Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 79/09.03.2017
Jagbir Singh s/o Late Puran Singh
R/o H. No. 143, Shiv Mandir, Main Road,
Daryapur Kalan, Bawana North West,
Delhi-110039 …Complainant
Versus
Max Bupa Health Insurance Co. Ltd.
39, Samyak Towers, 3rd floor, WEA,
Pusa Road, Near Pillar No. 121, Karol Bagh,
New Delhhi-110005 ...Opposite Party
Date of filing/Institution : 09.03.2017
Coram: Date of Order : 07.03.2024
Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
ORDER
Inder Jeet Singh , President
1.1. (Introduction to case of parties) –The complainant has grievances of deficiency of services and of unfair trade practice trade practice against the OP that despite having valid medical claim of hospitalization bills, during the currency of insurance policy taken from the OP, the claim was declined on flimsy reason as if the case of complainant was of non-emergency case. Whereas, he was hospitalized from 17.08.2016 to 22.08.2016 for treatment requirement.
1.2. The OP denies the allegations of deficiency of services and of unfair trade practice as well as the claim is not within the parameter of terms and conditions of policy, since the complainant’s treatment was not falling within the definition of ‘emergency’ of terms and conditions of policy to make out a case of claim within 90 days from the date of commencement of the policy and because of waiting period of 90 days, the exclusion clause 4(b) is applicable.
2.1. (Case of complainant) –The complainant took health insurance policy no. 30553093201600 dated 28.07.2016. On 16.08.2016 because of fever, he went to Max Hospital, Shalimar Bagh, where he was told to be patient of typhoid but advised that in case symptoms do not improve, he will require hospitalization. He came back to his residence but his condition became serious, he went to hospital again on 17.08.2016, thence he was hospitalized and remained under treatment till 22.08.2016. During that period of hospitalization, he incurred medical expenses of Rs. 78,204/-.
2.2. When complainant became fit, he lodged claim on 15/16.10.2016 vide claim no. 213774, which was rejected by OP. The complainant was not disclosed grounds for rejection, however, on his persistent inquiry and requests, then he came to know the rejection was on the ground that case of complainant was treated as non-emergency case. The OP also told to the complainant that as per terms and conditions of policy, the initial awaiting period of 90 days (excluding medical emergency) from day one of policy is not covered. Whereas, the complainant was in urgent medical treatment due to his illness and that is why he was admitted and hospitalized for treatment, the complainant was under the hope that OP will pay the medical bills amount.
Moreover, the complainant had been visiting the office of OP and asked settlement of his claim but there was no satisfactory answer given by the OP, in fact he was threatened by the officials of OP. Whereas, the complainant has legal right to make claim of his valid medical expenses and OP has no option but to reimburse the medical expenses. Further, the complainant had taken loan of Rs. 80,000/- on interest at the rate of 10% pm for meeting the treatment expenses and he has also paid Rs. 56,000/- till date, being continuing to pay. The OP is liable to pay Rs. 80,000/- besides Rs. 56,000/- alongwith interest.
That is why, the present complaint for direction to OP to refund entire amount of Rs. 80,000/- alongwith of Rs. 56,000/- with interest besides compensation of Rs. 1 lakh on account of physical and mental harassment, agony, which have been caused because of deficiency of services and unfair trade practice besides litigation cost of Rs. 25,000/-.
2.3 The complaint is accompanied with copies of - insurance cover note with terms and conditions, medical prescriptions, admission and discharge of complainant, medical bills inclusive of medicine bills, claim form, OP’s letter dated 16.11.2016 of declining the claim, besides request for reopening of claim.
3.1 (Case of OP)- The complaint is opposed by the OP that it is vexatious, misconceived and it is also based on misrepresentation of facts, therefore, it is not maintainable and it is liable to be dismissed.
3.2. The insurance policy was issued after submission of proposal form no. 200700302828 dated 28.07.2016, proposing for insurance cover to the complainant himself, his wife and son. The proposal form was signed by the complainant after going through the terms and conditions of policy besides its detail was also explained by the insurance agent/sales representative and after apprehending them the proposal form was signed and then policy was issued from 28.07.2016 to 27.07.2017 for sum insured of Rs. 18 lakhs, as opted in the proposal form. The complainant has not exercised the option of free-look period of 15 days nor there was any objection to the terms and conditions of policy, therefore, the complainant is bound by the terms and conditions of policy strictly.
3.3. The OP had received claim request from the complainant, however, by virtue of clause 4 (b), there is waiting period of 90 days for all illnesses (except accident and emergency), the claim was not admissible since the claim was for hospitalization of period from 17.08.2016 to 22.08.2016 and policy came into existence on 28.07.2016, the period of 90 days had not elapsed from the commencement of policy. Moreover, the treatment rendered does not fulfill the requirement of emergency, that is why the claim is not tenable. The OP reproduces the exclusion clause 4(b) alongwith definition of accident and emergency, the same is as under:-
Exclusions- clause 4 (b)- Waiting period : “90 days waiting period: we will not cover any treatment taken during the first 90 days since the date of commencement of the policy, unless the treatment needed is a result of an Accident or Emergency. This waiting period does not apply to any subsequent and continuous renewals of your Policy”.
Clause-6 (definition 1) of the policy defines Accident or Accidental. It states that, “Accident or Accidental means a sudden, unforeseen or involuntary event caused by external, visible and violent means”.
Clause-6 (definition 16) of the Policy defines Emergency. It states that, “Emergency means a severe illness or injury which results in symptoms which occur suddenly and un-expectantly, and requires immediate care by a Medical Practitioner to prevent death or serious long term impairment of the Insured Person’s health”.
3.4 Since the claim is not covered under the terms and conditions of the policy, therefore, the repudiation letter to this effect was issued to the complainant. The OP is not liable to pay any amount much less Rs. 80,000/- alongwith Rs. 56,000/- or interest at the rate of 10%pm, compensation of Rs. 1 lakh or litigation cost of Rs. 25,000/- or the relief. The complaint deserves dismissal. The reply is accompanied with authority letter dated 31.01.2017 in favour of Ms. Sheetal Patwa, Manager-Legal, who authored the reply.
4.1. (Evidence)- The complainant led evidence by filing his own affidavit in detail, on the pattern of complaint coupled with documentary record filed in support of complaint.
4.2. The OP also led evidence through the affidavit of evidence of Ms. Sheetal Patwa, constituted attorney of OP, the affidavit is also replica of the written statement of OP.
5.1 (Final hearing)- The parties were given opportunity for filing written arguments and for oral submission. Both the parties have filed their respective written arguments, which are blend of pleading and evidence.
5.2. However, at the stage of oral submissions, the complainant has not made any oral submission but by Ms. Simran Verma, Advocate with the authority of Ms. Anita Kumar, Advocate for OP. There is discharge summary as a part of medical papers filed by the complainant, its typed text version was filed by the OP to make it legible for reading. Since the written arguments of complainant are on record, it will be considered as substitute of oral submissions on behalf of complainant.
6.1 (Findings)-The case of both the sides are considered, keeping in view the material on record especially the documentary record. The same is assessed. By taking into stock of all the material, the following conclusions are drawn:-
(i). There is no dispute in respect of tenure of the policy, the sum insured, the period of hospitalization, the bills amount but dispute is in respect of entitlement for reimbursement of medical bill amount claimed by the complainant from the OP vis-à-vis plea of OP of the exclusion clause 4(b) r/w definition clauses 6(16).
(ii). The complainant has proved prescriptions and accordingly it is acclaimed that he had visited the hospital on 16.08.2016 and he was advised that in case symptoms do not improve, he will need hospitalization and then on the next day he was admitted in the hospital and remained there admitted till 22.08.2016 because of his serious condition. It is to be construed within the terms and conditions of the policy and he is entitled for the amount claimed.
Whereas, according to OP the situation of complainant is not covered within the definition of emergency, which excludes the claim. Had it been a case of emergency within 90 days from the date of commencement of policy, the claim would be payable by the OP but the treatment of complainant is not falling within the criteria of emergency, which means “Emergency means a severe illness or injury which results in symptoms which occur suddenly and un-expectantly, and requires immediate care by a Medical Practitioner to prevent death or serious long term impairment of the Insured Person’s health”.
(iii). It is not disputed, but also settled law, that the parties are bound by the terms and conditions of the insurance policy contract. Now the narrow question is whether the admission in hospital of complainant falls in the category of emergency? The clause 6 (definition 16) means ‘emergency’ by specific terminology and it is not inclusive definition. Ordinarily, medical emergency means “an acute injury or illness that poses an immediate risk to a person’s life or long-term health”. Therefore, either by ordinary meaning of medical emergency or otherwise by virtue of the term emergency defines under the insurance policy contract between the parties, the first prescription of 16.08.2016 or subsequent discharge-summary; do not decipher to be a case of emergency of the complainant.
(iv). The complainant was examined by the doctor on 16.08.2016 in OPD and he was hospitalized from 17.08.2016 to 22.08.2016 but for want of fulfilling the criteria of ‘emergency’, it falls under the exclusion clause of 4(b), that the insurance claim is not available during waiting period of 90 days from the date of commencement of policy on 28.07.2016.
(v). The claim declining letter dated 16.11.2016 mentions the reasons of exclusion clause 4(b) of the insurance policy and the terms and conditions of insurance policy are also proved by the complainant, it contains such exclusion clause 4(b) along-with other clause 6 (definition 1) and clause 6 (definition 16).
6.2 In view of the analysis and conclusions drawn hereinabove, the complaint fails. The complaint is dismissed. No order as to cost
7. Announced on this 7thth day of March 2024 [फाल्गुन 17, साका 1945]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliance, besides to upload on the website of this Commission.
[Inder Jeet Singh]
President
[Shahina]
Member (Female)
[ijs32]
