Haryana

Karnal

CC/38/2022

Bittu Kumar - Complainant(s)

Versus

Max Bupa Health Insurance Company Limited - Opp.Party(s)

Apaar Singh Bedi

11 Jun 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No.38 of 2022

                                                        Date of instt.20.01.2022

                                                        Date of Decision:11.06.2024

 

Bittu Kumar son of Shri Satpal, resident of 127, Ganjo Garhi, Karnal.  Aadhar no.6023 6490 9457.

 

                                                                   …….Complainant.

                                              Versus

 

Max Bupa Health Insurance Company Limited, Logix Infotech Park, plot no.D-5, Sector-59, Noida, Gautam Budh Nagar, Uttar Pradesh 201301, through its authorized signatory.

                                                                     …..Opposite Party.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Dr.  Suman Singh…..Member

 

 Argued by: Shri Apaar Singh Bedi, counsel for the

    complainant.

                    Shri Rajesh Gupta, counsel for the OP.

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that the complainant obtained a policy bearing no.50162600202100, product name Max Health Plus and the said policy was valid from 29.05.2021 to 29.06.2022. On 30.10.2021, complainant was suffering from viral fever with thrombocytopenia and he was admitted in Shree Balajee Multispecialty Hospital, Panipat and discharged on 03.11.2021. Complainant spent an amount of approximately Rs.70,000/- on his treatment. After getting discharge from the hospital, complainant submitted the claim with the OP alongwith required documents for reimbursement of the said amount. But OP did not pay the claim amount and rejected the claim of complainant on the ground of mis-representation of material facts whereas no facts have been concealed or mis-represented by the complainant. Thereafter, complainant requested the OP several times for releasing the claim amount but to no avail. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence this complaint.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the Bajaj Finance Ltd. entered into an insurance contract with OP, whereof a group master policy no.50162600202100 was issued on 29.05.2021 to Bajaj Finance Ltd. The Bajaj Finance Ltd. has taken the said group policy for its customer/member for their benefit. Accordingly a certificate no.113002174624 was issued to the complainant upon the request received from the said group master policy holder. The said certificate was issued w.e.f. 30.06.021 to 29.06.2022 for one year covering the complainant for sum insured of Rs.1,00,000/-. Under the said health policy, the complainant was entitled for various benefit, which includes medical expenses. The OP received the claim bearing no.ID200001662 of Rs.60,000/- from the complainant with respect to the expenditure, allegedly incurred in his treatment at Shree Balajee Multi Specialty Hospital, Panipat. The said claim was investigated by the investigator of the OP. During investigation it was revealed as under:-

.       Complainant was reported to be admitted in Shree Balaji Multi Specialty Hospital, Panipat on 30.10.2021 for c/o fever, weakness, Nausea/vomiting.

.       As per the vital chart the complainant was Afebrile through out with normal SPO-2 but as per treatment chart, complainant was nebulized thrice a day from 01.11.2021 to 03.11.2021, but complainant denied to have nebulization throughout his hospitalization.

.       In final bills, oxgen support (24 hours) was included but nowhere in treatment chart or in whole ICP oxgen support was specified, even complainant denied to have on OT Support.

.       As per ICP or insured statement, no complaint related to chest pain was specified but patient TROP-1 and ECG was advised and conducted during hospitalization.

.       ECG Report provided by the complainant were of only three days but in final bill 9 ECG Tests were included.

.       As per the ICP, complainant had c/o fever, weakness, Nausea/vomiting but no such complaint were being specified by complainant other than fever.

.       Even though complainant had almost Afebrile but complainant was being administered with Anti PyreticINJ-08 and 12 hourly.

.       Complainant was admitted in the ICU for four days of hospitalization but complainant clinical condition to be admitted in ICU for four days as patient have slightly high SGOT/SGPT Value with PLT Count in between 63000 to 220000 LAC/ CMM with normal body temperature.

From the above facts, documents and submissions, it was manifested there was misrepresentation of material facts on the part of the complainant with regard to his claim. The claim was based on falsehood. Since the claim was based on dishonesty, fraud and misrepresentation, accordingly, the same was rejected as per clause 5.1.27 as per the terms and condition of the policy. The rejection of the claim of the complainant was proper, legal, valid and justified made as per the terms and condition of the policy and in accordance with law. There is no deficiency in service on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of aadhar card Ex.C1, copy of certificate of insurance Ex.C2, copy of discharge summary Ex.C3, copy of IPD service receipt Ex.C4, copy of OPD procedure /service detail Ex.C5, copy of pharma receipt Ex.C6, copy of email Ex.C7, copy of payment of bill receipts Ex.C8 to Ex.C11 and closed the evidence on 21.02.2023 by suffering separate statement.

5.             On the other hand, OP failed to tender its evidence despite availing several opportunities including three last opportunities. Thus, the evidence of OP was closed, vide order dated 06.02.2024 of the Commission.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for the complainant, while reiterating the contents of complaint, has vehemently argued that complainant had obtained a health insurance policy from the OP. On 30.10.2021, complainant was suffering from viral fever with thrombocytopenia and was admitted in Shree Balajee Multispecialty Hospital, Panipat and has spent an amount of Rs.70,000/- on his treatment. After discharge from the hospital, complainant submitted the claim with the OP alongwith required documents but OP did not pay the claim amount and rejected the claim of complainant on the ground false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that that the Bajaj Finance Ltd. entered into an insurance contract with OP, whereof a group master policy was issued on 29.05.2021 to Bajaj Finance Ltd. The Bajaj Finance Ltd. has taken the said group policy for its members for the period from 30.06.021 to 29.06.2022 for one year, covering the complainant for sum insured of Rs.1,00,000/-. The OP received the claim of Rs.60,000/-. The said claim was got investigated by the OP. During investigation it was found that there was misrepresentation of material facts on the part of the complainant. Thus, the claim of complainant was rightly repudiated by the OP and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant was insured in Group Master Policy taken by Bajaj Finance Ltd. from OP. It is also admitted that during the subsistence of said insurance policy, complainant was hospitalized and submitted the medical bills of Rs.60,000/- for reimbursement.

11.           The claim of the complainant has been repudiated by the OP on the following grounds, which are reproduced as under:-

.       Complainant was reported to be admitted in Shree Balaji Multi Specialty Hospital, Panipat on 30.10.2021 for c/o fever, weakness, Nausea/vomiting.

.       As per the vital chart the complainant was Afebrile through out with normal SPO-2 but as per treatment chart, complainant was nebulized thrice a day from 01.11.2021 to 03.11.2021, but complainant denied to have nebulization throughout his hospitalization.

.       In final bills, oxgen support (24 hours) was included but nowhere in treatment chart or in whole ICP oxgen support was specified, even complainant denied to have on OT Support.

.       As per ICP or insured statement, no complaint related to chest pain was specified but patient TROP-1 and ECG was advised and conducted during hospitalization.

.       ECG Report provided by the complainant were of only three days but in final bill 9 ECG Tests were included.

.       As per the ICP, complainant had c/o fever, weakness, Nausea/vomiting but no such complaint were being specified by complainant other than fever.

.       Even though complainant had almost Afebrile but complainant was being administered with Anti PyreticINJ-08 and 12 hourly.

.       Complainant was admitted in the ICU for four days of hospitalization but complainant clinical condition to be admitted in ICU for four days as patient have slightly high SGOT/SGPT Value with PLT Count in between 63000 to 220000 LAC/ CMM with normal body temperature.

 

12.           The claim of the complainant has been repudiated by the OP on the abovesaid grounds. To prove its version OP has failed to lead any cogent evidence after availing several opportunities. Thus, the evidence produced by the complainant goes unchallenged and unrebutted and there is no reason to disbelieve the same. Furthermore, on perusal of the medical record, there is no such type of misrepresentation on which the claim cannot be allowed.

13.           Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

14.           Keeping in view the ratio of the law laid down in the abovesaid authority, facts and circumstances of the present complaint, we are of the considered view that the act of the OP while denying the claim of complainant amounts to deficiency in service and unfair trade practice, which is otherwise proved a genuine one.

15.           The complainant has claimed Rs.70,000/- and in this regard he has submitted the medical bills Ex.C4, Ex.C5, Ex.C8 to Ex.C11. The said bills have not been denied and rebutted by the OP. Thus, complainant is entitled for the said amount alongwith compensation for mental pain, agony and harassment and litigation expenses etc.

16.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.70,000/- (Rs. seventy thousand only) to the complainant. We further direct the OP to pay Rs.10,000/- to the complainant on account of mental agony and harassment and Rs.5500/- towards the litigation expenses. This order shall be complied with within 45 days from the receipt of copy of this order.  It is made clear if the awarded amount is not paid by the OP within stipulated period then this amount will carry interest @ 9% per annum from the date of announcement of the order till its realization. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:11.06.2024                                                                    

                                                                President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.      

(Vineet Kaushik)        (Dr. Suman Singh)    

                     Member                   Member