Chandigarh

DF-I

CC/825/2021

Amrik Singh - Complainant(s)

Versus

Max Bupa Health Insurance Co. Ltd. - Opp.Party(s)

Shekhar Choudhary

03 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/825/2021
Date of Institution	:	26/11/2021
Date of Decision	:	03/10/2023

 

Amrik Singh, resident of house No.1869/2, Phase 10, SAS Nagar, Mohali, Punjab.

… Complainant

V E R S U S

1. Max Bupa Health Insurance Co. Ltd. through its Managing Director, Regd. Office : C-98, Lajpat Nagar 1, Delhi-110024.

Second Address

Max Bupa Health Insurance Co. Ltd., Servicing Branch, SCO No.55-56-57, Second Floor, Sector 8-C, Madhya Marg, Chandigarh.

2. Neva Bupa Health Insurance Co. Ltd., formerly known as Max Bupa Health Insurance Co. Ltd., Regd. Office : C-98, Lajpat Nagar 1, Delhi-110024.

Second Address

Servicing Branch, SCO No.55-56-57, Second Floor, Sector 8-C, Madhya Marg, Chandigarh.

3. Max Super Speciality Hospital, Mohali (A unit of Hometrail Buildtech Pvt. Ltd.), Near Civil Hospital, Phase-6, Mohali.

… Opposite Party

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

 

ARGUED BY	:	Sh. Shekhar Choudhary, Advocate for complainant
	:	Sh. Gaurav Bhardwaj, Advocate for OPs 1 & 2
	:	Sh. Yoginder Bansal, Advocate for OP-3

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Amrik Singh, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that in the year 2020, complainant had obtained a health insurance policy (Annexure C-1) from OPs 1 & 2 which was valid w.e.f. 30.1.2020 to 29.1.2021 with sum insured of ₹5,00,000/- by paying gross premium of ₹18,060/-. The aforesaid policy was further renewed by the complainant w.e.f. 30.1.2021 to 29.1.2022, by paying premium of ₹19,087/- vide receipt (Annexure C-3).  In the month of October, 2021, complainant suffered from high fever and when he got his blood count tested, he was diagnosed with dengue and the platelet count was found as 1,52,000.  On the next day i.e. 22.10.2021, again he got his blood count tested and his platelet count was found reduced to 1,06,000.  On 23.10.2021, upon testing the platelet count further reduced to 96,000.  On the intervening night of 23/24.10.2021, when the complainant was in his washroom, he fell down and immediately he was brought to Max Super Speciality Hospital (OP-3) for treatment where he was immediately hospitalized and his treatment started.  As the platelet count and fever of the complainant were fluctuating, he remained in the hospital till 25.10.2021, on which date he got himself discharged. For the treatment of the complainant, OP-3 hospital had raised a bill of ₹45,399/-. The complainant had intimated OPs 1 & 2 for the cashless treatment, but, the same was denied on the ground that condition of the complainant was not such that required hospitalisation, rather he could have been taken care of in OPD and the claim of the complainant was covered under the exclusion clause. Due to the said act of the OPs, the complainant was compelled to firstly pay ₹10,000/-  vide receipt dated 24.10.2021 (Annexure C-10) after borrowing the same from his friend whereas the remaining amount of ₹35,369/- was paid vide receipt dated 25.10.2021 (Annexure C-11).  In this manner, the aforesaid act of OPs 1 & 2 amounts to deficiency in service and unfair trade practice.  OPs 1 & 2 were requested several times to admit the claim, but, with no result. Hence, the present consumer complaint.
2. OPs 1 & 2 resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, concealment of facts and also that the claim of complainant was denied as per clause 6 of the permanent exclusions of the policy.  On merits, admitted that the subject policy was issued to the complainant, but, denied that the cashless facility was wrongly denied to complainant. It is alleged that, in fact, the treatment which complainant had taken from OP-3/Hospital, could have been taken without hospitalisation and his claim was denied as per terms and conditions of the policy. The facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In its separate written version, OP-3 took preliminary objections of maintainability, cause of action and also that a false complaint has been filed against the answering OP.  However, it is admitted that the complainant was treated by the answering OP and bill of ₹45,369/- was raised.  On merits, facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
4. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had obtained a health insurance policy and was insured at the relevant time under the subject policy attached with the letter (Ex.R-4), which was valid w.e.f. 30.1.2021 to 29.1.2022 and he was admitted at OP-3 hospital on 24.10.2021 at 3.53 a.m. and was discharged on 25.10.2021 at 7.01 p.m. for the treatment of dengue, as is also evident from the settlement receipt and discharge summary (Annexure C-7 and C-8) and further that the cashless treatment to the complainant was denied by OPs 1 & 2, as a result of which the complainant was compelled to pay an amount of ₹45,399/- from his own pocket, as is also evident from the receipts (Annexure C-10 & C-11), the case is reduced to a narrow compass as it is to be determined if OPs 1 & 2 are unjustified in denying/ repudiating the claim of complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant or if OPs 1 & 2 are justified in denying/ repudiating the claim as per terms and conditions of the subject policy, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy as well as the medical record, having been relied upon by both the parties qua the treatment of the complainant, and for that purpose, the same are required to be scanned carefully.
   3. It is also the defence of the OPs, the cashless facility to the complainant was denied as per clause 6 of the subject policy which is relating to the permanent exclusion qua the claims.  However, perusal of the permanent exclusions nowhere indicates that the treatment for dengue related disease is excluded from making medi-claim.
   4. As per further defence of the OPs, though the complainant was diagnosed with dengue, but, he could have been treated as an outdoor patient and he was not required to be admitted and as it has come on record that the complainant got himself discharged from the OP-3 hospital on the next day i.e. 25.10.2021, it is clear that the claim of the complainant falls under exclusion clause 6 of the subject policy and the OPs have rightly denied the cashless facility to the complainant. It is also evident from the cashless denial letter (Ex.R-6) that OPs 1 & 2 have given the reason for denial of the cashless facility and the relevant portion of the same is reproduced below :-

       “Denial Remarks

        As per Permanent Exclusion Hospitalization not justified (as per received documents vital and oxygen saturation is wnl and it can be manage in OPD BASIS) Admission solely for the purpose of evaluation, investigations, diagnosis or observation services or not consistent with standard treatment guidelines (as defined by Clinical Establishments (Registration and Regulation) Act 2010 and amendments thereafter) or Evidence Based Clinical Practices.”

However, the aforesaid ground for denial of the cashless facility by the OPs has been proved wrong even as per the medical documents proved on record by the complainant.

5. Perusal of Annexure C-4 clearly indicates that the platelet count in the blood of the complainant was found as 1,52,000 on 21.10.2021 and on the very next day i.e. 22.10.2021 the same was reduced to 1,06,000 as is also evident from Annexure C-5.  Not only this, on the very next day i.e. 23.10.2021, the said platelet count had again fallen to 96,000, as is also evident from Annexure C-6.  Further, when it is the case of the complainant that he had fallen in his washroom on the intervening night of 23/24.10.2021 and immediately he was shifted to OP-3 hospital where he was hospitalized and treated upon and on the next day i.e. 25.10.2022, when his condition became stable, he got himself discharged, as is also evident from the discharge summary (Annexure C-8), to our mind it was the medical officer who was the best person to decide whether hospitalisation of the patient was required or not. As OPs 1 & 2 have formed their own opinion that the complainant could have been treated as an outdoor patient, without proving the opinion of any medical expert, they have wrongly denied the cashless facility to the complainant despite of the fact that he was insured with sum of ₹5,00,000/- at the time of his treatment.
6. In view of the foregoing, it is safe to hold that the OPs 1 & 2 were unjustified in denying/repudiating the claim of the complainant and said act amounts to deficiency in service on their part and, therefore, the present consumer complaint deserves to succeed against them.
7. Now coming to the quantum of relief to be awarded to the complainant, since he has proved payment of ₹45,399/- through receipts (Annexure C-10 & C-11), it is safe to hold that OPs 1 & 2 are liable to pay the said amount to the complainant alongwith interest and compensation etc. for the harassment suffered by him.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP 1 & 2 are directed as under :-

1. to pay ₹45,399/- to the complainant alongwith interest @ 9% per annum from the date of denial of cashless facility/repudiation of the claim i.e. 25.10.2021, till the date of payment.
2. to pay an amount of ₹15,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by OPs 1 & 2 within thirty days from the date of receipt of its certified copy, failing which, the payable amounts mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Since no deficiency in service or unfair trade practice has been alleged or proved against OP-3, therefore, the consumer complaint against it is dismissed with no order as to costs.
7. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
8. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 03/10/2023 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member