BEFORE THE TELANGANA STATE CONSUMER DISPUTES REDRESSAL COMMISSION : HYDERABAD.

F.A.No. 700 OF 2021 AGAINST ORDERS IN C.C.147/2019 DISTRICT CONSUMER COMMISSION-III, HYDERABAD Between:

1. The Authorized Signatory, Religare Health Insurance Co., Ltd., (Now Care Health Insurance Ltd.,), Vipul Tech Square, Tower C, 3r Floor, Sector-43, Golf Course Road, Gurugram – 122 009.

2. The Authorized Signatory, The Religare Health Insurance Co., Ltd., (Now Care Health Insurance Ltd.,), 2nd Floor, Brij Tarnag, Commercial Complex, H.No.6-3-1191/1 to 6-3-1196/2C, Besides Green Land Guest, Begumpet, Hyderabad, Telangana-500 016.

………..Appellants/ Opposite Parties And:

Smt. Ponnapalli Prashanti, W/o P.Ashok Kumar, Aged : 53 years, Occ.: Household, R/o Flat No.502, Murali Harmony Apartments, 13^th Lane, Santhi Nagar Colony, Eluru, W.G.Dist.

………Respondent/ Complainant Counsel for the Appellants/ Opposite Parties : M/s. N.Srinath Rao For the Respondent/Complainant : Called absent HON’BLE SMT. JUSTICE DR.G.RADHA RANI, PRESIDENT HON’BLE SMT. MEENA RAMANATHAN, MEMBER – (NJ)

MONDAY, THE 23^rd DAY OF FEBRUARY TWO THOUSAND TWENTY SIX *******

Order :

PER HON’BLE SMT. MEENA RAMANATHAN, MEMBER (NON-JUDICIAL)

1. The appeal is filed u/s 41 of Consumer Protection Act, 2019 by the Opposite Parties No. 1 & 2, aggrieved by the order of District Consumer Commission-III, Hyderabad, dated 07.09.2021 in CC 147/2019 and prays this Commission to set aside the impugned order and to pass such other order or orders which may deem fit and proper in the circumstances of the case.

2. The brief averments of the complaint are that the complainant, aged 53 years old was travelling to U.S. and availed a worldwide policy from the opposite parties with effect from 07th August 2018 to 28th January 2019. The policy plan is Gold-WW (Single) and sum insured is USD 100000. On 20.10.2018 she suddenly fainted and was treated in the emergency care at Greenville Health Center, Seneca, SC. She was discharged at 05:00 p.m. The said hospital is under the list of hospitals covered under the policy and the copy of the Insurance policy was submitted to the hospital. The treatment at the hospital costed her 585 USD for consultation and 5207.55 USD towards charges for emergency treatment.

Despite initiating the claim, the hospital authorities informed the complainant that there was no response and gave a deadline to the complainant to clear the dues by 11.01.2019. The complainant’s daughter sent several emails to opposite parties to clear the dues at Greenville Health Centre, but there was no response. The complainant paid the huge amount of Rs.19,973/- as premium for the policy but the opposite parties have wantonly breached the terms and this amounts to deficiency in service and therefore, the present complaint is raised for redressal.

3. The opposite parties No.1 & 2 filed their written version. They admit that the complainant availed Travel Insurance Policy vide No.12806614 w.e.f. 07.08.2018 to 28.01.2019, subject to policy terms and conditions. The complainant was admitted to Green Ville Memorial Hospital on out-patient basis and filed cashless claims via email for the hospitalization. The cashless claim was rejected by the opposite parties on 18.12.2018. They have relied on clause 2.1.4 (a)

(i) R/w clause1.26- wherein cashless facility is available only if hospitalization is for more than 24 hours. Since, the hospitalization of the complainant was for less than 24 hours, the claim was denied. The complainant was asked to file reimbursement, which is yet to be received by the opposite parties. Post denial of the claim, the complainant sent a legal notice to the opposite parties and it was replied to vide letter dated 21.02.2019, explaining the reasons for rejection of claim. It is therefore, prayed the Commission to dismiss the complaint with costs in the interest of justice.

4. Before the Commission below, complainant filed evidence affidavit as PW1 and marked Ex. A1 to A11. One Ms. Shreya Chandsoria, Manager