The complainant Parveen Kumar (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986, ( Now C.P. Act, 2019 here-in after referred to as 'Act') before this forum (Now Commission) against Max Bupa Health Insurance Company Limited and another (here-in-after referred to as opposite parties).
Briefly stated, the case of the complainant is that complainant has bank savings account with opposite party No.2 vide account No.50100258398499, customer ID 118691309. The opposite party No. 2 introduced health policy of opposite party No. 1 to complainant and accordingly complainant purchased a cashless family Health plan namely Health Companion Family Plan vide policy No. 30890677201900, customer ID 2000479090 valid from 08 February 2019 by paying Rs.10,504/- premium for one year for sum assured of Rs. 3 lac.
It is alleged that on 13.05.2019 son of complainant namely Parshav Goyal aged 12 years admitted to Chandigarh Clinic & Nursing Home due to typhoid and he was treated by Dr. Amit Taneja. The son of complainant was discharged on 17/05/2019. On 19.05.2019 complainant filled the claim form for reimbursement through Dr Amit Taneja. The complainant submitted all bills and relevant documents to opposite party No.1 and on the pretext of formalities, investigator of opposite party No.1 got signed from complainant and his wife some blank papers and assured that they will reimburse all the medical bills and same will be reflect in bank account of complainant but there after opposite party No. 1 declined the request of complainant for reimbursement.
It is further alleged that complainant spent huge amount during the admission of his son in hospital and also after discharge. The complainant also got upon the opposite parties via email in this regard, but to no effect.
On this backdrop of facts, the complainant has prayed for directions to the opposite party to reimburse the amount of Rs.24,829/- and to pay compensation amount of Rs.2.00 lac on account of harassment, humiliation, botheration, mental tension, agony and deficiency in services besides Rs.22,000/- as litigation expenses.
Upon notice, opposite party No. 1 appeared through counsel and contested the complaint by filing written written reply raising preliminary objections that the complaint is not maintainable. Complainant has attempted to misguide and mislead this Commission and has created a false story by concocting and distorting the facts and circumstances of the present case.
It has been pleaded that complainant had submitted to the opposite party online proposal/application for the purchase of Health Companion Family Plan. The proposal was accepted on the standard rates based on the information provided by the complainant and consequently the policy was issued bearing policy No.30890677201900 dated 08.02.2019 and the same commenced from 08.02.2019. The policy term was one year and gross premium was Rs.10,504/- yearly. The complainant had already received the policy, therefore, he cannot wriggle out of the terms and conditions of the policy. It has been pleaded that before acceptance of the proposal by opposite party No.1, the contents of the proposal/application form were read and explained to the complainant in the language best known to him. Accordingly, after understanding all the terms and conditions of the proposal form was submitted by the complainant to that effect. In addition to it necessary guidance was also provided by the concerned financial consultant/agent and were duly explained to the complainant.
It has been further pleaded that opposite party No.1 received a claim form on 27.5.2019 for reimbursement wherein it was stated that the son of the complainant i.e. Parshav Goyal fell ill and was admitted on 13.05.2019 to Chandigarh Clinic & Nursing Home due to typhoid and was discharged on 17.05.2019 after getting the treatment. While processing the claim, internal investigation was conducted by opposite party No.1 whereby it was revealed that there were discrepancies in the claim form submitted through the Doctor and the treatment taken by the insured. As per the revised statement of the mother of the insured/patient, the insured/patient took treatment from Chandigarh Clinic and Nursing home from 13.05.2019 to 17.05.2019 for fever and abdominal pain. However, from 13.05.2019 to 16.05.2019, the patient took treatment while being admitted in hospital and came back to home during night time on 16.05.2019 and later on again went to hospital on 17.05.2019 and took the treatment on day care basis but to the utter shock, surprise and dismay to the opposite party No.1, the discharge summary was made from 13.05.2019 to 17.05.2019 intentionally to grab extra expenses from opposite party No.1. Moreover, as per ICP, vitals are made in single stretch and no vitals are noted for the Night time and no treatment was given to the patient during Night time.
It has also been pleaded that in the present case the case of complainant seems to be a case of OPD, however, the same was converted to IPD for grabbing the claim money from opposite party and the same is done by the complainant in connivance with the treating Doctor. Since there is Discrepancy and Misrepresentation of the facts between the hospital and insured with the claim documents and as such the claim was disallowed by the Opposite party vide letter dated 27.09.2019 as per clause 10.21 of the policy terms and conditions.
On merits, opposite party No.1 has reiterated its version as pleaded in preliminary objections and detailed above. After controverting all other averments of the complainant, the opposite party No. 1 prayed for dimissal of complaint.
In view of the statement of learned counsel for the complainant, name of opposite party No. 2 was deleted from the array of the parties vide order dated 11-09-2019.
In support of his complaint, the complainant has tendered into evidence his affidavit dated 9.9.2019 (Ex. C-29) and documents (Ex.C-1 to Ex.C-28 and Ex.C-30 & Ex.C-31).
In order to rebut the evidence of complainant, the opposite party has tendered into evidence affidavit of Ms.Chandrika Bhattacharayya dated 16.10.2019 (Ex. OP-1//7) and documents (Ex. OP-1/1 to Ex.OP-1/6).
The learned counsel for the complainant has argued that the complainant had purchased cashless family plan insurance namely Health Companion family Plan Ex. C-1 from opposite party No. 1 and family members were covered under the policy for one year for sum assured of Rs. 3.00 Lacs. It is further argued that son of the complainant namely Parshav Goyal suffered from health problem on 13-5-2019 and remained admitted at Chandigarh Clinic & Nursing Home upto 17-5-2019. It is further argued that on 19-5-2019, complainant filed claim with opposite party No. 1 with required documents and thereafter Investigator of opposite party No. 1 visited the house of the complainant and obtained signature of wife of the complainant and his minor son on blank papers with false assurance that same is being obtained for reimbursement and thereafter claim of the complainant was rejected by opposite party on false and flimsly grounds which amounts to deficiency in service.
On the other hand, learned counsel for opposite party argued that opposite party No. 1 received claim form on 27-5-2019 for reimbursement wherein it was stated that son of the complainant Parshav Goyal fell ill and was admitted on 13-5-2019 at Chandigarh Clinic & Nursing Home due to typhoid and was discharged on 17-5-2019 after getting treatment. It is further argued that claim was got investigated and it was revealed that mother of the patient had given statement that patient took treatment from 13-5-2019 to 17-5-2019 for fever and abdomen pain. However, from 13-5-2019 to 16-5-2019, the patient took treatment while being admitted in the hospital and came back to home during night time on 16-5-2019 and later on went to the hospital on 17-5-2019 and took treatment on day care basis. The discharge summary was made from 13-5-2019 to 17-5-2019 intentionally to grab extra expenses from opposite party No. 1. It is further argued that as per ICP, vitals are made in single stretch and no vitals are noted for the night time. No tretment was given to the patient during night time and the case seems to be of OPD and was wrongly converted to IPD for grabbing the claim money from opposite party in connivance with treating doctor. The claim was rejected as per clause No. 10.21 of the policy terms and conditions which reads as under :
“Clause 10.21 : Disclosure of information norms :
Disclosure of information and Norms means the policy shall be void and premium paid herein shall be forfeited to the company, in the event of misrepresentation, mis-description or non-disclosure of any material facts.”
Learned counsel for opposite party No. 1 further argued that the complaint is liable to be dismissed.
We have heard learned counsel for the parties and gone through the file carefully.
It is admitted fact that complainant had obtained/purchased Health Companion Family Plan on payment of premium. It is further admitted fact that son of the complainant namely Parshav Goyal was also covered under the policy. It is also admitted fact that Parshav Goyal remained under treatment at Chandigarh Clinic & Nursing Home.
The only disputed question before this Commission is that mother of patient gave statement to the Investigator wherein she disclosed that on 16-5-2019, patient came to home in the night time and thereafter went to the hospital in the morning on 17-5-2019 meaning thereby that patient never remained admitted in the hospital on the night of 16-5-2019 and it is further revealed that it was a case of OPD and was wrongly converted into IPD to claim insurance amount from the opposite party. This Commission has gone through the statement recorded by Investigator which has been produced on record by opposite party and exhibited as Ex. OP-1/5 alongwith report of Investigator. Now the main question before this Commission is whether the claim lodged by the complainant can be declined by opposite party by relaying upon the report of Investigator Ex. OP-1/5 and what is evidentiary value of the report of the Investigator and statement allegedly obtained from the minor son of the complainant and his mother. A perusal of statement shows that Investigator deputed by opposite party No. 1 has crossed the limits while recording the statement and got the said statement signed from Parshav Goyal who was admittedly 12 years old at that time and was a minor. Moreover, further perusal of statement shows that the said statement is not certified or witnessed by any responsible person of area and the wording written in the last three lines clearly shows that the Investigator has not done his duty correctly and the entire story was prepared by the investigator with a motive to decline rightful claim of the complainant. Moreover, this Commission is of the view that Investigator has no authority to record the statement of any party rather the duty of the Investigator is to collect the record and secretly investigate the case and submit his report to the insurer, but in this case, the investigator has indulged in recording of statements without any lawful authority and that also of a minor aged 12 years. As such, this Commission is of the considered opinion that rejection of claim of the complainant for reimbursement of medical expenses by opposite party No. 1 on the basis of report of Investigator Ex. OP-1/5 is totally unjustified as it is proved on record that patient namely Parshav Goyal remained admitted in the hospital and the treatment obtained is duly proved from the discharge summary and related documents.
Accordingly, present complaint is partly allowed and opposite party No. 1 is directed to settle and pay the claim to the complainant alongwith interest @9% p.a. from the date of filing of this complaint till realization. The complainant is also held entitled to damages to the tune of Rs. 5,000/- on account of mental tension, harassment and cost of litigation.
The compliance of this order be made by opposite party No. 1 within 45 days from the date of receipt of copy of this order.
The complaint could not be decided within the statutory period due to heavy pendency of cases.
Copy of order be sent to the parties concerned free of cost and file be consigned to the record room.
Announced:-
17-05-2023
- (Lalit Mohan Dogra)
President
(Shivdev Singh)
Member
