Case No. 203/2022   

IN THE MATTER OF

Ram Prakash Sharma S/o Late Karan Singh Sharma R/o 370 Shivaji Park ke Pass Awas Vikas Colony, Aligarh UP

                                                         V/s

Religare Heath Insurance, Unit no. 640-607, 6^th Floor Tower-C Unitech Cyber Park, Sector-39 Gurugram-122001(Haryana) through bits Director-services                                  (Through: Arun Kumar Agrawal)

CORAM

 Present:

1. Shri Hasnain Qureshi, President
2. Shri Alok Upadhyaya
3. , Member

PERONOUNCED by Shri Hasnain Qureshi, President

JUDGMENT

1. The present complaint has been filed by the complainant before this commission for  the following reliefs-

1. The Op be directed to pay to the complainant Sum Rs. 476617/with interest at the rate 12% per annum.
2. The Op be directed to pay the complainant Rs. 50000/ as compensation for harassment and Rs. 25000/ as litigation expenses.

2. The Complainant has stated that he and his sons Jai Sharma and Ritish Sharma has purchased the group policy in the year2019 bearing group policy no.11561922 which was effective in the year 2019-20, 2020-21 to cover the risk upto Rs.100000/ on 26.08.2022 at about 9.30AM, complainant was standing infront of his house where he met with an accident. A four wheeler hit the complainant and run away. Complainant suffered injuries and he was admitted in Tyagi Trauma Centre, Sasni Gate, Aligarh at about 9.50 A.M. on 26.8.2022. the op was informed by the hospital at its toll free no. The policy was renewed w.e.f. 11.08.2022 to 10.8.2023 changing its group policy no. and new policy no. 17499225 was issued in place of policy no. 45227036. The hospital got the impression    having seen the different no. of the policy on the website of the Op that the policy had been closed and was not effective and refused to provide the facility by the hospital.  On refusal to provide the facility by the hospital, premium amount Rs.21016/ was again paid to the OP on 30.8.2022 whereas the said policy premium amount had earlier been paid on 9.8.2022. The policy had already been renewed substituting the new policy number. The policy was effective from 11.8.2022 to 10.8.2023 and claim was made by the complainant enclosing all the papers and legal notice was given on 2.09.2022 informing the OP all the facts concerning the consequences of the change in the policy number. Op had sent a deficiency letter dated 21.9.2022to the complainant asking additional information regarding the claim. Complainant replied all the 7 point asked by the Op and all the query were explained in the replied letter dated 3.10.2022. Complainant was reffered to higher centrefor further management and treatment on 26.8.2022 by Tyagi Hospital and he was brought to Neelkanth Hospital Gurgoan Hariyana on 26.8.2022 where he was admitted at 22.27’o clock. He remained under treatment there and was discharged on 6.9.2022 at 20.45’o clock. Complainant incurred expenses in his treatment at Tygi Hospital amounting Rs. 7967/ and he incurred expenses in his treatment at Neelkanth Hospital amounting Rs.348495/. he had also incurred expenses in carrying him in ambulance amounting Rs.8500/. complainant have incurred total amount Rs. 364962/ till the date of submitting of claim request to the Op on 8.9.2022 and thereafter he had also incurred expenses in his treatment as a outdoor patient in Neelkanth Hospital amounting Rs.9654/. Complainant’s brother Sri Ram Kumar Sharma had attended the complainant through out and he had to incurred the expenses Rs.12000/ on stay of his brother with him. Complainant had also suffered loss at the rate Rs1500/ per day for 60 days amounting Rs.90000/ on account of his inability to carry out the work as an associate with the deed writer at the court at Aligarh. OP has not settled the claim hence the complaint was filed. Op has not only failed in discharging his obligations but also adopted unfair trade practice of misleading representation.
3. Op stated in the WS that the Op had issued a group health insurance policy to the group policy holder i.e. P.N.B. vide group policy no. 11561922 thereby covered Mr. Ram Prakash sharma , Mr. Jai Sharma and Mr. Ritish sharma with effect from 11.8.2019 to 10.8.2020 for a sum insured upto Rs.1000000/. the said policy was renewed from 11.8.2020 to 10.8.2021 and from 11.8.2021 to 10.8.2022 op issued the group health insurance policy with better product feature vide group policy no. 17499225 covering   Mr. Ram Prakash sharma , Mr. Jai Sharma and Mr. Ritish sharma  with effect from 11.8.2022 to 10.8.2023 for a sum Rs.1000000/. complainant filed a claim for hospitalization charges at Neelkanth Hospital from 26.8.2022 to 6.9.2022. Op raised queries but no reply received and again op raised a remainder but no reply received from complainant. Op found that the complainant was deficient in providing documents in processing the claim hence claim is still pending deficiency of documents.
4. Complainant submitted in his replication that he had replied the 7 point vide letter date 3.10.2022 for the queries asked by the Op in its deficiency letter dated 21.09.2002. complainant had submitted all the necessary papers to the op as demanded under queries and his brother Ram Kumar sharma had met CRM Mr. Nishant on 30.9.2022 who was assured to settle the claim at the earliest on compliance of deficiency letter dated 21.9.2022 which was handed over to him. His entry is recorded in register at serial no 27.Op has failed  to settle the claim in spite of completion of the formalities.
5.  Complainant has filed his affidavit and papers in support of his pleadings. Ops have also filed affidavit in support of their pleadings.
6. We have perused the material available on record and heard the parties counsel.
7. The first question of consideration before us is whether the complainant submitted all the necessary papers to settle the claim of reimbursement? If so, its effect.
8. Complainant has stated that the claim request no.3008202576 was submitted by him enclosing all the papers marking serial no. 1 to 125 and he has file those papers with the complaint. Further complainant stated that a deficiencies letter dated 21.09.2022 sent by the Op asking additional information for the claim no. 9261749101 was reply by him by his letter datedc3.10.2022 in which all the queries made by the op were explain. Complainant file deficiency letter annexure 6 and his reply annexure 7. Complainant had also stated that the claim was not settled despite of submitting all the necessary letter and submitting reply dated 3.10.2022 against deficiency letter 21.09.2022 and then complainant’s brother Sri Ram Kumar Sharma met CRM Mr. Nishant on 30.9.2022 and again on 14.10.2022 and his entry was recorded in the register. He was assured that all the formalities have been completed and there was no deficiency in making settlement of the claim but the claim was not settle. The Op has alleged that the claim could not be processed on account of not providing documents by the complainant but the said allegation is demolished in view of above discussion and it is held that the complainant had submitted all the papers to settle the claim and op had wrongly denied to process the claim for settlement. Accordingly complainant is entitled for reimbursement as per terms of the policy. As per terms of the policy complainant is entitled for hospitalization expenses in-patient care / day care treatment upto the sum insured,  post hospitalization medical expenses for 60 days and domestic road ambulance upto Rs. 1000/ per claim. Thus the complainant is entitled for hospitalization expenses at Rs. 348495, post hospitalization medical expenses at Rs.9654/ and domestic road ambulance at Rs.1000/ total Rs.359149/ .
9.  The question formulated above is decided in favour of the complainat.
10. The Second question of consideration before us is whether the OP  had applied unfair trade practice in receiving the premium amount 21016/ twice and misleading the hospital by the new policy no ? if so, its effect.
11. Complainant has stated that he was issued group policy by the OP in the year 2019 for himself and his sons Jai Sharma and Ritish Sharma and certificate of insurance no. 4522706 having group policy no 11561922 were issued was effective from 11.8.2019 to 10.8.2020 and 11.8.2020 to 10.8.2021. The policy was to be renewed from 11.8.2022 to 10.8.2023. The   premium Rs. 21016/ was paid on 9.8.2022 to renew the policy and the policy was renewed by changing its group policy no and certificate of insurance no.and new group policy no. 17499225 and new certificate of insurance no. 45227036. These numbers were different from earlier number of the policy and the hospital got the impression having seen different policy no. on the website of the op that the policy had been closed and was not effective.  On refusal to provide the facilities by the hospital, premium amount Rs. 21016/ was again paid on 30.8.2022 whereas the policy had already be renewed  replacing group policy and certificate policy no. Complainant had stated that the Op made a misleading representation and adopted deceptive practice of misleading representation which amounts to unfair trade practice. OP has stated that the policy was renewed better product feature vide group policy no. 17499225. It is clear that the policy was renewed with different no. and the complainant was not informed about the change of number and the change was not indicated in the new policy no. with the reference of old policy number. Under the circumstance no reasonable and prudent person could know the facts that the policy had been renewed assigning new policy number and certainly it was a misleading representation on the part of the op which false within deceptive practice amounting to unfair trade practice under the provisions of the Act. The complainant had to pay the premium amount Rs. 21016/ twice and he is entitled for the refund of excess premium amount Rs. 21016/ and also for compensation for the harassment Rs. 25000/ and Rs.10000/ as litigation expenses.
12.  The question formulated above is decided in favour of the complainat.
13.  Keeping in view the facts of the present case, we hereby direct to Op to pay to the complainant  the hospitalization expenses at Rs. 348495, post hospitalization medical expenses at Rs.9654/ and domestic road ambulance at Rs.1000/ total Rs.359149/,excess premium amount Rs.21016/, compensation for the harassment Rs. 25000/ and Rs.10000/ as litigation expenses
14. Op shall comply with the direction within a month failing which OPs shall be prosecuted for non-compliance in accordance with section 72 of the Act for awarding punishment against him.
15. A copy of this judgment be provided to all the parties as per rule as mandated by Consumer Protection Act, 2019. The judgment be uploaded forthwith on the website of the commission for the perusal of the parties.
16. File be consigned to record room along with a copy of this judgment.