District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.149/2023.
Date of Institution:01.03.2023.
Date of Order: 30.01.2024.
Gurudatta Parija son of Shri Shy7am Sunder Parija, resident of House No. E-812, Dabua Colony, Near Bank of NIT, Faridabad, Haryana.
…….Complainant……..
Versus
1. Care Health Insurance Limited, Formerly known as Religare health Insurance Co. Ltd., U it NO. 604-607, 6th floor, Tower No.C, Unitech Cyber Park, Sector-39, Gurugram through its authorized person.
2. Care Health Insurance Limited, Formerly known as Religare Health Insurance Co. Ltd., 5th floor, 19 Chawla House, Nehru Place, New Delhi – 110 019 through its authorized.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Deepak Shrma, counsel for the complainant.
Sh. PḶ.Garg , counsel for opposite party .
ORDER:
The facts in brief of the complaint are that the complainant had already taken the care Health Insurance Policy on dated 6.3.2021 vide policy No. 30569655 valid from 6.3.2021 to 05.03.2022 for the insured sum of Rs.5,00,000/-. During the mediclaim policy the complainant suffering from final diagnosis entric fever, septicemia, transamnitis and in this regard the complainant was admitted in Manvi Medical centre, New Bharat colony Opp. Chaddar Godem, near Mahaban farm Kheri Road, Grater Faridabad Haryana on dated 25.12.2021 at 3:45 p.m. and was discharged on 30.12.2021 at 5.00p.m. and the hospital raised the final bill amount of Rs.46,599/- which was paid by the complainant in cash from his own pocket. Although the said amount was to be paid by the opposite parties to the hospital according to the terms and conditions of the Care Health Insurance Policy. As per the said policy of the terms and conditions , the opposite party is liable to pay the daily allowance + Rs.10,000/- per day and the complainant was admitted in the hospital for 6 days which comes to Rs.60,000/- to the complainant was liable to receive the total claim amount of Rs.46,599/- +60,000/- = Rs.1,06,599/- from the opposite parties. Later on the complainant had sent all related documents regarding the treatment of the complainant for getting the imbursement of the claim amount but the opposite parties issued the deficiency letter on dated 12.01.2022. The complainant had submitted all papers to opposite party No.1 in respect of deficiency letter and the documents had been received by the opposite party No.1 and also made the receiving stamp on dated20.01.2022 and later on the opposite parties sent a letter and denial the claim letter on 28.01.2022. The complainant sent the emails to the opposite parties on dated 29.01.2022 and 22.03.2022.The complainant sent legal notice dated 23.01.2023 to the opposite parties but all in vain. The aforesaid act of opposite parties amounts to deficiency
of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) make the mediclaim amount of Rs.46,599/- which was paid by the complainant form his own pocket during the mediclaim insurance period vide policy No. 30569655 and daily allowance + Rs.10,000/- per day the complainant was admitted in hospital for 6 days which comes to Rs.60,000/- and the total claim amount of Rs.46,599 + Rs.60,000/- total Rs.1,06,599/- alongwith interest @ 18% p.a.
b) pay Rs.50,000/- as compensation for causing mental agony and harassment .
c) pay Rs.22,000/- as litigation expenses.
2. Opposite parties Nos.1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 & 2 refuted claim of the complainant and submitted that the opposite party company issued a health insurance policy namely “POS Care” vide policy No. 30569655 covering the complainant himself w.e.f 06.03.2021 to 05.03.2022 for a sum insured of Rs.5,00,000/-.
Reimbursement (92104727-00)
a) a reimbursement claim was received from the complainant for his hospitalization at Manvi Medical centre, Faridabad form 25.12.2021 to 30.12.2021 for the treatment of Enteric Fever, Septicaemic and Transamnitis.
b) Upon receipt of the claim a query letter dated 12.01.2022 and reminder letter dated 19.01.2022 was raised and the complainant was asked to provide following documents:
i) Complete indoor case papers with admission notes, history sheet, doctor’s notes, nursing notes and vital chart. For present illness.
c) Upon receipt of the claim the opposite party company triggered an investigation to check the veracity of the claim. Upon investigation the following points came to light:
i) Treating doctor of the complainant was working in two hospitals at the same timings.
ii) As per document dated 22.01.2022 provided by Manvi Hospital, Dr. Noor Alam was permanent employee since 4-5 months & available in hospital from 10:00a.m to 1:00pm & from 05:30p.m. to 07:30p.m. whereas as per document dated 03.01.2022 provided bny M.L.Hospital, Dr. Noor alam was permanent employee of M.L.Hospital sine 6 months & available in hospital from 08:00 a.m. to 11:30am & 06:30 pm to 08:30p.m.
iii) As per medical document provided by Manvi Medical Centre, Faridabad, all nursing notes was in single hand whereas which was not possible for single nursing staff to work for 24 hours for hospitalization without break.
d) In light of the facts, the opposite party company rejected the claim of the complainant on the ground of discrepancy in medical documents vide letter dated 28.01.2022.
Opposite parties Nos.1 & 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties–M/s. Care Health Insurance Limtied with the prayer to: a) make the mediclaim amount of Rs.46,599/- which was paid by the complainant form his own pocket during the mediclaim insurance period vide policy No. 30569655 and daily allowance + Rs.10,000/- per day the complainant was admitted in hospital for 6 days which comes to Rs.60,000/- and the total claim amount of Rs.46,599 + Rs.60,000/- total Rs.1,06,599/- alongwith interest @ 18% p.a. b) pay Rs.50,000/- as compensation for causing mental agony and harassment . c) pay Rs.22,000/- as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW-1/A – affidavit of Gurudatta Parija, Ex.C-1 – insurance policy,, Ex.C2 – discharge summary, Ex.C-3- bill, Ex.C4 & 5 – receipts,, Ex.C-6 – deficiency letter dated 12.01.2022 , Ex.C8 – claim denial letter,, Ex.C9 & C-10 – emails, Ex.C-11 –legal notice,
On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties Ex.RW1/A – affidavit of Shri Deepak Mishra, Legal Manager of Care Health Insurance Co. Ltd., Ex.R-1 – insurance policy,, Ex.R-2 – claim form, Ex.R-3 – discharge summary,, Ex.R-4 & R-5 – deficiency letter, Ex.R-6 & 7– medical documents, Ex.R-8 – General IPD file, Ex.R-9 – claim denial letter.
6. As per Ex,C1,the complainant obtained Care Health insurance Policy bearing No. 30569655 valid from 6.3.2021 to 05.03.2022 for the insured sum of Rs.5,00,000/-. As per discharge summary, vide Ex.C2, the complainant suffering from final diagnosis entric fever, septicemia, transamnitis and in this regard the
complainant admitted in Manvi Medical centre, New Bharat colony Opp. Chaddar Godem, near Mahaban farm Kheri Road, Grater Faridabad Haryana on dated 25.12.2021 at 3:45 p.m. and was discharged on 30.12.2021 at 5.00p.m. The hospital raised the final bill amount of Rs.46,599/- vide Ex. C-3 which was paid by the complainant in cash from his own pocket. Counsel for the complainant argued that as per the said policy of the terms and conditions the insurance company, the opposite party is liable to pay the daily allowance + Rs.10,000/- per day and the complainant was admitted in the hospital for 6 days which comes to Rs.60,000/- to the complainant was liable to receive the total claim amount of Rs.46,599/- +60,000/- = Rs.1,06,599/- from the opposite parties. Opposite parties have repudiated the claim of the complainant on 28.01.2022 vide Ex.C-8.
7. In this complaint, the opposite parties have failed to prove their case that the repudiation done by the opposite parties are not justified as per letter dated 12.01.2022 vide Annexure -4, letter dated 19.01.2022 vide Annexure R-5, letter dated 28.01.2022 vide Annexure R-9 .. The date of admission of the patient was 25.12.2021 and date of discharge was 30.12.2021. It is almost admission of 5 days. The opposite parties fail to resolve the issue of the complainant. This is an admitted fact that the complainant is insured with the opposite parties for daily allowance + Rs. 10,000/- par day and the opposite parties repudiated the claim of the complainant in whole. Now-a-days the Government of India promoted for the fair mediclaim policy and Care Health Insurance Limited had repudiated the claim of the complaint without any reason which is not justified. In the interest of justice, the complaint is allowed.
8. Opposite parties are directed to process the claim of the complainant amounting to Rs.46,599/- and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing complaint till its realization Opposite
parties are also directed to pay the daily allowance +Rs.10,000/- per day for 5 days.. The opposite parties are also directed to pay Rs.5500/- as compensation on account of mental tension, agony and harassment alongwith Rs.5500/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. In case of fraud, opposite parties can file the complaint against the hospital in proper court/competent authorities to recover that amount . Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 30.01.2024. (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
