Chandigarh

DF-I

CC/624/2019

Manish Goyal - Complainant(s)

Versus

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

Amit Jhanji

05 Mar 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/624/2019
Date of Institution	:	21/06/2019
Date of Decision	:	05/03/2021

 

 

Manish Goyal son of Surender Kuamr Goyal resident of House No.618, Sector 18B, Chandigarh.

… Complainant

V E R S U S

1. Max Bupa Health Insurance Company Limited, B-1, I-2, 90/2, Mathura Road, Mohan Cooperative Industrial Estate, New Delhi, Delhi 110044 through its Director.
2. Max Bupa Health Insurance Company Limited, SCO No.55, 56 & 57, Sector 8-C, Madhya Marg, Chandigarh 160009 through its Regional Manager.

… Opposite Parties

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                               

ARGUED BY	:	Sh. Shashank Shekhar Sharma, Vice Counsel for Sh. Amit Jhanji, Counsel for complainant
	:	Sh. Gaurav Bhardwaj, Counsel for OPs

Per Rattan Singh Thakur, President

1.      Averments are, in the year 2011, complainant had purchased a health policy and kept on renewing it on payment of premium.  The premium was paid till the year 2016.  The policy was named Family First Gold 2 lacs + 15 lacs and it was for a period of one year commencing from 10.10.2015 to 9.10.2016. The policy covered the family members of the complainant namely Ms. Darshan Goyal (mother), Mr. Surinder Kumar Goyal (father), Ms.Kajal Goyal (spouse), Mr. Rehan Goyal (son) and Mr. Viren Goyal (son). Further case is, Ms.Darshan Goyal mother of the complainant was diagnosed with right mouth (Buccal Mucosa) carcinoma, squamous cell, Kertinizing type by Surgical Pathology report dated 11.3.2016 of PGI, Chandigarh and was admitted in Lilavati Hospital and Research Centre, Mumbai. She remained admitted there for treatment from 25.3.2016 to 5.4.2016. However, the cashless facility was denied. Thereafter, the complainant had to pay the bills. On claim raised, it was rejected and OPs had cancelled the policy and forfeited the premium vide letter dated 15.4.2016 for concealment of pre-existing disease. Being aggrieved, the matter was moved before the Hon’ble State Commission, UT, Chandigarh and submitted claim of ₹15,81,499/- alongwith interest and also prayed for restoration of the policy.  The Hon’ble State Commission vide its order dated 22.3.2018 restored the policy and granted the claim of ₹7,00,023/- alongwith interest besides compensation of ₹75,000/- and ₹33,000/- as litigation expenses.  However, liberty was granted to the complainant to submit the remaining claim of ₹8,81,476/- separately. The claim was submitted but it was denied which amounts to disobedience of the order of the Hon’ble State Commission. Averred, the complainant had paid ₹2,99,879/- on 7.3.2019 for the renewal of the policy, but, the same was not renewed. These facts according to the complainant amounts to deficiency in service and unfair trade practice on the part of the OPs. Hence, the present consumer complaint for directing the OPs to settle the claim of the complainant filed in June 2018 alongwith interest; renew the insurance policy of the complainant; pay compensation of ₹5,00,000/- and ₹50,000/- as litigation expenses
2.     OPs contested the consumer complaint, filed their joint written reply and claimed the present consumer complaint is not maintainable.  Their case is, the Hon’ble State Commission, UT, Chandigarh never gave liberty to the complainant to prefer a claim of ₹8,81,476/-.  No such claim was ever received by the OPs. The order of the Hon’ble State Commission was complied with and the amount which was due under the order was discharged to the complainant. It was denied, any claim of ₹10,30,723/- was submitted. The claim of ₹28,493/- raised on 31.5.2018 was repudiated by the OPs. Besides it, various claims as many as 6-7 in number were already paid to the complainant in the year 2012, 2013, 2014, 2016 and 2018. It was submitted, parties cannot travel beyond the terms and conditions. Averred the liability which was due already stood discharged. Maintained, under the order of the Hon’ble State Commission the policy has also been renewed till 9.10.2020.  On these lines, the cause is sought to be defended.
3.     Rejoinder was filed by the complainant and averments made in the consumer complaint were reiterated.
4.     Parties led evidence by way of affidavits and documents.
5.     We have heard the learned counsel for the parties and gone through the record of the case, including the written arguments of the complainant. After scanning of record, our findings are as under:-
6.     The foundation of the claim of the complainant is the order dated 22.3.2018 passed by the Hon'ble State Commission, UT, Chandigarh in Complaint case No.234 of 2017. The relief part of the order is reproduced below :-

“14. For the reasons recorded above, this complaint is partly accepted, with costs, with following directions to the opposite parties:-

1. To restore the policy, in question, in favour of the complainant and his family members, referred to above, after adjusting the premium, if any, already paid by him and/or on receiving payment of premium, if due towards him.
2. To pay an amount of Rs.7,00,023/- to the complainant, alongwith interest @9% p.a. from the date of its repudiation.
3. To pay compensation, in the sum of Rs.75,000/- for causing mental agony and physical harassment to the complainant.
4. To pay cost of litigation to the tune of Rs.33,000/- to the complainant.
5. This order shall be complied within a period of 45 days, from the date of receipt of certified copy thereof, failing which the amount at Sr.No.(ii) above, shall further carry penal interest @12% from the date of default i.e. after expiry of 45 days and the amount at Sr.Nos.(iii) and (iv) shall carry interest @9% p.a. from the date of filing of this complaint till realization.”

 

Its perusal shows, the policy was ordered to be restored after adjustment of the premium, if any, already paid besides payment of ₹7,00,023/- alongwith interest; compensation of ₹75,000/- and ₹33,000/- as litigation expenses. However, in the earlier paragraph of the judgment, preceding relief granted, the Hon’ble State Commission held as under:-

“As far the remaining amount of Rs.8,81,476/-, referred to above, is concerned, it may be stated here that since, the complainant failed to place on record any document to prove that claim in respect of the said amount was raised before the opposite parties and the same has been repudiated by them, as such, any dispute with regard to the same cannot be entertained by this Commission, at this stage. At the time of arguments, it was contended by Counsel for the complainant that had the claim in respect of said amount been raised before the opposite parties, the same would have also been repudiated by them, on similar grounds. It may be stated here that this Commission is not bound to grant relief to the consumers, on presumptions and assumptions. To get relief, the party concerned has to prove its case, by placing on record, cogent and convincing documents. As such, relief claimed by the complainant, in respect of amount of Rs.8,81,476/- is declined at this stage, being premature. However, in the interest of justice, the complainant is at liberty to file complaint in respect of any amount, legally due to him, over and above Rs.7,00,023/- in respect of the policy, in dispute, if the same when raised is repudiated by the opposite parties, illegally, which shall be decided as per facts and will have no binding effect of the findings passed in this order.”

 

7.     A perusal of this order of the Hon’ble State Commission shows, relief of ₹8,81,476/- was declined, being premature and obiter dicta was made to file a consumer complaint, if any amount is found due over and above the awarded amount of ₹7,00,023/- in respect of the policy.  There was no such direction this amount was due; rather this claim was rejected, though liberty was granted to the complainant to file a complaint if the same when raised is repudiated. 
8.     The pleading of the complainant is, this order was disobeyed by the OPs. If it was so, instead of filing a fresh consumer complaint, the proper course with the complainant was to move an application for execution of the order of the Hon’ble State Commission, UT, Chandigarh or to make a criminal complaint before the Hon’ble State Commission with regard to failure or omission of OPs to comply with the order of the Hon’ble State Commission. The remedy was not to file a fresh consumer complaint.   
9.     As per Annexure C-7, the order of the Hon’ble State Commission is dated 22.3.2018. Now the complainant states, he has submitted a claim of ₹10,30,723/- on 29.5.2018. It is not made out to which period this claim pertained to. This plea is not substantiated with medical bills or any verification by the hospital concerned where the treatment was taken. The OPs have denied any such bill was received by them.  In which hospital such treatment was taken and what was the bill raised by them which was paid by the complainant has not been explained. If the claim was submitted then photocopies of the bills of medicines which were prescribed by the doctor and purchased by the complainant could have been annexed with the consumer complaint, but, these have not been annexed at all.
10.     However, with the rejoinder one claim form is submitted which shows claim for post hospitalization expenses of ₹10,30,723/- was raised. What were those post hospitalization expenses have not been detailed. At the cost of repetition, we may refer here, the bills so raised by the hospital have not at all been annexed with the present consumer complaint to fortify the claim made by the complainant which was submitted hardly 2-3 months after the decision by the Hon’ble State Commission and the Hon’ble State Commission had already rejected the said claim being premature. Complainant had the opportunity to get the copies if submitted before the Hon’ble State Commission or said file could have been got requisitioned in order to render corroboration and truthfulness to the claim submitted.  Thus, we are of the view the consumer complaint is in the air.
11.      There was a direction for restoration of the policy which was already forfeited and as per the reply furnished by the OPs, it has been renewed till 2020 in compliance with the order of the Hon’ble State Commission.
12.     Now we shall refer to the reliefs prayed for by the complainant i.e. firstly for directing the OPs to settle the claim which was raised in the month of June 2018.  However, what was that claim, what were the documents annexed in support of the claim and the amount has not been specified. The second prayer is to direct the OPs to renew the insurance policy.  However, of which period it has to be renewed has not been asked for. There was a reference in the consumer complaint itself, complainant had concealed the factum of his mother, Mrs. Darshan Goyal had history of oral cavity in 2009 and tuberculosis in 2001. How the complainant is entitled to get it renewed, its basis has not been disclosed. A blanket order in favour of the complainant and against the OPs cannot be passed. The claim made has not been substantiated to record a finding of deficiency in service or unfair trade practice qua the OPs.
13.     In view of the above discussion, the consumer complaint is meritless and is accordingly dismissed leaving the parties to bear their own costs.
14.     Certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
05/03/2021	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	Member	President