt of the policy kit, implying that the complainants are satisfied with the terms and conditions thereof. They failed to comply with the requirements despite repeated requests. The required documents were never supplied to opposite party No.1. It is also mentioned that as per discharge summary issued by the hospital, at the time of admission, all the body vitals of the patient were normal within limits except for temperature hike of 102 degree 'F', which could have been managed on OPD basis. The complete blood counts report dated 6.4.2016 and 8.4.2016 suggest that the patient was not detected with any active disease or ailment. The patient underwent certain investigations prior to the hospitalization, during which he was not diagnosed with any active disease or ailment. As per vital charts prepared by the hospital authorities, the patient was afebrile (without temperature) throughout the entire period of hospitalization with a maximum temperature of 100 degree 'F'. Further all other body vitals recorded were normal and well within limits. It is further mentioned that in the light of above observations, the query was sent to complainants regarding need for hospitalization from the treating doctor in view of normal temperature and vital charts. No reply has been received till date from the complainants. It is further revealed that the claim has not been rejected till date and claim is pending for the above mentioned documents. Once demanded documents are received, opposite party No.1 shall assess the claim of the complainants in the light of the same as per policy terms and conditions. It is also revealed that it is specifically mentioned that as per 'treatment advised on discharge' clause of the discharge summary of Chandigarh Clinic and Nursing Home, Bhatinda, it is clearly mentioned 'discharge on request'. The patient wanted to go to the higher Centre thereby implying that there was no recommendation by the nursing home to get admitted at Fortis Hospital, Mohali. It is admitted that the complaint was lodged. All other averments of the complainants are denied. In the end, opposite party No.1 has prayed for dismissal of complaint. Parties were asked to produce the evidence. In support of their claim, the complainants have tendered into photocopies of discharge summary, (Ex.C1 and Ex.C2); photocopy of bills, (Ex.C3); photocopy of prescription, (Ex.C4); photocopies of letters, (Ex.C5, Ex.C7 and Ex.C14); photocopy of treatment record, (Ex.C6); photocopy of policy renewal detail, (Ex.C8); photocopy of policy certificate, (Ex.C9); his affidavit dated 21.3.2017, (Ex.C10); photocopies of e-mails, (Ex.C11 and Ex.C12); affidavit of Subhankar Aggarwal dated 1.4.2017, (Ex.C13) and submitted written arguments. To rebut the claim of the complainants, opposite party No.1 has tendered into evidence affidavit of Ramnique Sachar dated 7.12.2016, (Ex.OP1/1); photocopy of covering letter, (Ex.OP1/2); photocopies of policy certificates, (Ex.OP1/3 and Ex.OP1/6); photocopies of premium details, (Ex.OP1/4 and Ex.OP1/7); photocopies of application, (Ex.OP1/5, Ex.OP1/35); photocopy of proposal form, (Ex.OP1/8); photocopy of terms and conditions, (Ex.OP1/9); photocopy of form, (Ex.OP1/10); photocopies of insurance certificate, (Ex.OP1/11 and Ex.OP1/12); photocopy of desktop, (Ex.OP1/13); photocopy of electronic clearance service, (Ex.OP1/14); photocopy of closure, (Ex.OP1/15); photocopies of discharge summary, (Ex.OP1/16 and Ex.OP1/33); photocopies of bills, (Ex.OP1/17, Ex.OP1/18 and Ex.OP1/20); photocopy of receipt, (Ex.OP1/19); photocopy of advise, (Ex.OP1/21); photocopy of lab report, (Ex.OP1/22); photocopies of reports, (Ex.OP1/23 to Ex.OP1/26 and Ex.OP1/40); photocopy of ECG, (Ex.OP1/27); photocopy of prescription slip, (Ex.OP1/28); photocopies of query letters, (Ex.OP1/29, Ex.OP1/34, Ex.OP1/36 and Ex.OP1/38); photocopies of reminders, (Ex.OP1/30 to Ex.OP1/32 and Ex.OP1/45); photocopies of handwritten, (Ex.OP1/37, Ex.OP1/39 and Ex.OP1/43); photocopies of retail invoice, (Ex.OP1/41 and Ex.OP1/42); photocopy of OPD slip, (Ex.OP1/44) and closed the evidence. We have heard learned counsel for parties and gone through the file as well as written arguments submitted by learned counsel for complainants. Learned counsel for complainants has submitted that the material facts are not in dispute. It is not disputed that the complainants availed the insurance policy of opposite party No.1, which covers both the complainants and other family members. The complainants have also claimed that the complainant No.2 took treatment from Chandigarh Clinic and Nursing Home. The discharge summary, (Ex.C1) also proves this fact. As the condition of the complainant No.2 was not improving, therefore, he took the treatment from Forties Hospital. Ex.C2, proves this fact. Amount spent by the complainants for treatment is also detailed in the bills submitted by them. Opposite party No.1 has admitted receipt of claim, but it has so far not released the amount. Opposite party No.1 in the written version has rather pleaded that the complainants failed to reply to its letter. The complainants have also placed on record letter dated 31.5.2016. Vide this letter, they were asked to provide Pre Hospitalization OPD Consultation, but this document is not in their possession and it has no relevancy for settlement of claim. Opposite party No.1 has also asked the complainants to provide indoor papers, admission notes, doctors notes, nursing notes and vital chart. The complainants were not supposed to be in possession of these documents. The treatment obtained by the complainant No.2 stands proved from the discharge summaries issued by both the doctors. Therefore, opposite party No.1 is unnecessarily delaying the claim. It amounts to deficiency in service and unfair trade practice on the part of opposite parties. As such, the complaint be accepted in terms of reliefs as claimed for. On the other hand, learned counsel for opposite party No.1 has reiterated its stand as taken in the written version and detailed above. It is further submitted by learned counsel for opposite party No.1 that the settlement of claim is pending for want of documents required from the complainants Of-course, the complainants have claimed treatment firstly from Chandigarh Clinic and Nursing Home and relied upon discharge summary, (Ex.C1). This document proves that the complainant No.2 was diagnosed for enteric fever. There was no other disease/diagnose, which requires hospitalization of the complainant No.2. This document also proves that the patient was discharged on his request as he wanted to go to the higher institute. The complainants have also placed on record notes, (Ex.C6) of Chandigarh Clinic and Nursing Home from 6.4.2016 onwards. These notes also prove that the vital was checked properly in time. There was no fresh complaint from the patient. The patient was discharged on 8.4.2016. The note dated 8.4.2016 shows that vital was sustainable. The complaint was only regarding abdominal pain and fever and there was no other complaint of the patient. It proves that his condition was improving. There was no reason for treatment from Forties Hospital, Mohali. Keeping in view these circumstances, the complainants were asked to furnish certain documents required for processing the claim. They have admittedly not furnished the documents. Therefore, delay is only due to lapse on their part. Opposite party No.1 cannot be held responsible for any delay. We have given careful consideration to these rival submissions. Undisputed facts are that the complainants took the mediclaim policy of opposite party No.1 from time to time. The complainant No.2 took treatment from Chandigarh Clinic and Nursing Home and then from Fortis Hospital, Mohali. The complainants submitted the claim alongwith documents, but the claim is not finally settled. Opposite party No.1 has pleaded that the delay is mainly for the reason that the complainants have failed to submit the required documents. Opposite party No.1 has produced on record copy of letter dated 5.6.2016, (Ex.OP1/15). Vide this letter, the complainants were asked to submit the following documents:- “Provide indoor case papers with doctor notes, nursing notes; Provide temperature and vitals chart and investigation reports; Provide all OPD consultation papers prior to admission; Provide detailed line of treatment.” The version of the complainants is that the documents in their possession have already been submitted. They have produced on record copy of discharge summaries, (Ex.C1 and Ex.C2) issued by both hospitals. Therefore documents mentioned at serial No.1 has already been supplied to opposite party No.1. The complainants were also asked to provide temperature and vitals chart and investigation reports. They were not supposed to be in possession of these documents and these documents are not relevant for settlement of claim. They were also asked to provide OPD consultation papers prior to admission. There is nothing to show that the complainants took consultation prior to admission. Therefore, opposite party No.1 was not having reason to require these documents. The complainants were also asked to provide detailed line of treatment, but it is also mentioned in the discharge summaries issued by both hospitals. Therefore, keeping in view all facts, it can be safely concluded that the documents in possession of the complainants and required for settlement of claim have already been supplied to opposite party No.1. Opposite party No.1 has caused unnecessarily delay in settlement of claim, which amounts to deficiency in service on its part. For the reasons recorded above, this complaint is partly accepted with Rs.10,000/- as cost and compensation against opposite party No.1 and dismissed qua opposite party No.2. Opposite party No.1 is directed to settle the claim as per terms and conditions of the policy documents and to pay the amount found payable to the complainants. Opposite party No.1 will also furnish the details of the payment being made to the complainants with reference to the relevant terms and conditions of the policy documents. It is made clear that in case, the complainants will not be satisfied with the amount paid to them, they can avail any other legal remedy. The compliance of this order be made within 45 days from the date of receipt of copy of this order. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record. Announced:- 14-05-2018 (M.P Singh Pahwa) President (Jarnail Singh) Member (Sukhwinder Kaur) Member
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