Religare told to pay Rs 2.91L claim, give Rs 2L for needy patients at PGI

Sandeep Rana

Tribune News Service

Chandigarh, July 15

For denying a claim, the District Consumer Disputes Redressal Forum directed Religare Health Insurance Company to pay Rs 2.91 lakh as medial reimbursement, along with interest, but also ordered it to deposit Rs 2 lakh in the cardiology department of the PGI for the treatment of needy patients. Besides, it told the company to pay Rs 10,000 litigation fee to the complainant. 

According to a complaint filed by Ram Sarup (61), a resident of Sector 47, he took a health insurance policy of the company and underwent knee surgery on October 22 last year at Max Super Specialty Hospital, Mohali. He had stayed at the hospital from October 21 to 27.

It was averred that the pre-authorisation request of cashless hospitalisation of the complainant was denied by Religare on flimsy ground of non-disclosure of material facts/pre-existing disease. 

As such, the complainant had to pay a bill of Rs 2,91,354 on being discharged from the hospital. 

It was submitted that the complainant later requested the opposite party many a times to reimburse him, but it did not pay any heed, forcing him to approach the forum.

In its reply, the opposite party stated that he suppressed material facts from the company while taking the policy. At the time of pre-anaesthesia check-up, the complainant had revealed that he was suffering from hypertension for the past five years and was on regular medication. He was suffering from diabetes T-II DM for the past eight to ten years and was getting himself checked regular. However, he never disclosed about him suffering from hypertension and diabetes as pre-existing ailment when the policy was proposed or thereafter. 

In its order, the forum said the complainant was not a chronic patient of hypertension, as alleged. There is nothing on record to prove that he was under treatment for hypertension before his admission to Max Super Specialty Hospital, Mohali. Moreover, there is no link between the treatment taken by the complainant i.e. knee surgery and hypertension and DM-II.