Chandigarh

DF-I

CC/16/2020

Rajender Kumar Garg - Complainant(s)

Versus

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

Devinder Kumar

02 May 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/16/2020
Date of Institution	:	09/01/2020
Date of Decision	:	02/05/2023

 

Rajender Kumar Garg S/o Sh.Hans Raj Garg, aged about 57 years, R/o House No.183, Vinobha Basti, Sri Ganga Nagar, Rajasthan-335001.

… Complainant

V E R S U S

1. Max Bupa Health Insurance Co. Ltd., SCO No.55-56-57, Second Floor, Sector 8-C, Madhya Marg, Chandigarh through its Branch Manager.
2. Max Bupa Health Insurance Co. Ltd., Corporate Office: Block B1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi-110044 through Managing Director.

… Opposite Parties

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR	MEMBER

 

                                                

ARGUED BY	:	Sh.Devinder Kumar, Counsel for Complainant.
	:	Sh.Gaurav Bhardwaj, Counsel for OPs.

 

Per Surjeet kaur, Member

1.      Averments are that as per the direction of the OPs, the complainant paid a sum of Rs.25,064/- and OPs issued a policy w.e.f. 14.01.2019 to 13.01.2020 (Annexure C-1). In the month of the March, 2019, wife of the complainant faced problem i.e., Dizziness, Nausea, Weakness, Fever, Bodyache, Headache, darkness came before her eyes, accordingly she visited to Dr.L.D.Bhardwaj, Jawahar Nagar, Sri Ganga Nagar, Rajasthan on 25.03.2019. On this advice of the doctor some test has been conducted and on the medical report dated 25.03.2019 (Annexure C-2). On 30.03.2019 wife of the complainant again Dizziness, Nausea, Weakness, Fever, Bodyache, Headache, darkness came before the eyes of the complainant. Accordingly complainant taken to the complainant in Satyam Multi Specialty Hospital, Sri Ganga Nagar, Rajasthan. After going through the critical condition of the complainant, doctor admitted the complainant’s wife and started the treatment. After treatment wife of the complainant was discharge on 31.03.2019 (Annexure C-3) colly. Complainant spends a sum of Rs.9,779/- in hospital during treatment (Annexure C-4) colly. Due information was given to the OP and the complainant lodge the claim with the OP. Thereafter, the complainant submitted the post hospitalization bills amounting to Rs.18,681 with the OP with the request to release the claim (Annexure C-7). The complainant sends email dated 20.05.2019 to the OP with the request to release the claim amount. In response to the email of the complainant OP sent email 25.05.2019 (Annexure C-9 & C-9). Instead of paying the genuine claim, OP email dated 08.06.2019 rejected the claim of the complainant (Annexure C-10). The acts committed by the OPs clearly show that they are deficient in services, as they have not paid the genuine claim of the complainant. Hence, is the present consumer complaint.
2.     OPs contested the consumer complaint, filed their written statement and stated that the complainant has prayed for Rs.28,478/- as the amount spent on treatment but a mere perusal of the claim documents would reveal that the complainant has claimed only Rs.9797/- from the company and now in order to extort money from the OP company he has exaggerated the amount by almost 18,000/-. No bills/claim of the alleged amount of Rs.18,681/ have been raised with the company till. In the absence of any such claim the same cannot be ascertained by the company. Even otherwise also when the main claim has been repudiated the post authorization bill can also not be claimed by the complainant. It is also submitted that the discharge summary provided it was observed that the insured was diagnosed of Anemia and there was no active line of treatment given to the insured. During the entire hospitalization she was managed conservatively. It is further submitted that the discharge summary clearly mentions that the insured was advised rest and prescribed medicines. On these lines, the case is sought to be defended by the OPs.
3.     Rejoinder was filed 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.
6.     It is evident from Annexure C-1, the copy of the health insurance policy which is valid from 14.1.2019 to 13.01.2020 and complainant paid a sum of Rs.25064/- as premium. When the wife of the complainant suffered with Dizziness, Nausea, Weakness, Fever, Bodyache, Headache etc., she was treated by a doctor. The complainant spent Rs.9779/- (Annexure C-4 colly) in the hospital during the treatment. As per email Annexure C-5 dated 2.5.2019 the OPs approved the claim to the tune of Rs.7488/- but had not come forward to pay the same. On the other hand as per Annexure C-9, dated 25.05.2019 even the approved claim was denied. Annexure C-10 says that “As per submitted documents admission primarily for investigation and evaluation. Patient treated mainly with oral medications. Hence, claim stands repudiated as per clause 6.15.”
7.     As per OPs claim of an amount of Rs.18,681/- have not been raised with the company till date. But perusal of the various bills on record show that it was not any other person but the complainant’s wife only who after getting hospitalized visited various qualified doctors of Rajasthan as well as Chandigarh who have prescribed various medicines and medical tests for which complainant had to spent another amount of Rs.18,681/-.
8.     Hence, in our opinion as the wife of the complainant is duly covered under the alleged medical insurance policy, therefore, the claim raised by the complainant cannot be denied. We feel that it was the choice of the concerned doctor to admit the patient i.e., the complainant’s wife and not the sweet will of the patient. Also it is out of our understanding that what was the reason to approve the claim and thereafter rejecting of the same. Hence, the act of the OPs for repudiating the genuine claim of the complainant without any specific valid reason proves deficiency in services on their part and their indulgence in unfair trade practice.
9.     In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OPs are directed as under :-

1. To refund amount of ₹7488/- + ₹18,681/-to the complainant alongwith interest @ 9% per annum from the date of repudiating the claim till realization.
2. to pay an amount of ₹8,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹8,000/- to the complainant as costs of litigation.

10.     This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
11.     Certified copies of this order be sent to the parties free of charge. The file be consigned.

			Sd/-
02/05/2023			[Pawanjit Singh]
Ls			President
			Sd/-
			[Surjeet Kaur]
			Member