Chandigarh

DF-I

CC/165/2016

Harpal Singh - Complainant(s)

Versus

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

Sunil Narang

18 Apr 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

============

Consumer Complaint  No	:	CC/165/2016
Date  of  Institution	:	10/03/2016
Date   of   Decision	:	18/04/2017

 

 

 

 

 

 

Harpal Singh s/o Sh. Amar Singh, R/o Street No.2, Sadhu Nagar, House No.1, Derabassi, Distt. SAS Nagar, Punjab.

 

….Complainant

Vs.

 

1.   Max Bupa Health Insurance Company Ltd.,  SCO 55-56-57, Second Floor, Sector 8-C, Madhya Marg, Chandigarh, through its Chairman/ Managing Director.

        

2.   Max Bupa Health Insurance Company Ltd., having registered office at Max House, 1, Dr. Jha Marg, Okhla, New Delhi, through its Chairman/Managing Director.

…… Opposite Parties 

 

 

BEFORE:   MRS.SURJEET KAUR             PRESIDING MEMBER

SH. SURESH KUMAR SARDANA     MEMBER

 

 

For Complainant	:	Sh. Sunil Narang, Adv.
For OPs	:	Sh. Gaurav Bhardwaj, Adv.

 

 

PER SURJEET KAUR, PRESIDING MEMBER

 

 

 

                The facts, in brief, are that complainant purchased a Heartbeat Health Insurance Policy on 24.11.2014 from the OPs opting plan Family First Silver 5 lacs +15 lacs commencing w.e.f. 27.11.2014 to 26.11.2015.  The complainant paid premium amount of Rs.20,480/- towards the said policy. On 11.2.2015 he complainant undergone coronary angiography in Escort Heart Institute and Research Centre Ltd. New Delhi and spent a sum of Rs.4,62,978/- on his treatment at the above said hospital. Subsequently, the complainant claim with OP No.1 for payment of Rs.4,65,178/-.  However, the OPs repudiated the claim of the complainant vide letter dated 15.7.2015 on the ground that “claim fall under 1^st 90 days waiting period hence claim stands denied under policy clause 4b. It is pleaded that as per clause 4b case of emergency is duly covered that the case of the complainant was emergency nature and certificate to this effect has been duly issued by Dr. T.S. Kler which is already on record as Annexure C-8 but the OPs ignored this fact and wrongly rejected the claim of the complainant.  Alleging the aforesaid act of the OPs as deficiency in service and indulgence into unfair trade practice the instant case has been filed.

 

2.      Notice of the complaint was sent to Opposite Parties, seeking their version of the case.

 

3.     Opposite Parties in their joint reply while admitting the factual matrix of the case stated that the complainant was hospitalized from 10.2.2015 to 13.2.2015 for treatment of the disease in question. Thereafter he filed reimbursement of the medical expenses incurred by him. It is asserted that during the course of investigation it was revealed that the complainant was not hospitalized due to emergency  and it was found that the claim of the complainant is not payable as per exclusion clause 4 (b) as reproduced in para 11 of the reply. Accordingly, the claim of the complainant was repudiated as per terms and conditions of the policy.  Denying all other allegations and stating that there is no deficiency in service or unfair trade practice on their part, Opposite Parties have prayed for dismissal of the complaint.

 

4.     Parties were permitted to place their respective evidence on record in support of their contentions.

 

5.     We have heard the learned counsel for the parties and have also perused the record.

 

6.     There is no dispute about the fact that the Complainant had filed a claim with the Opposite Party No.1 for payment of Rs.4,65,178/- which he had spent on his treatment at Escorts Heart Institute and Research Centre Limited, New Delhi. However, the Opposite Parties vide letter dated 15.07.2015 (Annexure C-10) rejected the claim of the Complainant on the ground that the claim falls under 1^st 90 days waiting period hence claim stands denied under policy Annex-B clause 4(b). However, we are not impressed with the reasoning so given by the Opposite Parties coined to reject the well-founded claim of the Complainant. The Opposite Parties held their nerve contending that the claim of the Complainant is not payable as per exclusion clause 4(b) of the Policy. The said clause 4(b), for the sake of precision, is reproduced hereinbelow: -

 

“b. 90 days Waiting Period.

We will not cover any treatment taken during the first 90 days since date of commencement of the Policy, unless the treatment needed is the result of an Accident or Emergency. This waiting period does not apply for any subsequent and continuous renewal of your policy.”

 

          In view of the afore-extracted clause, we are of the opinion that the Opposite Parties have deliberately ignored the fact that treatment need in the case of the Complainant was an emergency which is duly covered under Clause 4(b) of the Insurance Policy and Certificate regarding emergency condition of Complainant issued by Dr. T.S. Kler (Annexure C-8) has not been taken into consideration, while arriving at a final decision only to reject the claim of the Complainant. The Complainant was in emergency situation and was not in any way supposed to postpone his angioplasty for the sake of completing 90 days since the date of commencement of policy, thereby putting his life to danger.  

 

7.     In the light of above observations, the present complaint succeeds against the Opposite Parties. The same is allowed qua them. We direct the Opposite Parties, jointly and severally, as under:- 

 

(i)  To pay the claimed amount of Rs.4,65,178/- to the Complainant;

(ii) To pay Rs.15,000/- as compensation to the complainant for the unfair trade practice and harassment caused to him.

(iii)  To also pay a sum of Rs.10,000/- to the complainant as litigation expenses. 

8.      This order be complied with by Opposite Parties No.1 to 2 within one month from the date of receipt of its certified copy, failing which they shall make the payment of the amount mentioned at Sr. No.(i) and (ii) above, with interest @ 12% per annum from the date of filing of the present complaint, till realization, apart from compliance of direction at Sr. No.(iii) above.
9.      The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

18^th April, 2017                                                  

Sd/-

(SURJEET KAUR)

       PRESIDING MEMBER

 

Sd/-

(SURESH KUMAR SARDANA)                                                                                                      MEMBER