Haryana

Fatehabad

CC/166/2020

Sandeep Monga - Complainant(s)

Versus

Religare Health Insurance - Opp.Party(s)

Manjeet Kajla

15 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION FATEHABAD.

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

 

                                                                    C.C.No.166 of 2020.                                                                                            Date of Instt.: 11.08.2020.                                                                                   Date of Decision:15.03.2023

 

Sandeep Monga son of Mahender Singh Monga resident of House No.310 Bigher Road, Near Kath Mandi, Fatehabad -125050 (Haryana).

                                                                             ..Complainant

                              Versus

1.Religare Health Insurance Company Limited Service Branch, Vipul Tech Square Tower-C, Third Floor, Sector 43-,Golf Course Road, Gurugram - 122009 through its Chairman-cum-Managing Director/ Managing Director/ Divisional Manager/ Authorized person.

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

3. Religare  Health Insurance Company Limited, Branch Office, SCO 93, Ist Floor, Green Square Market, Hisar-125001 through its Branch Manager.

                                                                   ..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.                                 This complaint has been filed under Section 35 of the Consumer Protection Act, 2019 (in short Act) against the Ops with the averments that the complainant had obtained an insurance policy bearing No.13570206 having validity from 08.01.2019 to 07.01.2020 in the name of his father Sh.Mahender Singh Monga (hereinafter referred as insured) under care and cover type individual plan; that he made insurance premium amounting to Rs.57,436/- in cash to Ops for sum assured of Rs.5,00,000/-; that on 05.04.2020, insured fell ill and remained admitted in Mahatma Gandhi Institute, ITI Chowk, Hisar from 05.04.2020 to 08.04.2020 and spent Rs.37,535/- on his treatment; that the insured again fell ill and remained admitted in the same hospital from 20.04.2020 to 27.04.2020 and further spent Rs.1,65,079/- on his treatment; that the complainant had submitted all the requisite documents with the Ops for reimbursement of the total amount of Rs.2,02,614/- and also got served legal notice upon the Ops but despite that the amount has not been released till date. In the end, Rs.50,000/- has been claimed as damages for harassment, physical injury, mental agony besides cost of treatment in sum of Rs.2,02,614/-.

2.                          Averments of the complaint have been strongly opposed in the joint written statement filed on behalf of Ops wherein several preliminary objections such as maintainability, concealment of material facts, locus standi and estoppal etc. have been taken. It has been further submitted that the complainant had approached the Ops for claim reimbursement of his father for the treatment taken by him from various hospitals and in order to process the lodged claims some queries were put to him but those queries were not fulfilled, due to which the claim was not rejected rather it was closed for deficiency in documents. It has been further submitted that the company has already paid the same post reconsidering the claim and now nothing is due to be paid by the insurance company to the complainant on account of reimbursement of claim. 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 as Annexure CW1/A and documents Annexure C1 to Annexure C19. On the other hand learned counsel for the Ops has tendered affidavit of Sh.Ravi Boolchandani as Ex.RW1/A and documents Annexure R1 to Annexure R9.

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

5.                          It is not disputed that father of the complainant had obtained an insurance policy bearing No.13570206 under the plan Care and Cover type Individual for a sum of Rs.5,00,000/- having validity for the period from 08.01.2019 to 07.01.2019  and for this premium to the amount of Rs.57,436/- was also deposited (Annexure C6).  The fact regarding hospitalization of the insured has also not been disputed.  As per the complainant a sum of Rs.2,02,614/- was spent on the treatment of the insured and as per the terms and conditions of the policy, so obtained by the insured, the insurance company had to reimburse the amount spent on the treatment of the insured because he was hospitalized during the currency of the policy in question. It is also disputed that the insured had died on  27.04.2020 (Annexure C7). On the other hand, learned counsel for the Ops has argued that some quarries were put to the complainant but he did not fulfill the same, therefore, the claim in question was only closed and not rejected. However, the claim to the sum of Rs.1,69,376/- has already been paid to the complainant after post reconsidering  and now noting is due to be paid to the complainant.  

6.                          Learned counsel for the Ops drew the attention of this Commission towards the document Annexure R2 and argued that an amount of Rs.29688/- was not covered under the policy in question, therefore, it was not paid to the complainant.   The inventory of the deducted amount is as under:

Particulars	Reasons for deduction	Amount
Non payable	Attendant charge	6000
Non payable	CMO BMW Cooler Monitor charge	7260
Non payable	Oxygen Resuscitation Line Nebuip Diet Charge	5050
Non payable	Non medical expenses	1788
Non payable	Hospital Discount	9400
Non payable	Miscellaneous charges	200
Total Deductions		29688

 

7.                          Perusal of the case file reveals that the Ops have failed to prove on the case file that as to on what basis the amount (Rs.7260/-) with regard to CMO BMW Cooler Monitor charge, (Rs.5500/-) with regard to Oxygen Resuscitation Line Nebuip Diet Charge, (Rs.1788/-) on account of Non medical expenses and (Rs.200/-)  on account of miscellaneous charges were deducted. However, the grounds for deduction of Rs.9400/- on account of hospital discount and Rs.6000/- on account of attendant charges are justified. Therefore, the end of justice would be met if we allow the complaint partly with a direction to the Ops/insurance to pay a sum of Rs.14288/- (after deducting Rs.9400/- and Rs.6000/-) to the complainant.

8.                           Keeping in view the above facts and circumstances of the case, this Commission is of the considered view that the present complaint deserves acceptance partly 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 partly with a direction to the Ops to pay Rs.14288/- (Rs.Fourteen Thousand Two Hundred Eighty Eight) alongwith interest @ 6 % per annum from the date of filing of the complaint till its realisation. We further allow Rs.11,000/-, (Rs.Elevent Thousand) in lump sum, towards mental harassment and agony suffered by the complainant and also towards litigation expenses. The liability of the Ops is joint as well as several.  The compliance of the order be made by the Ops within 30 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:15.03.2023

                                                                                                        

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