State Consumer Disputes Redressal Commission
1. The Authorized Signatory, The ... vs Smt. Ponnapalli Prashanti on 23 February, 2026
1
BEFORE THE TELANGANA STATE CONSUM ER DISPUTES
REDRESSAL COM M ISSION : HYDERABAD.
F.A.No. 700 OF 2021
AGAINST ORDERS IN C.C.147/2019
DISTRICT CONSUM ER COM M ISSION-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, 13th 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 SM T. JUSTICE DR.G.RADHA RANI, PRESIDENT HON'BLE SM T. M EENA RAMANATHAN, M EMBER - (NJ) M ONDAY, THE 23rd DAY OF FEBRUARY TW O THOUSAND TW ENTY 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 2 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 07 th August 2018 to 28 th 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 3 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 (Legal) of opposite parties filed evidence affidavit and got marked Ex.B1 to B4. Both the parties filed their written arguments respectively.
5. The District Commission, after hearing and considering the material on record, allowed the complaint in part, directing the opposite parties to pay US $ 5,207 as on the date of filing of the complaint i.e. 09.04.2019, in an Indian Currency and to pay a reasonable compensation of Rs.50,000/- to the complainant within 45 days from the date of this order. If the opposite parties fail to comply the order within 45 days, the above amounts awarded to the complainant shall carry interest @ 9% per annum after the expiry of the stipulated period, till the realization".
6. Aggrieved by the above orders, the Opposite Parties No.1 & 2 preferred this appeal contending that the Commission below failed to consider the following grounds:
The Commission below failed to consider the pleadings mentioned in the written version by the appellants and did not advert to the main issue raised in the complaint and thereby misdirected itself and allowed the complaint by exceeding its power and jurisdiction.
That the Commission below ought to have seen that the appellants vide its mail dated 18.12.2018 rejected the cashless treatment facility request on the ground that the respondent got hospitalized for less than 24 hours on Out-4
Patient Day (OPD) basis by relying on clause 2.1.4 (a) read with clause 1.26 which stipulates that cashless facility is available only if the hospitalization is more than 24 hours. Since, the hospitalization of the complainant was for less than 24 hours, the cashless claim was denied and the complainant was asked to file for reimbursement That the Commission below ought to have seen that the appellant has not taken any decision under clause 2.1.2. For taking any decision under clause 2.1.2., the respondent needs to submit all the necessary documents along with claim form under clause 2.1.5, however, respondent did not do so. In such a circumstance, the Commission below ought not to have passed the award.
With these grounds and others that will be urged at the time of arguments, requested to set aside the order of the Commission below and to dismiss the complaint.
7. As per the docket proceedings dated 04.02.2026, heard the counsel for appellant. No representation for respondent, since the service of notice upon them on 25.01.2022. Hence, reserved for orders.
8. For the sake of the convenience, the parties will be addressed as the complainant and the opposite parties, as arrayed in the impugned order.
9. The point that arises for consideration is whether the impugned order as passed by the District Commission suffers from any error or irregularity or whether it is liable to be set aside, modified or interfered with in any manner ? To what relief ?
10. POINT : The admitted facts are that the complainant availed a Travel Insurance Policy bearing No.12806614 w.e.f. 07.08.2018 to 28.01.2019. The policy provided a coverage of 1,00,000 USD. On 20.10.2018 the complainant suddenly fainted in the morning and was taken to the emergency room at Greenville Health Centre, Seneca, SC. Her claim for cashless treatment was rejected vide email dated 18.12.2018.
5The main issue that must be addressed is whether the complainant is eligible for cashless treatment as per the policy terms and conditions and whether the rejection of claim amounts to deficiency in service.
The perusal of the material placed before us discloses the following details:-
Ex.A1 is the proposal form for Gold -WWW (Single) policy for sum insured US $ 1,00,000 and valid for the period from 07.08.2018 to 28.01.2019.
The schedule of benefits reveals :-
Sl.No. Name of Benefits Sum Insured Deductibles
1. Hospitalization Upto Sl Upto 10% USD 100 Expenses In- of Sl for life Patient Care Sub- threatening limits as per clause conditions for PED 2.1.1.H Additional 100% of Sl for accidental hospitalization
2. Hospitalization Upto USD 50,000 USD 100 Expenses-Out Patient Care
11. Under the policy terms and conditions, Clause 1.8 reads as follows:-
"Cashless facility means a facility extended by the Company to the insured person where the payments of the costs of treatment undergone by the insured person in accordance with the policy terms and conditions and directly made to the Network provider by the Company to the extent pre-authorization approved".
Clause 1.22 reads as follows:-
"Emergency Care means management for a severe illness or injury which results in symptoms which occur suddenly and unexpected and requires immediate care by a Medical Practitioner to prevent death or serious long term impairment of the insurer person health".
Clause 1.26 reads as follows:-
"Hospitalization means admission in a Hospital for a minimum period of 24 In-patient case consecutive hours except for specified 6 procedure/treatments where such admission could be for a period of less than 24 consecutive hours".
The complainant has filed Ex.A5, evidencing the cost of treatment amounted to 5207 USD for hospital services and consultation charges of 585 USD.
Her claim for cashless facility was denied vide Ex.A4 on the grounds that cashless facility is provided only in case of in-patient treatment where hospitalization is for more than 24 hours. The complainant was requested to pay the hospital bills and claim reimbursement.
In their defense and grounds urged, the opposite parties have cited clause 1.26 (which we have already referred to) and clause 2.1.4 which is reproduced for easy reference:-
Claim Procedure (Cashless) Application to Benefits:-
Cashless Facility : Cashless facility is available only at Network providers. The insured person can avail of this cashless fa cility at the time of admission into a Network provider by completing the following procedure:-
(i) Pre-authorization. The policy holder or insured person must ............... the Company's Assistance Service Provider's call center as specified in the policy certificate and request authorization for the proposed treatment by way of submission of a completed pre-authorization form at least within 24 hours of admission to hospital if the hospitalization is required.
(ii) The Company will process the request for authorization after having obtained accurate and complete information in respect of the illness or injury .................. which cashless facility is sought tobe availed. The Company of the Assistance Service Provider will confirm in writing authorization or rejection of authorization to avail cashless facility for the insured person's hospitalization.
(iii) If the request for availing cashless facility is authorized by the Company or the Assistance Service Provider, then payment for the medical expenses incurred in respect of the insured person shall not have tobe made to the extent that such medical expenses are covered under this policy and fall within the amount authorized in writing by the Company for availing cashless facility. Payment in respect of all deductions and amount exceeding the sub-limits as applicable shall be made directly by the policy holder or insured person to the network provider.7
(iv) If the Company or the Assistance Service Provider does not authorize the cashless facility due to insufficient sum insured or insufficient information provided to the Company or the Assistance Service Provider to determine the admissibility of the claim or if the treatment is not taken at a Network provider, payment for the treatment will have to be made by the policy holder or insured person to the network provider following which a claim for reimbursement may be made to the Company which will be considered by the Company subject to the terms and conditions and exclusions under the policy.
(v) It is the agreed and understood tha t in all cases where availing of cashless facility has been authorized in writing by the Company or the Assistance Service Provider all the information and documents as specified below in clause 2.1.5 shall be submitted to the Company or the Assistance Service Provide immediately and in any event before the insured person's develop from Network Provider.
12. It is the argument of the complainant that for emergency care she required immediate attention and was treated as an out-patient and was there are a period of less than 24 hours and denial of cashless facility is not as per terms of policy.
The schedule of benefits clearly specifies that the insured is entitled to out-patient care upto USD 50,000. Out-patient care in Travel Insurance Policy refers to medical treatment consultation or tests that do not require an overnight stay at the hospital or admission. This benefit is specifically extended to the insured by way of the present policy. We find it necessary to emphasize that the policy specifically included out-patient care.
13. The opposite party can only deny a cashless facility if it is not listed as a benefit or if the hospital is non-listed in their network.
In the instant case, out-patient care - hospitalization is clearly listed in the schedule of benefits and the hospital is listed in the insurer's network. The complainant took treatment in a hospital that was on the insurer's list and the hospital submitted the paperwork to the TPA and the policy specified the out-patient care benefit, yet her claim for cashless facility was unfairly repudiated.
8It is not the case of the opposite party that they were not notified promptly or that the hospital is not on the approved list.
Cashless travel insurance is meant to be a stress free safety net, yet when insurance companies/opposite parties deny the facility despite the complainant/insured having followed all the conditions, the deficiency of service is most unfair and unjustified. Hence, considering the facts and aforesaid discussions, we are of the view that the complainant proved the deficiency of service and unfair trade practice of the opposite parties and the impugned order required to be modified.
14. In the result, the appeal is dismissed without costs by confirming the impugned order, dated 07.09.2021 in CC No.147/2019 passed by the District Consumer Commission-III, Hyderabad, The Respondent Complainant is at liberty to withdraw the amount deposited by appellants/Opposite Parties to the credit of this appeal along with accrued interest thereon, towards part satisfaction of the decretal amount after the lapse of revision time.
Typed to my dictation by Stenographer on the System; corrected by me and pronounced by us in the Open Court on this the 23rd day of February' 2026.
Sd/- Sd/-
PRESIDENT M EM BER (NON-JUDICIAL)
Dated : 23.02.2026
*AD