DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.

Complaint Case No : CC/63/2018

Date of Institution : 17.05.2018

Date of Decision : 19.08.2019

Bhushan Kumar aged about 44 years son of Hargopal r/o H. No. 41, Ward No. 1, Saran Patti, Handiaya, Tehsil and District Barnala-148107.

…Complainant

Versus

1. Max Bupa Health Insurance Co. Ltd., Registered Office: Max House, 1 Dr. Jha Marg, Okhla, New Delhi-110020 through its Director/ Manager.

2. The Federal Bank Ltd., Branch Barnala, Opposite Ram Bagh, New Grain Market Road, Barnala, District Barnala through its Branch Manager-148101.

…Opposite Parties

Complaint Under Section 12 of Consumer Protection Act, 1986.

Present: Sh. SK Kotia counsel for complainant.

Sh. Dhiraj Kumar counsel for opposite party No. 1.

Sh. JK Kapil counsel for opposite party No. 2.    

Quorum.-

1. Sh. Kuljit Singh : President

2. Sh. Tejinder Singh Bhangu : Member

3. Smt. Manisha : Member

(ORDER BY KULJIT SINGH, PRESIDENT):

1.    The complainant Bhushan Kumar has filed present complaint under Consumer Protection Act against Max Bupa Health Insurance Co Ltd, New Delhi and anr. (In short as opposite parties). 

2. The facts leading to the present complaint are that the complainant is account holder with the opposite party No. 2 bearing Account No. 20510100008774 who has tied up with the opposite party No. 1 and opposite party No. 2 has been working as an Agent of the opposite party No. 1. It is further alleged that under the said tied up scheme the opposite party No. 2 has got insured the complainant from the opposite party No. 1 and a policy of insurance (Group Health Insurance) has been duly supplied to the complainant having policy No. 00215300201700 dated 28.6.2017 effected from 15.9.2017 to 14.9.2018. This policy also covered the complainant's family including his wife and son for sum assured of Rs. 2,00,000/- against the premium of Rs. 4,783/- which was received by the opposite parties vide cheque No. 422053 debited from the account of the complainant. 

3. It is further alleged that son of the complainant was suffering from the typhoid fever so on 27.12.2017 he was admitted in Bhushan Children Hospital, New Grain Market Road, Barnala and hospitalized there from 27.12.2017 to 3.1.2018 and an amount of Rs. 22,200/- has been expended on his treatment for admission fee, nursing care, room charges and doctor visiting fee vide bill dated 3.1.2018 which was duly received from the complainant vide receipt No. 108 of the same day. Further, an amount of Rs. 28,086/- has been expended on the medicines, laboratory tests and others. The medicines were purchased from Rattan Medicine Traders and tests were conducted at Garg Computerized Laboratory. The complainant applied for the claim of Rs. 46,286/- with the opposite party No. 1 but vide letter dated 26.3.2018 opposite party No. 1 rejected the claim of the complainant on illegal grounds which amounts to deficiency in service on their part. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties be directed to pay the claim of Rs. 46,286/- alongwith interest at the rate of 12% per annum till its realization.  

2) To pay Rs. 21,000/- on account of mental tension and physical harassment.           

3) To pay Rs. 10,000/- as litigation expenses.  

4) Any other relief which this Forum deems fit and proper. 

4. Upon notice of this complaint, the opposite party No. 1  filed written version taking preliminary objections interalia on the grounds of not maintainable and not come to Forum with clean hands. It is admitted that Group Insurance Policy issued to the policy holder i.e. Federal Bank Limited having No. 00215300201700 and complainant Bhushan Kumar, Karamjeet Kaur and Abhdeep Bhardwaj were included in the policy. The risk inception date of the policy was 15.9.2017 and claim was repudiated on the ground that the claim is not genuine and same is fraudulent for which it is pertinent to mention here that the in house Lab Reports were done and signed by a technician as no MD Pathologist so reports not valid. Moreover, it is surprising to note that an 18 years old adult was taken for treatment to a Pediatrician for treatment of typhoid, so this is require a proper trial by a civil court.  Further, it is mention that individual laboratory technician cannot be allowed to run pathological laboratory independently without engaging a pathologist registered with the medical council so the opposite party has rejected the claim of the complainant as laboratory reports were signed by a technician and not a pathologist. Further, there is no deficiency in service on the part of the answering opposite party. It is admitted that the complainant had chosen Group Health Insurance whereby he, his spouse and his child covered. It is also admitted that answering opposite party received a claim request from the complainant for reimbursement of Rs. 46,286/- alongwith documents for typhoid fever treatment of his son Abhdeep Bhardwaj. The investigation revealed that no medical reports of Abhdeep were submitted with the claim and only bills of the report of Garg Pathology were submitted which was in House Lab and all tests/reports were done by technician as no Pathologist was attached with the lab so the reports were not valid. Further, no hospital bill was submitted and only receipts were submitted. Further, Abhdeep Bhardwaj who is an adult was admitted under a paediatrician (Child Specialist) so on these grounds the claim was rejected as per terms and conditions of the policy which was communicated to the complainant. Further, the present complaint is an abuse of the process of law. 

5. On merits, it is admitted that complainant and his family included in the policy as members. Further, in reply to complaint on merits the opposite party No. 1 reiterated the preliminary objections  so there is no need to explain the same again. However, it is submitted that no any conduct of the answering opposite party has put the complainant under mental agony and harassment. Lastly, the answering opposite party prayed for dismissal of the present complaint with costs.  

6. The opposite party No. 2 also filed written version taking legal objections on the grounds of no locus standi or cause of action, abuse of process of law, complainant is not a consumer, no jurisdiction, false complaint and bad for non joinder of necessary parties. 

7. On merits, it is admitted that complainant is account holder of the opposite party No. 2 having Account No. 20510100008774 and opposite party No. 2 has tied up with the opposite party No. 1 and opposite party No. 2 has been working as an Agent of the opposite party No. 1. Further, there is no deficiency in service on the part of the answering opposite party and opposite party No. 2 prayed for the dismissal of the present complaint with costs. 

8. In support of his case, the complainant tendered into evidence copy of policy as Ex.C-1, copy of passbook as Ex.C-2, copy of hospital bills as Ex.C-3, copy of discharge summary as Ex.C-4, copy of receipt No. 108 as Ex.C-5, copy of certificate dated 3.1.2018 as Ex.C-6, copy of medical bills as Ex.C-7 to Ex.C-13, copy of bill of lab test as Ex.C-14, copy of reports of lab tests as Ex.C-15 to Ex.C-22, copy of rejection letter dated 26.3.2018 as Ex.C-23, affidavit of complainant as Ex.C-24 and closed the evidence. 

9. To rebut the case of the complainant, the opposite party  No. 1 filed in evidence copy of Certificate of Insurance Ex.OP-1/1, copy of claims reimbursement checklist Ex.OP-1/2, copy of investigation report Ex.OP-1/3, copy of certificate of Bhushan Children Hospital, Barnala Ex.OP-1/4, copy of letter dated 1.6.2018 Ex.OP-1/5. The opposite party No. 2 filed in evidence affidavit of Ankit Arora Manager of opposite party No. 2 as Ex.OP-2/1.  

10. We have heard the learned counsel for the parties and have gone through the record. Written arguments filed by the parties have also been gone through.

11. It is an admitted fact between the parties that the complainant and his family was insured with the opposite party No. 1  vide policy Ex.C-1 for sum assured of Rs. 2,00,000/- for the period from 15.9.2017 to 14.9.2018 and premium of Rs. 4,783/- of this policy was duly received by the opposite party No. 1 vide cheque No. 422053.      It is also admitted by the opposite parties that son of the complainant has been hospitalized within the validity period of the insurance policy i.e. from 27.12.2017 to 3.1.2018. The complainant submitted in his complaint and affidavit Ex.C-24 that he expended Rs. 46,286/- on the treatment of his son and claimed this amount from the insurance company but the opposite party No. 1 repudiated the claim of the complainant vide letter dated 26.3.2018 Ex.C-23. The opposite party No. 1 submitted in their version and letter dated 1.6.2018 Ex.OP-1/5 that they repudiated the claim of the complainant on two grounds i.e firstly Garg Pathology is a house lab and all reports done by a technician as no MD Pathologist attached with the said lab so these reports not valid and secondly son of the complainant was an Adult at the time of admission but he admitted under a Pediatrician so authenticity of claim not established.  

12. Firstly, we deal with the first objection of the opposite party No. 1 that Garg Computerized Laboratory is a house lab and all reports not valid due to not signed by MD Pathologist and only signed by a technician. To support their plea the opposite party No. 1 relied upon order dated 12.12.2017 of Hon'ble Supreme Court in SLP (Civil) 28529 of 2010 titled North Guj. Unit of Asn. Of Self. Emp. Owners Versus North Gujarat Pathologists Assn. And Ors, in which the Hon'ble Apex Court of India held as under.-

“Though it is open to any person or institute to run a pathology laboratory, but no report can be issued without the signature or counter signature of the practicing pathologist recognized by the Medical Council of India. The respondents are directed to ensure that no pathology laboratory is run by any unqualified person or institute having no recognized pathologists registered with the Medical Council. However, if such pathological laboratory is run a pathologist registered with the Medical Council, or if such pathological laboratory engages a pathologist registered with the Medical Council, the respondents may allow such laboratory to run. Individual Laboratory Technician cannot be allowed to run pathological laboratory independently without engaging a pathologist registered with the Medical Council.”

From the perusal of bill and reports Ex.C-14 to Ex.C-22 it is proved on the record that these reports were signed by a Technologist and in view of above mentioned citation of the Hon'ble Apex Court of India these reports are not valid in the eyes of law, so we are of the view that the complainant is not entitled for the amount which he expended on the tests in this lab to the tune of Rs. 2,100/-. 

12. Secondly, we deal with the other objection of opposite party No. 1 that as son of the complainant was an Adult at the time of admission but he admitted under a Pediatrician so authenticity of claim not established. To rebut this objection of the opposite party No. 1 the   complainant relied upon insurance policy Ex.C-1 in which date of birth of son of the complainant namely Abhdeep Bhardwaj is mentioned as 22.11.1999 and he was admitted in the hospital on 27.12.2017 so at the time of admission in the hospital his age was about 18 years and one month. Alongwith the written arguments the complainant also filed a document taken from the website www.everydayhealth.com in which it is clearly mentioned that Pediatricians are specially trained to care for newborns to 21 years olds, and some keep their patients through college. Research indicates that there is not one correct age for kids to transition to the adult family doctor, instead it depends on the needs and desires of the patient. From this document it is well proved on the file that a Pediatrician can treat a person up to the age of 21 whereas age of the son of the complainant Abhdeep was only about 18 year 1 month at the time of his admission in Bhushan Children Hospital, Barnala. Further, opposite party No. 1 never mentioned in their terms and conditions that an adult person up to the age of near about 18 years 1 month cannot take treatment from a pediatrician. So, this plea of opposite party No. 1 has no force and it is just an excuse to repudiate the claim of complainant on baseless grounds. 

13. Hon'ble Punjab and Haryana High Court Chandigarh in case titled New India Assurance Company Ltd Vs Smt. Usha Yadav & Ors. 2008(3) RCR (Civil) Page-111 held as under.-

:It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.

The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs. 5,000/- for luxury litigation being rich.”

This citation is fully applicable to the present case as in the present matter also the opposite party No. 1 has earned premium from the complainant but when he applied for his genuine claim then they repudiated the same on flimsy grounds so there is deficiency in service and unfair trade practice on their part and complainant is entitled to insurance claim from the opposite parties except the amount which he has expended on lab tests comes to Rs. 26,286/- which includes hospital bill of Rs. 22,200/- and medicines bills of Rs. 4,086.

14. As a result of the above discussion, present complaint is  partly allowed against the opposite party No. 1 and the opposite party No. 1 is directed to pay the amount of Rs. 26,286/- to the complainant on account of insurance claim alongwith interest at the rate of 6% per annum from the date of institution of the present complaint till actual realization and to pay Rs. 5,000/- as compensation to the complainant for mental tension and harassment and Rs. 3,000/- on account of  litigation expenses. Compliance of order be made within the period of 30 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.

  ANNOUNCED IN THE OPEN FORUM:

19th Day of August 2019

 

 

            (Kuljit Singh)

           President

 

           (Tejinder Singh Bhangu)                Member

 

(Manisha)

Member