Chandigarh

DF-II

CC/168/2021

Jorawar Singh Lubana - Complainant(s)

Versus

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

Ravi Lubana adv

10 Nov 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	168 of 2021
Date  of  Institution	:	09.03.2021
Date   of   Decision	:	10.11.2022

 

 

 

 

 

 

Jorawar Singh Lubana, r/o House No.2045, Sector 27-C, Near Sanatan Dharam Mandir, Chandigarh. 160019

             …..Complainant

 

Versus

 

1]  Max Bupa Health Insurance Company Ltd., Registered Office at SCO No.55-56-57, Sector 8-C, Madhya Marg, Chandigarh 160019, through Managing Director & CEO.

 

2]  Max Bupa Health Insurance Company Ltd., Registered Office t B-1/1-2, Mohan Cooperative Industries Estate, Mathura Rod, New Delhi 110044 through Regional Managing Director & CEO

 

    ….. Opposite Parties

 

BEFORE:  SMT.PRITI MALHOTRA    PRESIDING MEMBER 

                    SH.B.M.SHARMA                 MEMBER

                               

Argued by  : Sh.Ravi Lubana, Adv. for complainant.

   Sh.Gaurav Bhardwaj, Adv. for OPs.

 

PER PRITI MALHOTRA, PRESIDING MEMBER

         The complaint of the complainant in brief is that he obtained Medical Health Insurance Policy from OPs on 5.3.2020 having sum assured of Rs.5 lacs on making payment of due premium (ann.C-1). During the currency of said medical insurance policy, the complainant felt chest  discomfort  and as such was admitted in Fortis Hospital on 10.10.2020.  After getting treatment, the complainant was discharged on 13.10.2020 and a total expenditure of Rs.1,20,000/- was incurred on it (Ann.C-2 & C-3).  Thereafter, the complainant lodged claim with OPs for reimbursement of the medical expenses but the same was rejected by them vide letter dated 17.12.2021 taking the ground of non-disclosure of pre-exist disease (Ann.c-4).  Then complainant sent a legal notice dated 1.1.2021 to OPs, which was replied by them vide letter dated 20.1.2021 wherein they agreed to settle the claim for an amount of Rs.1,11,700/-.  The complainant sent acceptance letter dated 4.2.201 to OPs for the said amount, but still nothing was paid (Ann.C-5 to C-8).  Hence, this complaint has been filed.

 

2]       The Opposite Parties have filed joint reply and while admitting the factual matrix of the case, stated that at the time of reviewing the claim documents filed by complainant, it was found that the complainant failed to disclose the pre-existing medical illness/conditions at the time of applying the health insurance policy, therefore, the OPs cancel the policy of complainant (Ann.D).  It is  submitted that in response to the legal notice served by complainant, the OPs sent reply dated 20.1.2021 and proposed a settlement of Rs.1,11,700/- with deduction of non-payable amount, but despite the propose settlement, the complainant did not provide any response. Denying all other allegations and pleading no deficiency in service, the OPs have prayed for dismissal of the complaint.

 

3]       Rejoinder has also been filed by the complainant thereby controverting the assertions of the OPs made in their reply.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have perused the entire record including written arguments.

 

6]       Admittedly, the Health Insurance Policy in question has been availed by the complainant and during its subsistence, he felt chest pain, as such hospitalized & treated and thereby incurred expenses to the tune of Rs.1,20,000/-.  A claim lodged by the complainant for reimbursement of said amount was repudiated by the OPs. 

 

7]       The thorough perusal of the record reveals that after having rejected the claim of complainant, the OPs on the representation of the complainant, again considered his claim and then approved it for an amount of Rs.1,11,700/- vide letter dated 20.1.2021 (Ann.C-7).  The complainant also furnished his acceptance to the said approved amount. 

 

8]       It is the plea of the complainant that despite having given his acceptance to the offered/settled amount of Rs.1,11,700/-, the OPs even failed to pay that amount in the account of the complainant, which forced him to indulged into present litigation.  The documents on record duly corroborate the assertions raised by the complainant in regard to the offer and acceptance been made between the parties. 

 

9]       In our view, once the OPs approved and offered a sum towards the claim and it has been accepted by the complainant, then they cannot  wriggle out from such offer/settlement.  Now the plea taken by the OPs about pre-existing disease etc. is not justified and is an afterthought. Hence, the deficiency in service on the part of OPs is writ large. 

 

10]      Taking into consideration the above discussion and findings, we are of the opinion that the OPs remained deficient in their service.  Therefore, the present complaint is allowed against OPs No.1 to 3 with direction to pay to the complainant an amount of Rs.1,11,700/- along with interest @9% p.a. from the date of discharge i.e. 13.10.2020 till the date of payment, apart from paying a compository amount of Rs.20,000/- towards compensation for the harassment suffered by him and for thrusting avoidable litigation upon him.

         This order shall be complied with by the OP No.1 to 3 within a period of 45 days from the date of receipt of copy of this order, failing which it shall be liable to pay additional cost of Rs.15000/- apart from above relief.

         Certified copy of this order be sent to the parties, free of charge. After compliance, file be consigned to record room.

Announced

10^th November, 2022                                                     Sd/-

(PRITI MALHOTRA)

PRESIDING MEMBER

 

Sd/-

 (B.M.SHARMA)

MEMBER