Delhi

North East

RBT/CC/197/2022

RAJENDER KUMAR - Complainant(s)

Versus

MAX BUPA HEALTH INS.CO.LTD. - Opp.Party(s)

13 Sep 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

RBT/Complaint Case No.197/22

 

 

In the matter of:

 

	Shri Rajender Kumar, S/o Shri Ram Phal, R/o House No. A-62, East Friends Enclave, Sultanpuri, Delhi-110086	Complainant
	Versus
1.         2.	Max Bupa Health Insurance Co. Ltd. Through its Branch Manager, Block B1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi-110044   Jaipur Golden Hospital Through Its Medical Supritendent, Sector 3, Rohini, Delhi-110085	Opposite Parties

 

DATE OF INSTITUTION:        JUDGMENT RESERVED ON:                           DATE OF ORDER:

11.06.18 28.02.23 13.09.23

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

ORDER

Anil kumar Bamba, Member

The Complainant has filed the present complaint under Section 12 of the Consumer protection Act, 1986.

 

Case of the Complainant

1. The case of the Complainant as revealed from the record is that the Complainant purchased cashless mediclaim policy bearing no. 30698280201700 from Opposite Party No. 1 for sum insured of Rs. 5,00,000/- for the period of 12.09.17 to 11.09.18. The said policy covered Complainant along with his wife, son and daughter. The Complainant stated that his daughter got ill and got admitted in Opposite Party No.2 hospital on 03.10.17 and got discharged on 07.10.17. The total expenses paid by Complainant on treatment was Rs. 41,330/-. The Complainant stated that in spite of mediclaim policy / cashless policy Complainant was compelled by Opposite Party No.1 to get treatment and to pay the expenses incurred. The total bill of Rs. 41,330/- was paid by Complainant. The Complainant applied/requested to Opposite Party No.1 to release the claim but no satisfactory response was given by Opposite Party No.1. The Complainant stated that he has supplied all the relevant documents to Opposite Party No.1, Opposite Party No.1 is not giving proper response nor releasing his claim. The Complainant stated that he had approached Opposite Party No.1 many times but no satisfactory response received by Complainant nor the claim was released. The Complainant stated that despite having mediclaim/ cashless policy Opposite Party No.1 failed to release the claim. Hence, this shows deficiency on the part of Opposite Parties. Complainant has prayed to direct the Opposite Party to release the claim amounting to Rs. 41,330/- with interest @ 24 % p.a. till realization and Rs. 1,00,000/- for mental harassment.  

Case of the Opposite Party No.1

2. The Opposite Party No.1 contested the case and filed written statement. It is stated that the Complainant approached Opposite Party company for availing a health insurance policy. As per the process involved, insured submitted proposal form for issuance of a health insurance policy namely Health Companion Family Floater Policy so as to provide an insurance over to himself, wife Mrs. Sonia, Son Mr. Trun Kansa and daughter Ms. Divya Kansal.
3. The Complainant was duly informed about the terms and conditions of the policy and only after being satisfied by the terms mentioned in the policy the Complainant signed and submitted the proposal form.
4. That believing the above said declaration, information and details provided by the proposer  (for himself as well as for other insured) including the medical history in the proposal form to be true, correct and complete in all respect, give due credence to the under writing norms of Opposite Party No.1 company, a policy no. 30698280201700 was issued for sum assured opted as per proposal form, to the proposer for the period 12.09.17 to 11.09.18. The policy is governed by the terms and conditions which were duly supplied to the Complainant along with the policy schedule.
5. That the present complaint is not maintainable. As per the terms of he policy contract if the policy is not suitable, the policy holder may get his/her policy reviewed by returning the policy and policy documents within 15 days. ( free look period) from the day the policy holder received the policy. The insurance company will return the premium paid to the policy holder after making certain deductions specified therein. In the present case, the policy along with the policy documents was dispatched to the policy holder and the same was duly received as admitted. The Complainant after the receipt of the subject policy and policy documents did not approached the replying Opposite Party and got his subject policy reviewed/cancelled within free look period implying that he Complainant duly accepted the subject policy and its documents with its terms and conditions. The policy holder never approached the replying Opposite Party with any grievance pertaining to the subject policy and its terms and conditions. The Complainant is bound by the policy contract and given up relinquish/waved his right by not exercising the free look provision. Thus, the complaint is devoid of any merit and it liable to be dismissed. That the Opposite Party as per clause 4 91) and 6 (2) of the IRDA Regulations, 2002, sent the policies and policy documents along with proposal form to the Complainant giving him an opportunity to review/cancel the policy within free look period. Despite receipt of the policy and policy documents, the policy holder failed to approach the Opposite Party within free look period making any grievance with respect to the policy or its terms and conditions, implying the policy and its terms and conditions were duly accepted by the policy holder and were in order.
6. Further, 04.10.17, a pre auth request was received by the Opposite Party from Jaipur Golden Hospital, Rohini, Delhi for the hospitalisation of daughter of the Complainant Ms. Divya Kansal, who was admitted for the diagnosis of Dengue fever. However on verification of the documents submitted by the Hospital on behalf of the Complainant, it was found that the hospitalisation period falls under the initial waiting period of 30 days from the date of commencement of the policy. Therefore, the Opposite Party denied the authorization for the above said hospitalisation of the Complainant as per clause 5.2 (erroneously mentioned as 4 (b) in the denial letter) of the terms of the policy.
7. The Opposite Party would like to put on record that the insurance company has duly responded to all the emails containing the grievance of the Complainant. In view of the aforesaid facts and circumstances, it is crystal clear that since there is a 30 day waiting period provided under the clause 5.2 of the terms and conditions of the policy and the cashless request received within the 30 days waiting period, Hence the Opposite Party No.1 has rightly rejected the pre authorization request as per the terms and conditions of the policy. Therefore, the present complaint is liable to be dismissed with exemplary costs.
8. The Complainant has with malafide and dishonest intention not only concealed the material facts from the Hon’ble Forum but also twisted and distorted the same to suit his convenience and to mislead this Hon’ble Forum. It is submitted that it is well established principle through a catena of judgments including that of the Supreme Court in United India Insurance Co. Ltd. Vs. Harchand Rai Chand Rai Chandanlal I (2003) CPJ 393 & Vikram Greentech (I) Ltd. & Anr. Vs. New India Assurance Co. Ltd. II (2009) CPJ 34 that an insurance policy is to be construed strictly as per the terms and conditions of the policy document which is a binding contract between the parties and nothing can be added or subtracted by giving a different meaning to the words mentioned therein. Therefore, in light of this, Complainant is bound by the terms and conditions of policy. Further, the Hon’ble Supreme Court in Export Credit Guarantee Corporation of India Ltd. Vs. Garg Songs International [ 2013 (1) SCALE 410] held that while construing the terms of the contract of insurance, the court must give paramount importance to the terms used in the said contract. That in the case of Reliance Life Insurance Co. Ltd. Vs. Madhavacharya (Revision petition no. 211 of 2009) wherein it was held by the National Commission that “since the insurance between the insurer and the insured is a contract between the parties, the terms of the agreement including applicability of the provision and also its exclusion had to be strictly construed to determine the extent of the liability of the insurer”. In the case of Ravneet Singh Bagga vs. KLM Royal Dutch Airlines (2000) 1 SCC 66 the Hon’ble Supreme Court has laid down the test of deficiency in service by stating that   “The deficiency in service cannot be alleged without attributing fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be performed by a person in pursuance of a contract or otherwise in relation to any service. The burden of proving the deficiency in service is upon the person who alleges it. The Complainant has, on facts, been found to have not established any wilful fault, imperfection, shortcoming or inadequacy in the service of the Opposite Party. The deficiency in service has to be distinguished from the tortuous acts of the Opposite Parties. In the absence of deficiency in service the aggrieved person may have a remedy under the common law to file a suit for damages but cannot insist for grant of relief under the Act for alleged acts of commission and omission attributable to the Opposite Party which otherwise do not amount to deficiency in service. In case of bona fide disputes no wilful fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance in the service can be informed (sic). If on facts it is found that the person or authority rendering service had taken all precautions and considered all relevant facts and circumstances in the course of the transaction and that their action or the final decision was in good faith, it cannot be said that there had been any deficiency in service. If the action of the Opposite Party is found to be in good faith, there is not deficiency of service entitling the aggrieved person to claim relief under the Act. The rendering of deficient service has to be considered and decided in each case according to the facts of that case for which no hard and fast rule can be laid down. Inefficiency, lack of due care, absence of bona fides, rashness, haste or omission and the like may be the factors to ascertain the deficiency in rendering the service. ”

Case of the Opposite Party No.2

9. The Opposite Party No.2 contested the case and filed common filed written statement. Opposite Party No.2 stated that all the allegations/ claims are against Opposite Party No.1 and Opposite Party No.2 has been impleaded as a proforma party and has no liability in the present case.

Evidence of the Complainant

10. The Complainant in support of his complaint filed his affidavit wherein he has supported the averments made in the complaint.

Evidence of the Opposite Parties

11. In order to prove its case Opposite Party No.1 has filed affidavit of Ms. Chandrika Bhattacharya, Constituted Attorney of Opposite Party No.1 and Opposite Party No.2 has filed affidavit of Dr. Nishith Mittal, Medical Superintendent at Opposite Party No.2, wherein the averments made in the written statements of Opposite Parties have been supported.

 

 

Arguments & Conclusion

12. We have heard the Ld Counsel for the Complainant and Opposite Parties. We have also perused the file and the written arguments filed by parties.  The case of the Complainant is that he has purchased a cashless mediclaim policy from Opposite Party No. 1 for the sum insured of Rs. 5,00,000/- for the period of 12.09.17 to 11.09.18. The said policy covered Complainant along with his wife, son and daughter. As per Complainant his daughter got ill and got admitted in Opposite Party No.2 hospital on 03.10.17 and got discharged on 07.10.17. The total expenses paid by Complainant on treatment was Rs. 41,330/-. The Complainant stated that in spite of mediclaim policy / cashless policy Complainant was compelled by Opposite Party No.1 to get treatment and to pay the expenses incurred. The Complainant applied/requested to Opposite Party No.1 to release the claim but no satisfactory response was given by Opposite Party No.1. Hence, this shows deficiency on the part of Opposite Parties.
13. The case of the Opposite Party No.1 is that it is admitted that Opposite Party No.1 has issued mediclaim policy to the Complainant for the period 12.09.17 to 11.09.18 which covers the Complainant, his wife, son and daughter. The policy is governed by the terms and conditions which were duly supplied to the complainant along with the policy schedule and as per para 5.2 of the Health Companion Policy Document which read as follows :-   “Initial waiting period (30 days)

All the benefits under the policy and any treatment taken unless the treatment needed is the result of an accident that occurs during the policy period will be subject to a waiting period of 30 days since the inception of the first policy with us.”

14.  The Complainant Claim falls under the initial waiting period of 30 days from the date of commencement of the policy. Hence, Opposite Party denied the authorisation for the hospitalisation of the Complainant daughter. It is also stated by the Opposite Party that they have duly responded to all the emails containing the grievances of the Complainant. It is further stated by the Opposite Party that the policy along with policy document were dispatched to the policy holder and the same was duly received by the Complainant and which is not contested by the Complainant so the Complainant is bound by the policy contract and given up relinquish/waved his right by not exercising the free look provision.
15. The Hon’ble Supreme Court of India in United India Insurance Co. Ltd. Vs. Harchand Rai Chand Rai Chandanlal I (2003) CPJ 393 & Vikram Greentech (I) Ltd. & Anr. Vs. New India Assurance Co. Ltd. II (2009) CPJ 34 that an insurance policy is to be construed strictly as per the terms and conditions of the policy document which is a binding contract between the parties and nothing can be added or subtracted by giving a different meaning to the words mentioned therein.
16. In view of the above, the complaint is dismissed.
17. Order announced on 13.09.23.

Copy of this order be given to the parties free of cost.

File be consigned to Record Room.

 

(Anil Kumar Bamba)           Member

(Surinder Kumar Sharma) President