Chandigarh

DF-I

CC/218/2020

Somnath Aggarwal - Complainant(s)

Versus

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

Devinder Kumar

07 Oct 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/218/2020
Date of Institution	:	08/07/2020
Date of Decision	:	07/10/2022

 

Somnath Aggarwal son of Sh. Roshan Lal Aggarwal, aged about 37 years, r/o House No.1256, Universal Enclave, Sector 48-B, Chandigarh.

… Complainant

V E R S U S

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

… Opposite Parties

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR	MEMBER
	SURESH KUMAR SARDANA	MEMBER

 

                                                

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

Per Surjeet kaur, Member

1.      Briefly stated allegations are that on the assurances given by the OPs, the complainant purchased health insurance policy for himself, his wife and his daughter. The complainant paid an amount of Rs.73,500/- to the OPs and the said policy was valid from 28.11.2019 to 27.11.2021 (Annexure C-1). The daughter of complainant was born on 16.04.2016 and copy of birth certificate which is annexed as Annexure C-2. As per complainant, in the month of December, 2017 daughter of complainant faced toe walking problem; accordingly visited to Indraprastha Apollo Hospital, Sarita Vihar, Delhi-Mathura Road, New Delhi in Pediatrics Orthopedic Department. After consulting Dr.Ramani Narshimhan, thereafter complainant was continuously following up with the same docter only. In December 2019, the docter diagnosed the complainant’s daughter with Idiopathic toe walking and advised for surgery for treating it.

         As per surgery protocol, the daughter of the complainant was admitted in the hospital on 24.12.2019 and discharged on 27.12.2019 (Annexure C-4). The complainant applied for pre-approval of insurance claim through treating Hospital, Delhi on 13.12.2019 through cashless claim request, but the OPs denied the cashless authorization claim vide letter dated 13.12.2019 (Annexure C-5). The complainant paid a sum of Rs.3,33,376/- to the Indraprastha Apollo Hospital, Sarita Vihar, Delhi-Mathura Road, New Delhi at the time of discharge for treatment of his daughter (Annexure c-8). After surgery the complainant submitted the physical claim form on 16.01.2020 along with required documents to the OPs with the request to release the claim amount (Annexure C-9). The complainant also paid other expenses after the surgery i.e. the amount of Rs.18,328/- till 16.01.2020 and Rs.38,110/- till 25.02.2020 amounting to total of Rs.56,438/- as post hospitalization  expenses are covered till 60 days covered in policy (Annexure C-10). Instead of paying the genuine claim of the complainant, OPs issued letter dated 14.02.2020 and repudiated the claim of the complainant with mala fide intention on the following grounds.

         “As per submitted documents & investigation done by us it found that patient taken for external congenital anomaly, as per policy external congenital anomaly treatment is not covered, hence claim denial as per policy clause 6.8”.

         Copy of Repudiation letter dated 14.02.2020 is annexed as Annexure C-12. After going through the rejection letter dated 14.02.2020, Dr.Ramani Narasimhan informed that he had clearly diagnosed with problem of Idiopathic Toe Walking and he had also written it in his prescription and also in discharge summary. Alleging that the aforesaid act amounts to deficiency in service and unfair trade practice on the part of the OPs, the complainant has filed the instant complaint.

2.       OPs contested the consumer complaint, filed their written reply and stated that in the complaint, the complainant has prayed for Rs.3,33,376/- as the amount spent on treatment and Rs.56,438/- as post hospitalization expenses, but a mere perusal of the claim documents would reveal that the complainant has claimed only 15,210/- as post hospitalization expenses from the company and now in order to extort money from the OP-Company he has exaggerated the amount by almost Rs.35,000/-. The complainant and his wife were the insured under the policy and the daughter of the complainant was later on added in the policy in 2017 post conducting medical examinations. Thereafter, the complainant renewed the policy also. The OP-Company has acted strictly as per the policy terms and conditions and have acted within the four corners of the statutory provisions, no case of deficiency in services. It is also submitted that “As per submitted documents & investigation done by us it found that patient taken for external congenital anomaly, as per policy external congenital anomaly treatment is not covered as per policy clause 6.8”. As per the documents received it is evident that patient was treated for external congenital disease. Pleading that there is no deficiency in service or unfair trade practice on their part, OPs prayed for dismissal of the consumer complaint.

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.       The sole grouse of the complainant through present complaint is that the OPs illegally, arbitrarily and even without confirming the facts from the treating doctors have repudiated the genuine claim of his daughter. Firstly, the complainant was denied the cashless claim on the pretext of the non-disclosure of pre-existing disease of his daughter. Secondly, OPs took contradictory stand to repudiate the final claim, after the discharge of the patient/daughter of the complainant on the following grounds.

         “As per submitted documents & investigation done by us it found that patient taken for external congenital anomaly, as per policy external congenital anomaly treatment is not covered, hence claim denial as per policy clause 6.8”.

         Hence, as per the complainant denial of the cashless facility in the hospital and thereafter repudiation of the genuine claim of the complainant is deficiency in service on the part of OPs. Hence, is the present complaint.

7.       The stand taken by the OPs is that the patient in question took the treatment for external congenital anomaly which is not covered as per the policy clause 6.8, hence as per the terms and conditions of the policy the claim of the complainant has been correctly denied.

8.       After careful scrutiny of the record it is very much clear that policy in question is in existence since 2014. Further as per Annexure C-2, the birth certificate of daughter of the complainant, she was born on 16.04.2016. Then complainant approached the OPs for the purpose of addition of the name of his daughter in the ongoing policy for which he was paying premium since year 2014, but he was denied that the name of the daughter of the complainant cannot be added as they do not cover the premature babies till they complete one year. On the pursuance of the OPs, the daughter of the complainant got cover in the second renewal from 28.11.2017 that too after proper medical test/verification as per the satisfaction of the OPs. The fact of conducting the test is crystal clear from the mail Annexure C-3, dated 21.11.2017. The OPs themselves fixed the date of medical of child in question for 22.11.2017. Meaning thereby the daughter of the complainant underwent proper medical test as per instructions of the OPs, as per their terms and conditions. Hence, there is no question of denying the cashless hospitalization to the patient, despite her being covered under the policy.

9.       Not only this, it is abundantly clear at page No.46 of the paper book Annexure R-3, clause-C which is reproduced as below:-

          “Pre & Post hospitalization Medical Expenses: Medical Expenses incurred due to illness up to 30 days period immediately before and 60 days immediately after an Insured Person’s admission to a Hospital.”

         Therefore, the denial of pre-hospitalization by the OPs was illegal, arbitrary and not as per their own policy.

10.      Now the next point to consider is the repudiation letter i.e. Annexure C-12, the content of which are as under:-

         “As per submitted documents & investigation done by us it found that patient taken for external congenital anomaly, as per policy external congenital anomaly treatment is not covered, hence claim denial as per policy clause 6.8”.

11.      The reason for the refusal/repudiation of the genuine claim of the complainant was denied/verified by the treating Dr. Ramani Narasimhan, Past-President, POSI, Sr Cons Peds Ortho Surgeon, Indraprastha Apollo Hospitals, ND, Orthoped Clinic, ND and informed to the complainant that:-

         “There was no congenital anomaly. This was bilateral ‘Idiopathic Toe Walking’ an acquired problem”.

         Copy of emails and letter dated 17.02.2021 are attached as Annexure C-13 to C-15.

12.      Now perusal of the opinion of the doctor (Annexure C-15) clearly reveals that the reasons for refusal of the genuine claim of the complainant is totally false. We opine that just to withhold genuine claim of the complainant, the OPs made false allegations against the complainant. Hence from the facts and circumstances of the present case, the act of the OPs for not providing cashless facility, repudiating the claim on the false grounds, non-honouring their own terms and conditions proves deficiency in service and their indulgence in unfair trade practice. 

13.      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 pay an amount of ₹3,33,376/- to the complainant alongwith interest @ 9% per annum from the date of repudiation till realization.
2. to pay an amount of ₹56,438/- to the complainant as post hospitalization expenses alongwith interest @ 9% per annum from the date of filing of this present complaint till realization.
3. to pay an amount of ₹25,000/- compensation for causing mental agony and harassment to him;
4. to pay ₹10,000/- to the complainant as costs of litigation.

14.     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) & (iii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iv) above.

15.     Certified copies of this order be sent to the parties free of charge. The file be consigned.

			Sd/-
07/10/2022			[Pawanjit Singh]
Ls			President
			Sd/-
			[Surjeet Kaur]
			Member
			Sd/-
			[Suresh Kumar Sardana]
			Member