District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 90/21
Date of Institution:18.02.2021
Date of Order:12.05.2023.
Natwar Thakur, A-157, Block – A, Gali NO.4, Jaitpur Part-2, Badarpur, Siuth Delhi -44.
…….Complainant……..
Versus
Max Bupa Health Insurance Co. Ltd., Logic X Insotech Park, D-5, 2nd floor, Opp: Sector-59 Metro Station, Noida, U..P - 201301
…Opposite party
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Santosh Goswami , counsel for the complainant.
Sh. Rakesh Dabaas , counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant was a policy holder of the respondent's company having Policy Number 30263595 and the policy was active at the time of admission of the complainant in the Hospital
and also at the time of putting up the claim. The complainant got hospitalized in Sattya Hospital, 376, LP Colony, Sector 30-33, Faridabad, Haryana 121003 on 08/10/2020 and diagnosed with AGE with dehydration, ARF and Deranged LFT and subsequently got discharged on 14/10/2020. The complainant paid a sum of INR 48,325/- (Forty eight thousands three hundred twenty five) only to the hospital as against the treatment Subsequently, claim documents were sent through mail on 02/11/20 & 03/11/2020. Furthermore, the hard copy of claim documents along with duly filled in claim form was despatched to the respondent on 05/11/20210 and the same was received by the respondent on 07/11/2020. The verification of the claim by the respondent both from the complainant as well as from the hospital took place around 23 or 24th November 2020 and upon the same the claim bearing No. 579454 was rejected by the respondent which was conveyed through mail on 04/12/2020. The claim was denied on the basis that there is misrepresentation of facts. Upon rejection of claim, mails were sent by the complainant seeking explanation for rejection and requesting for reconsideration. Explanation was sought as to the nature of misrepresentation but the respondent did not choose to rely to that. Mails were also sent to grievance redressal of the respondent's company but no satisfactory reply was furnished by the respondent. Upon request for reconsideration of claim by the complainant, the respondent company said that claim had been reviewed by the Panel of Doctors and its earlier stand of rejection remain so. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) Pay a sum of INR 48,325/- alongwith 12% interest commencing from 30 days after receiving of the claim document by the company.
b) pay INR 20,000/- as compensation for causing mental agony and harassment .
c) pay INR. 10,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the complainant neither had any cause of action nor and abusing standi in lodging of the present complaint before this Hon'ble Company. The true facts of the case are narrated as follows. The complainant submitted his claim documents vide 'claim form' dated 23.10.2020 & other medical documents with regards to his treatment from Sattya Hospital, L.P. Colony, Sector-32-33, Faridabad. The said claim was received by the opposite party on 23.10.2014. After receiving such documents, in order to the ascertain the veracity and genuineness of the claim, the opposite party had got investigated the matter particularly on the aspect to verify the treatment record as well as ascertain the status of the hospital in question through its investigators. On going through the questionnaire filled and the statement given by the complainant at the time of investigation and the medical records of the hospital, certain discrepancies were observed that throw in doubt the genuineness of the claim.
The finding under said report were being reproduced for kind perusal of the Hon'ble Commission in the following manner :-
On the bases of hospital, pathology, Dr statement pharmacy, IVR of Patient following points were found.
• As per available information patient is regularly applying fraudulent claim from Satya hospital Faridabad.
• According to retrieve information patient is EX nursing staff of Valencia hospital Faridabad.
Presently Valencia hospital is closed.
Treating Dr C.M Goswami was a EX resident Dr in valancia Hospital.
Both patient and DR were regularly file fraud claim. As per available patient claim H/o patient is regularly applying claims in every 3 months since last 2 years with different diagnosis,
• During IVR patient is highly non cooperative and abusing company and personal abuse to employee of company.
Last year also patient previous claim 465020 which was highlighted for misbehavior from hospital Dr in Shivinayak hospital
Dr. statement finding:
As per available Dr Statement he accepts patient was admitted between duration of 8-14/Oct 20,
As per available bio waste hospital has approval to have only 10 Beds
As per the law for reimbursement cases in metropolitan city hospital should have 15 beds approval which ws not available in hospital.
Pathology:
During investigation it was found hospital has no proper pathologist, no lab technician, no other staff.
. At time of visit pathology was locked nobody is available there.
Equipment of pathology not working, no proper was documentation, lab testing kit bills were not available.
• Mostly expired kits since last was there.
• Manual reading were upload in hospital desktop to make a report.
As per records patient was hospitalized 7 days and regularly lab test were done but no records was found in hospital for previous lab investigation.
• All reports were manual & and treating Dr had verified, no pathologist/lab technician were there.
Pharmacy bills :
As per available medicine batch no of patient used during hospitalization was not available or not in stock infect all medicines have negative stock in pharmacy computer (which clearly indicate all medicine were not in stock still medicine is given to patient)
Clearly indicate unavailable stock of medicine in pharmacy still it was mentioned in patient records. (misrepresentation of pharmacy bill)
Personal finding:
Patient was involve in nexus, he used to threaten investigator, last time (claim no. 465020) also patient hospital pressurize investigator (company employee) to approved the claim this time also patient do the same.
As per available video patient admit he was not admit in month of February, March still Max Bupa had approved patient previous claim. Kindly set a recovery for previous paid claims.
As such the misrepresentation of fasts has been established from the said investigation report as well as the treatment / IPD record of the hospital in question so obtained while investigating the matter, thus, the said claim of the complainant falls under the clause 10.21 incorporated in the insurance policy so issued in this regard. Hence, the insurance company have treated the subject claim as "No Claim" by closing the file in terms of "letter of intimation" dated 19.03.2021 which decision cannot be termed unconscionable at all and in terms of the proviso of the insurance policy, the insurance company have treated the said claim as 'No Claim' in a proper manner. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party–Max Bupa Health Insurance Co. Ltd. with the prayer to: a) Pay a sum of INR 48,325/- alongwith 12% interest commencing from 30 days after receiving of the claim document by the company. b) pay INR 20,000/- as compensation for causing mental agony and harassment . c) pay INR. 10,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – Affidavit of Natawar Thankur,, Ex.PW1/1 – Discharge summary, Ex.PW1/2 – Courier receipt, Ex. PW1/3 –Member Reimbursement statement, Ex.PW1/4 – claim denial letter dated 15.01.2021,, Ex. PW1/5 – email dated 3.12.2020.
On the other hand counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Bhuwan Bhashker, Senior Manager- legal, M/s. Niva Bupa Health Insurance Company Limited, 2nd floor, Plot NO. d-5, Logix Infotech Park, Sector-59, Noida, Uttar Pradesh, Ex.R-1 – letter of authorization, Ex.R-2 – proposal form, Ex.R-3 – insurance policy, Ex.R-4 – claim form, Ex.R-5 – investigation report, Ex.R-6 – repudiation letter dated 19.03.2021.
6. As per email Ex.R-14 it looks that the complainant’s hospital as well as the counsel are the same in all 5 cases. It creates doubt. i.e. the complainant has obtained so many policies from different company. The details are as under:
Sl. No. Complaint No. Title
1. 343/2021 Nisha Rani Vs. Raheja QBE
Policy No. : RQBE01-101616-20-000
Valid from 11.06.2020 to 10.06.2021
Address of Hospital : Sattya Hospital Faridabad
Disease : Fever, Severe Pain Abdomen, burning
maturation, vomiting and loose motion.
Date of admission : 02.11.2020
Date of discharged : 06.11.2020
Claimed amount : INR 54,646/-
2. 235/2021 Nisha Rani Vs. ICICI Lombard
Policy No. : 4128i/H/1663255384/00/000
Valid upto 03.02.2021
Address of Hospital : Sattya Hospital Faridabad
Disease : Fever, Headache, Pain and Swelling in
Perennial area.
Date of Admission : 08.10.2020
Date of discharge : 10.10.2020
Claimed amount : INR 32,742/-
3. 237/2021 Mousam Vs. Raheja QBE Gen. Ins.
Policy No. : RQBE01-10613-20-000
Valid from 11.06.2020 to 10.06.2021.
Address of the hospital : Sattya Hospital Faridabad
Disease : Fever, Burning Mituration, Pain in lower
Abdomen
Date of admission : 07.09.2020
Date of discharge : 12.09.2020
Claimed amount : INR 48421/-
4. 90/2021 Natwar Thakur Vs. Max Bupa Health Ins.
Policy No. : 30262595
Address of the hospital : Sattya Hospital Faridabad
Disease : dehydration, ARF and Deranged LFT
Date of admission : 8.10.2020
Date of Discharge : 14.10.2020
Claimed amount : INR 48,325/-
5. 80/2021 Brij Bihari Vs. Raheja QBE GIC Ltd.
Policy No. : RQBE01-101345-20-000
Valid from 04.05.2021 to 03.05.2021
Address of the hospital : Sattya Hospital Faridabad
Disease : Fever, burning micturation, body pain,
vomitting
Date of admission : 13.06.2020
Date of Discharge : 18.06.2020
Claimed amount : INR 48,554/-
7. As per the counsel for the opposite party argued at length and stated at Bar that as per the investigation report of opposite party it seems that all the 5 cases mentioned above belongs to the same Advocate with the same hospital and same kind of disease and same amount of the bill. It creates suspicion of the merit of the cases and during the course of arguments of the counsel for the complainant in relations with the opposite party i.e owner of hospital etc.
8. Keeping in view of the above submissions, Commission is of the opinion that all the five cases comes of collusion. Hence, no deficiency on the behalf of the opposite party has been proved. Hence, the complaint is dismissed. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 12.05.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
