BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.333 of 2023
Date of Instt. 22.08.2023
Date of Decision: 19.03.2024
1. Sarabjit Singh son of Gurcharan Singh R/o Flat No.7, Shaheed Bhagat Singh Colony, Jalandhar-144001, currently resident of Flat No.25, Second Floor, Near Verka Milk Plant, Guru Amar Dass Nagar, Jalandhar-1, Jalandhar-144004.
2. Simarpreet Kaur w/o Sarabjit Singh son of Gurcharan Singh R/o Flat No.7, Shaheed Bhagat Singh Colony, Jalandhar-144001, currently resident of Flat No.25, Second Floor, Near Verka Milk Plant, Guru Amar Dass Nagar, Jalandhar-1, Jalandhar-144004.
..........Complainants
Versus
1. The Reliance General Insurance Company Ltd, Head Office, Through its Authorised Person, 6th Floor, Oberoi Commerz- 1,International Business Park, Oberoi Garden City, Goregaon East, Mumbai-400063.
2. The Reliance General Insurance Company Ltd, Branch Office, Through its Authorized Representative, SCO 2, First Floor, PUDA Complex, Jalandhar- 144001.
3. The Reliance General Insurance Company Ltd, Regional Office, Through its Authorized Representative 7th Floor, Surya Tower, 108, The Mall, District Ludhiana, Punjab-141001.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Smt. Harleen Kaur, Adv. & Miss Anchita, Adv. Counsels for the Complainants.
Sh. V. K. Gupta, 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 complainants alongwith their family members obtained Reliance General Insurance Health Gain Policy with basic sum insured Rs.3,75,000/-. The medi-claim Policy covered risk to Reimburse/indemnify expenses for any disease contracted or suffered from any illness/ailments/disease or injury sustained by the insured person. The first health insurance Policy inception date 24/09/2021 was taken from OP No.1 through its authorized agent for policy period starting as in the Policy Schedule i.e. valid upto 23/09/2022. The Mediclaim policy Schedule was issued in the name of Complainant No.1 insured. The policy was again renewed and was effective from 24-09-2022 23-09-2023. The policy number to 200122228680003083 was allotted. The Cover Note and Policy Schedule of Policy was issued in the name of complainant. The total amount of renewal premium of Rs.16,704/- after allowing family discount and no claim discount as consideration was paid to the OP No.1 through its authorized agent/representative which was accepted after satisfying the continued insurability and without questioning the credentials of the insured persons without any demur and strings. The OP No.1 issued/delivered to the complainant Cover Note and Policy schedule of Reliance Health Gain from its inception to its renewal. The opposite party No.1 has agreed and undertaken to indemnify for medical and surgical expenses for illness/sickness, accident and surgical operation etc. Contracted between the period of insurance to the full extent without any deduction in any manner. Accordingly the complainant has got the right of indemnification/reimbursement for whole amount of medical and surgical expenses incurred and for any loss or damage of peril covered during the term of Reliance Health Gain Policy. At the time of taking the said Mediclaim Policy Complainant No.2 was not suffering from any disease of any nature whatsoever and was a healthy person performing and attending to her duties and daily chores and living a normal and healthy life. Also, at time of taking the policy complainants were provided with only the policy schedule however the policy document as per the mandate of IRDAI were never supplied to complainants. The Complainant no.2 i.e. Simarpreet Kaur, wife of the complainant no.1, co-insured with the OP No.1, complained of severe pain in abdomen, periumbilical region, pursuant to which she was taken to Sacred Heart Hospital, Maqsudan, GT Road, Jalandhar, 144008 and was admitted on 09/06/2023. Here, complainant no.2 was diagnosed with hernia in her umbilical and periumbilical region and was advised to undergo immediate surgery and was operated using diagnostic laparoscopy, Laparoscopic IPOM and Adhesiolysis under general anaesthesia. Thereafter, complainant no. 2 was discharged from hospital on 10/06/2023. The pre-authorization request was made by the complainant for a claim of Rs.1,15,524/- for medical and surgical expenses incurred and for reimbursement for hospitalization and on account of medicine incurred for reimbursement of hospitalization and treatment expenses, to OP No.2. However, the same was denied by the OP No.2 pertaining to the typographical error on the part of the hospital authorities. The typographical error attributed on the part of hospital authorities was corrected and various emails and clarifications were sent to OP No.2 by the hospital authorities themselves to reimburse the rightful, legitimate, genuine and bona fide claim of the complainants. Refusal to pay/reimburse just and rightful, legitimate genuine and bonafide Mediclaim by OPs is arbitrary malafide, perverse and against law on anon-existing grounds without any valid justification, there is wholly misapplication of independent mind based on conjecture and surmises and the same is not sustainable in the eyes of law. The act and conduct, approach and behavior of OPs have been arbitrary, irrational and malevolent causing lot of mental tension and harassment to the complainants 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/pay total amount of claim in the sum of Rs.1,15,424/- alongwith interest @ 12% per annum from the date of lodgment mediclaim till date of actual payment to the complainants. Further, OPs be directed to pay a compensation of Rs.50,000/- for causing mental tension and harassment to the complainant and Rs.35,000/- 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 instant complaint is false, malicious, incorrect and malafide and is nothing but an abuse of the process of law and it is an attempt to waste the precious time of this Commission as the same is filed by the complainant only to avail undue advantage. The complaint is thus liable to be dismissed under Consumer Protection Act, 2019. It is further averred that without prejudice to above objection, the OP submits at the outset the above complaint filed by the complainant is not at all maintainable either on question of fact or on question of law and as such is liable to be dismissed in limine. It is further averred that before providing reply to the allegations and contentions of the complainant as contained in the said complaint, the OP hereby raise a preliminary question as to the maintainability of the instant case inter-alia on the following grounds:-
i. The instant complaint is not maintainable in its present form in fact and/or in law and/or as per the provisions of the Consumer Protection Act, 2019 (as amended till date).
ii. The complainant has no cause of action for filing the instant case against the OPs.
iii. The complainant has suppressed the material facts and/or submitted distorted facts to mislead this Commission which will be apparent and sustained from the evidence of the O.P. hereinafter.
iv. The complainant has filed this complaint which is frivolous, bad in law and frustrating and vexatious, malafide in nature with ulterior motive to cause damage and harassment to the OPs.
v. There shall be defeat of justice and equity if the prayer of the complainant is granted.
vi. The complaint is nothing but a gross abuse of the process of this Forum.
vii. The instant complaint is filed is totally misconceived.
viii. Because of the above-mentioned reasons as such the instant complaint may be dismissed with exemplary costs.
The complaint is barred by the Consumer Protection Act, 2019 and the same is liable to be relegated to the civil court of competent jurisdiction since the adjudication of the matter requires recording of elaborate evidence, oral, documentary and medical and the same is not possible by the way of trial". It is further averred that the OP submits that claims are paid by any Insurance Company out of the common pool of funds belonging to all policyholders of the company and Insurance Company has to check the admissibility of a claim before honoring it as such and payment as claimed in the complaint would be an undue discrimination with the other policy holder who are insured in same risk pool. It is further averred that the complainant has concealed the material and correct facts and has not approached this Forum with the clean hands while stating, distorted and incorrect facts before this Forum, with malafide intentions of misleading this Forum. On merits, the factum with regard to availing the health insurance policy by the complainants is admitted and the factum with regard to repudiating the claim by the OP is also admitted, 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 not filed by the complainant.
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 admitted that the complainant took health insurance policy from the OP No.1 on 24.09.2021, which was effective from 24.09.2021 to 23.09.2022. The policy was renewed and the same was effective from 24.09.2022 to 23.09.2023 and the renewal premium was Rs.16,704/- as per Ex.C-1/OP-1. So, this fact is proved that the complainants had purchased the mediclaim policy from OPs.
7. The complainants have alleged that the complainant No.2 i.e. Simranpreet Kaur, wife of the complainant No.1 complained of severe pain in abdomen, periumbilical region and she was admitted in Sacred Heart Hospital on 09.06.2023 and was diagnosed with Hernia in her umbilical and periumbilical region and was advised to undergo immediate surgery and was operated and then discharged from hospital on 10.06.2023. Copy of the receipts and discharge summary are Ex.C-2 and Ex.C-3. The complainant made preauthorization request for a claim of Rs.1,15,524/- to OP No.2 and the same was denied by the OP No.2, vide repudiation letter Ex.C-5/OP-3 on the ground that ‘Violation of policy terms and conditions-Cashless facility cannot be extended as patient had complaints of hernia from 3 months after LSCS, the present ailment incisional Hernia and etiology are the complications of Maternity. Hence claim has been repudiated as per policy terms and conditions-4.1.18-Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization.’ Request has been made to allow the complaint.
8. The OPs have contended that the present complaint is premature and the OPs have only denied the cashless facility vide letter dated 10.06.2023 and denial of cashless facility does not mean that claim has been finally repudiated. The insured has the right to file reimbursement claim with the insurance company and on submission of said claim alongwith all documents relied upon by the insured, insurance company can take final decision about the admissibility of claim. The OPs have further contended that no reimbursement claim filed by the insured in the present complaint. Hence, the present complaint is premature. Ex.C-5 shows that the pre-authorization request was denied. Thereafter, no claim for reimbursement was lodged. Hence, the complaint is pre-mature.
9. 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.
10. 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
19.03.2024 Member Member President
