Haryana

Karnal

CC/403/2022

Nayab Singh - Complainant(s)

Versus

Chola MS General Insurance - Opp.Party(s)

Brij Bhushan Sharma

13 Dec 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.403 of 2022

                                                        Date of instt 15.07.2022

                                                        Date of Decision: 13.12.2024

 

Nayab Singh son of Shri Agar Singh, resident of village Koer, tehsil Nigdhu, district Karnal.

 

                                                                        …….Complainant.

                                              Versus

 

Chola MS General Insurance, SCO-334, Basement Mugal Canal Market, Karnal through its Manager.

 

                                                                   …..Opposite Party.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

              Ms. Neeru Agarwal…….Member

      Ms. Sarvjeet Kaur…..Member

 

Argued by:  Shri Brij Bhushan, counsel for the complainant.

                    Shri Naveen Khetarpal, counsel for the OP.

                   

                     (Sarvjeet Kaur, Member)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant purchased a mediclaim policy bearing no.2876/00041967/000003/000/00, valid from 02.01.2020  December, 2021 and thereafter policy was renewed from time to time. Ms. Savita wife of complainant was also covered under the said policy. The policy was meant for all types of illness and hospitalization. The said policy was cashless policy. On 16.04.2022, the wife of complainant was admitted in the Chaudhary Hospital, Medical and Maternity, Karnal and discharged on 21.04.2022. At the time of admission, complainant sought pre-authorization with the OP but OP denied the pre-authorization request of complainant. At the time of issuance of the policy, all the diseases were covered. OP never informed that hysterectomy is excluded from the policy. The OP has illegally and unlawfully denied the cashless claim of the complainant. OP has stated in the letter dated 18.04.2022 that insured can sent a request for consideration for reimbursement within 30 days from the date of discharge. The complainant sent pre-authorization request on 16.04.2022 and the said request can be treated for reimbursement of the amount. Complainant has spent an amount of Rs.32800/- on the hospitalization and Rs.50000/- on medicines and in this way complainant as spent total Rs.82800/- on the treatment of his wife. Complainant lodged the claim alongwith required documents with the OP for reimbursement of the said amount but till date no amount has been paid by the OP. Then complainant sent a legal notice to the OP but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence complainant filed the present complaint seeking direction to the OP to pay Rs.82,800/- i.e. amount spent by the complainant on the treatment of his wife alongwith 24% interest, to pay Rs.20,000/- as compensation for mental pain, agony and harassment and Rs.21000/- as litigation expenses.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that after getting the intimation regarding cashless treatment alongwith documents, it is observed that the present treatment hysterectomy which is excluded in the policy for the first two years. Hence the claim is inadmissible as per General Exclusion Clause 10.a.ii. No indemnity is available or payable for claims directly or indirectly caused by, arising out of or connected to the following Cataract, Benign Prostratic Hypertropy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Fistula in anus, Piles, interenal congenital disease, Sinusitis & related disorders, Gall Stones, Spondilitis, Spondilosis, Knee/Hip joint replacement, internal Congenital diseases, Osteoarthritis of any joint, Calculus diseases of Gall Bladder and Urogenital, Gastric and Duodenal ulcers, Internal Tumours, cysts, nodules, polyps including breast lumps (each of any kind unless malignant), Gout & Rheumatism, ENT disorders and surgery, surgery of genitor urinary system, surgery for prolapsed inter vertebral, disk, surgery of varicose veins & varicose ulcers, surgery on tonsils. Cashless treatment was denial to the hospital, vide letter dated 18.04.2022. The cashless approval is given by the OP only on a preliminary evaluation of documents submitted by treating hospital/insured and it is subject to review upon the receipt of further details/documents from the insured patient or at any time. If amount of treatment is exceeding to cashless approval or cashless approval is denied then insured can submit his final claim for the reimbursement of the medical expenses incurred by him with the OP insurance company with all the required documents. OP settles the claim according to terms and conditions of policy. The insured can sent a request for consideration through reimbursement within 30 days from the date of discharge. The insured is requested to submit the following original documents in this regard:

1.     Claim form duly filled and signed by the insured.

2.     Original Discharge Summary.

3.     Original Hospital final bill with break up details.

4.     All other original bills and original receipts.

5.     Investigation reports, x-ray, scan etc.

6.     Prescription of the treating doctor.

7.     Earlier treatment records, if any.

8.     A copy of a cancelled cheque to enable us to remit the amount in settlement of the admissible claim amount to your bank account.

9.     In case the claimed amount exceeds Rs.1,00,000/-, a copy of your PAN card as required by the provisions of the Prevention of Money Laundering Act.

There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.C1, copy of legal notice dated 31.05.2022 Ex.C2, copy of cashless denial letter dated 18.04.2022 Ex.C3, postal receipt Ex.C4, copies of insurance policies from the year 2021 to 2024 Ex.C5 to Ex.C7, copies of insurance cards Ex.C8 and Ex.C9, copy of medical bill Ex.C10, copy of insurance policy from 2^nd January, 2020 to 1^st January, 2021 Ex.C11, copy of insurance policy from 13.12.2020 to 12.12.2021 Ex.C12, copies of medical bills from Ex.C13 to Ex.C23, copy of aadhar card of complainant Ex.C24 and closed the evidence on 12.03.2024 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Sunil Gupta Ex.RW1/A, copy of cashless denial letter dated 18.04.2022 Ex.R1, copy of insurance policy Ex.R2, copy of terms and conditions of the insurance policy Ex.R3 and closed the evidence on 19.09.2024 by suffering separate statement.

 6.            We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant purchased a Health Insurance Policy from the OP. The sum insured under the policy is Rs.5,00,000/-. On 16.04.2022, during the subsistence of the insurance policy, the wife of complainant has taken the treatment from Chaudhary Hospital Medical and Maternity, Karnal and spent Rs.82800/- on her treatment. Complainant requested for the cashless claim with the OP but OP denied the cashless request of complainant on the false and frivolous ground. Thereafter, complainant lodged a claim and submitted all the required documents with the OP for reimbursement of said amount, but OP did not pay the claim amount and denied the claim of complainant on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued on receipt of claim intimation, the claim of the complainant was duly processed by the OP and observed that the present treatment hysterectomy which is excluded in the policy for the first two years. Hence the claim was not admissible as per General Exclusion Clause 10.a.ii. Thus, the claim of complainant was rightly denied by the OP and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

 10.          Admittedly, complainant purchased Health Insurance Policy from the OPs. It is also admitted that during the subsistence of insurance policy, wife of complainant has taken treatment from Chaudhary Hospital, Medical and Maternity, Karnal and spent Rs.82800/-.

11.           The claim of the complainant has been denied  by the OP, vide letter Ex.C3/Ex.R1 dated 18.04.2022 on the grounds, which are reproduced as under:-

“On perusal of the claim documents it is observed that the present treatment hysterectomy which is excluded in the policy for the first two years. Hence the claim is inadmissible as per General Clause 10.a.ii.No indemnity is available or payable for claims directory or indirectly caused by, arising out of or connected to the following Cataract, Benign Prostratic Hypertropy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Fistula in anus, Piles, interenal congenital disease, Sinusitis & related disorders, Gall Stones, Spondilitis, Spondilosis, Knee/Hip joint replacement, internal Congenital diseases, Osteoarthritis of any joint, Calculus diseases of Gall Bladder and Urogenital, Gastric and Duodenal ulcers, Internal Tumours, csts, nodules, polyps including breast lumps (each of any kind unless malignant), Gout & Rheumatism, ENT disorders and surgery, surgery of genitor urinary system, surgery for prolapsed inter vertebral, disk, surgery of varicose veins & varicose ulcers, surgery on tonsils.

A denial of cashless access is not to be considered in any way as a denial of treatment. The insured can send a request for consideration through reimbursement within 30 days from the date of discharge.

The insured is requested to submit the following original documents in this regard:

1.     Claim form duly filled and signed by the insured.

2.     Original Discharge Summary.

3.     Original Hospital final bill with break up details.

4.     All other original bills and original receipts.

5.     Investigation reports, x-ray, scan etc.

6.     Prescription of the treating doctor.

7.     Earlier treatment records, if any.

8.     A copy of a cancelled cheque to enable us to remit the amount in settlement of the admissible claim amount to your bank account.

9.     In case the claimed amount exceeds Rs.1,00,000/-, a copy of your PAN card as required by the provisions of the Prevention of Money Launder Act.

 

12.           The claim of the complainant has been denied by the OP on the abovesaid ground. OP has alleged that insured has taken the treatment of hysterectomy. The treatment of hysterectomy is excluded in the policy for the first two years.

13.           Complainant purchased first time policy Ex.C11 for the period of 02.01.2020 to 01.01.2021 and thereafter renewed the policy Ex.C12 from 13.12.2020 to 12.12.2021 and again renewed the policy Ex.C5 from 21.12.2021 to 20.12.2022 and also again got renewed the policy Ex.C6 for the period of 21.12.2022 to 20.12.2023. The wife of complainant has taken the treatment on 16.04.2022 of hysterectomy. The treatment has been taken by the insured after more than two years of the first policy. Hence the plea taken by the OP has no force.

14.           Furthermore, nowadays it has become a trend of insurance companies, they issued the policies by giving false assurances and when insured amount is claimed, they make such type of excuses. Thus, the denial of the claim of complainant is arbitrary and unjustified. In this regard, we place reliance on the judgment of Hon’ble Punjab and Haryana High Court titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, wherein the Hon’ble Punjab and Haryana High Court has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

15.           Keeping in view that the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, the act of the OP while repudiating the claim of complainant amounts to deficiency in services and unfair trade practice, which is otherwise proved genuine one.

16.           The complainant has spent an amount of Rs.82,800/- on the treatment of his wife and in this regard he has submitted the medical bills Ex.C13 to Ex.C23, the said amount neither denied nor rebutted by the OP.  Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental pain, agony harassment and litigation expenses etc.

17.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.82,800/- (Rs. eighty two thousand eight hundred only) alongwith interest @ 9% per annum from the date of filing the complaint 15.07.2022 till its realization to the complainant. We further direct the OP to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.5500/- towards the litigation expenses. This order shall be complied within 45 days from the date of receipt of copy of the order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated: 13.12.2024    

                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Neeru Agarwal)         (Sarvjeet Kaur)

                   Member                          Member