Punjab

Sangrur

CC/230/2022

Harwinder Sharma - Complainant(s)

Versus

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

Sh. Udit Goyal

25 Apr 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR, PUNJAB.

 

          Complaint Case No       : CC/230/2022

                                              Date of Institution                   : 07.03.2022

          Date of Decision            : 25.04.2024

Harwinder  Sharma aged about 31 years son of Sh. Baljit Kumar, resident of village Bugra, Tehsil Dhuri, District Sangrur.   

                                                                                          …Complainant

                                              Versus

 

1. MAX Bupa Health Insurance Company Limited (now merged into Niva Bupa Health Insurance Company Limited), Unit No. 3, Plot No. 88, 2^nd Floor, Mall Road, Opposite AXIS Bank Limited, Ludhiana, through its Manager;  

2.  MAX Bupa Health Insurance Company Limited (now merged into Niva Bupa Health Insurance Company Limited), Head Office: 4^th Floor, Capital Cyber Scape, Sector 89, Gurugram (Haryana), through its Managing Director;

3. Munish Kumar C/o RIMIT Financial Services, Mahavir Chowk, Opposite Excise and Taxation Office, Sangrur.                                                                                                                                            ...Opposite Parties.

Complaint under section 35 of the Consumer Protection Act, 2019

Present:       Sh. Udit Goyal counsel for complainant.

                   Sh. Jatinder Verma counsel for opposite parties No. 1 & 2.

                   Sh. Rajan Kapil counsel for opposite party No. 3.

Quorum.-

1. Sh. Jot Naranjan Singh Gill                    : President

2. Smt. Sarita Garg                           : Member
3. Sh. Kanwaljeet Singh                    : Member   

 

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT

1.                The complainant namely Harwinder Sharma has filed the present complaint under Section 35 of the Consumer Protection Act 2019, (amended upto date) against MAX Bupa Health Insurance Company Limited and others (in short the opposite parties).

2.                The facts leading to the present complaint as stated by the complainant are that the agent of opposite parties No. 1 & 2 approached the complainant and disclosed number of health policy schemes to the complainant. The complainant under the allurement of opposite party No. 3 purchased health insurance policy vide policy No. 31694946202100 for the period 29.4.2021 to 28.4.2022 and under the said policy the complainant and his wife was covered for a sum of Rs. 10 lakhs and will get cashless treatment in any hospital anywhere in India for any kind of disease. The complainant paid the premium amount of Rs. 11,917/- through online transaction with the opposite parties No. 1 & 2 and no separate terms and conditions were ever supplied to the complainant by the opposite parties at the time of getting the insurance policy or after that. At the time of issuing the health policy, the complainant and his wife were medically checked up and it was found that the complainant and his wife were not suffered from any kind of health problems and after that policy was issued. It is further alleged that in the second week of July 2021, wife of the complainant namely Gagandeep Kaur was suffering from stomach pain, then the complainant and his wife immediately approached Singla Surgical Hospital, Sangrur for medical checkup and after conducting various tests, the doctor advised the complainant and his wife to consult with urological doctor. Thereafter, the complainant and his wife consulted with urological doctor and doctor advised some tests and scan of the wife of the complainant and they went to Patiala for scan and some tests were conducted at Patiala as well as at Sangrur. After getting the reports of medical tests and scan, the complainant went to Healing Super Specialist Hospital, Chandigarh and consulted with Dr. Karun Singla and said doctor after going through the reports, advised for the operation. The complainant disclosed the doctor as well as the hospital staff that they have cashless medical policy. Then the staff of the hospital obtained the policy from the complainant and immediately sent the email to the opposite parties No. 1 & 2 for pre-approval of cashless treatment vide cashless claim No. 379512 dated 23.7.2021. But the opposite parties No. 1 & 2 refused to provide cashless treatment on the ground that “as per policy clause 5.3 genitourinary surgery falls under 24 months waiting period hence rejected”. The alleged rejection of the opposite parties is totally false and vague. Moreover, no terms and conditions were ever supplied to the complainant. It is further alleged that on 24.7.2021 the wife of the complainant got admitted in the said hospital and her operation was got conducted on the same day. The wife of the complainant remained admitted in the said hospital and was discharged in the evening of 25.7.2021. The complainant spent an amount of Rs. 90,000/- on the entire treatment of his wife from his own pocket. Thereafter, the complainant approached the opposite parties number of times and requested them to release the claim amount of Rs. 90,000/- but the opposite parties put off the matter on one pretext or the other by making lame excuses and later on flatly refused to release the claim amount to the complainant. As such, there is deficiency in service, negligence and unfair trade practice on the part of opposite parties. Hence, the present complaint is filed seeking the following reliefs.-

1. The opposite parties may be directed to release the claim amount of Rs. 90,000/- to the complainant alongwith interest @ 18% per annum from the date of start of treatment till realization.
2. To pay Rs. 50,000/- on account of mental agony and harassment and Rs. Rs. 22,000/- on account of litigation expenses. 

3.                Upon notice of this complaint, the opposite parties No. 1 & 2 appeared and filed written reply by taking preliminary objections interalia on the grounds that the complaint is not maintainable. The complaint is pre-mature being the complainant till date not lodged any reimbursement claim under the policy. The present complaint filed with malafide intention and complainant has not come with clean hands. That intricate questions of law and facts are involved in the matter in issue and parties should have to lead evidence by examining the witnesses and the other party should have to cross examine the witnesses and the same cannot be decided in summary manner and the complainant may approach to the Civil Court. No cause of action has been arisen to the complainant. Further, this Commission has no jurisdiction to entertain the present complaint etc.

4.                On merits, it is submitted that the complainant purchased the health insurance policy from the replying opposite parties after understand the entire scenario of the policy and accordingly given his consent and duly received premium from the complainant. It is admitted that the replying opposite parties issued the policy. It is alleged that the opposite parties received the cashless request from Healing Hospital and after going through the entire documents as provided by the concerned Hospital, they found that the claim as raised is not fall within the insurance as granted being the same is covered after 2 years of the insurance, hence the cashless request denied by them. It is further alleged that the opposite parties till date not received any reimbursement claim under the policy from the complainant. It is denied that the complainant has suffered any mental tension, harassment, agony, loss of time, loss of reputation due to the act and conduct of the replying opposite parties, rather the complainant himself violated the terms and conditions of the policy, which are already in the possession of the complainant and the complainant twisted the facts for his own benefits. Thus, there is no deficiency in service on their part and they prayed for the dismissal of complaint with costs.

5.                The opposite party No. 3 filed separate written reply by taking legal objections on the grounds that complaint is not maintainable, complainant has no locus-standi to file the present complaint and present complaint is bad for want of mis-joinder etc. On merits, the opposite party No. 3 submitted that answering opposite party No. 3 is not the agent of opposite parties No. 1 & 2 and the answering opposite party never approached the complainant and never disclosed the number of schemes to the complainant. All other allegations of the complaint are denied and prayed for the dismissal of complaint.

6.                In order to prove the case the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy Ex.C-2, copy of email Ex.C-3, copy of rejection letter Ex.C-4 (1 to 3 pages), copy of medical record (1 to 6 pages) Ex.C-5, copy of bills (1-5 pages) Ex.C-6 and closed the evidence.

7.                To rebut the case the opposite parties No. 1 & 2 tendered into evidence copy of letter Ex.O.P1&2/1, copy of policy Ex.O.P1&2/2, copy of policy schedule Ex.O.P1&2/3, copy of premium receipt Ex.O.P1&2/4,  copy of authorized hospital Ex.O.P1&2/5 (1 to 4 pages), copy of customer information slip Ex.O.P1&2/6 (1 to 4 pages), copy of terms and conditions (1 to 21 pages) Ex.O.P1&2/7, copy of Anexures Ex.O.P1&2/8 to Ex.O.P1&2/10, copy of Proposal Form (1 to 3 pages) Ex.O.P1&2/11, copy of medical declaration (1 to 3 pages) Ex.O.P1&2/12, copy of ID Card Ex.O.P1&2/13, copy of policy Part C (1 to 3 pages) Ex.O.P1&2/14, copy of cashless denial letter (1to 3 pages) Ex.O.P1&2/15, copy of medical report (1 to 2 pages) Ex.O.P1&2/16, copy of report (1 to 3 pages) Ex.O.P1&2/17, copy of clinical report Ex.O.P1&2/18, copy of Adhaar Card Ex.O.P1&2/19, affidavit Ex.O.P1&2/20 and closed the evidence.

8.                The opposite party No. 3 tendered into evidence Ex.Op3/1 affidavit of Munish Kumar and closed the evidence. 

9.                We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments filed by the complainant.

10.              Ld. Counsel for the complainant argued that the agent of opposite parties No. 1 & 2 approached the complainant and disclosed number of health policy schemes to the complainant and the complainant under the allurement of opposite party No. 3 purchased health insurance policy vide policy No. 31694946202100 for the period 29.4.2021 to 28.4.2022 and under the said policy the complainant and his wife was covered for a sum of Rs. 10 lakhs and will get cashless treatment in any hospital anywhere in India for any kind of disease (Ex.C-2) and the complainant paid the premium amount of Rs. 11,917/- through online transaction with the opposite parties No. 1 & 2. It is also argued that no separate terms and conditions were ever supplied to the complainant by the opposite parties at the time of getting the insurance policy or after that and at the time of issuing the health policy, the complainant and his wife were medically checked up and it was found that the complainant and his wife were not suffered from any kind of health problems and after that policy was issued. It is also argued by the Ld. Counsel for complainant that even the agent (i.e. opposite party No. 3) of the insurance company did not disclose any terms and conditions to the complainant at the time of purchasing the above said policy. It is further argued that in the second week of July 2021, wife of the complainant namely Gagandeep Kaur was suffering from stomach pain, then the complainant and his wife immediately approached Singla Surgical Hospital, Sangrur for medical checkup and after conducting various tests, the doctor advised the complainant and his wife to consult with urological doctor, as such the complainant and his wife consulted with urological doctor and doctor advised some tests and scan of the wife of the complainant and they went to Patiala for scan and some tests were conducted at Patiala as well as at Sangrur and after getting the reports of medical tests and scan the complainant went to Healing Super Specialist Hospital, Chandigarh and consulted with Dr. Karun Singla and said doctor after going through the reports, advised for the operation. It is argued that the complainant disclosed the doctor as well as the hospital staff that they have cashless medical policy and the staff of the hospital obtained the policy from the complainant and immediately sent the email to the opposite parties No. 1 & 2 for pre-approval of cashless treatment vide cashless claim No. 379512 dated 23.7.2021 (Ex.C-3). But the opposite parties No. 1 & 2 refused to provide cashless treatment on the ground that “as per policy clause 5.3 genitourinary surgery falls under 24 months waiting period hence rejected” (Ex.C-4). It is further argued that on 24.7.2021 the wife of the complainant got admitted in the said hospital and her operation was got conducted on the same day and the wife of the complainant remained admitted in the said hospital and was discharged in the evening of 25.7.2021 (Ex.C-5). It is also argued that the complainant spent an amount of Rs. 90,000/- on the entire treatment of his wife from his own pocket and the complainant approached the opposite parties number of times and requested them to release the claim amount of Rs. 90,000/- but the opposite parties put off the matter on one pretext or the other by making lame excuses and later on flatly refused to release the claim amount to the complainant, so there is deficiency in service on the part of opposite parties No. 1 & 2.

11.              Ld. Counsel for the opposite parties No. 1 & 2 argued that the complaint is pre-mature being the complainant till date not lodged any reimbursement claim under the policy and the present complaint filed with malafide intention and complainant has not come with clean hands. It is further argued that an intricate questions of law and facts are involved in the matter in issue and parties should have to lead evidence by examining the witnesses and the other party should have to cross examine the witnesses and the same cannot be decided in summary manner and the complainant may approach to the Civil Court and no cause of action has been arisen to the complainant. It is also argued that the complainant purchased the health insurance policy from the replying opposite parties after understand the entire scenario of the policy and accordingly given his consent and duly received premium from the complainant and it is admitted that the opposite parties issued the policy. It is argued that the opposite parties received the cashless request from Healing Hospital and after going through the entire documents as provided by the concerned Hospital, they found that the claim as raised is not fall within the insurance as granted being the same is covered after 2 years of the insurance, hence the cashless request denied by them. It is further argued that the opposite parties till date not received any reimbursement claim under the policy from the complainant. As such, there is no deficiency in service on their part and they prayed for the dismissal of complaint with costs.

12.              Ld. Counsel for the opposite party No. 3 argued that  complaint is not maintainable and complainant has no locus-standi to file the present complaint. It is further argued that the opposite party No. 3 is not the agent of opposite parties No. 1 & 2 and the opposite party No. 3 never approached the complainant and never disclosed the number of schemes to the complainant and all other allegations of the complaint are denied and prayed for the dismissal of complaint.

13.              It is admitted case of the complainant that the complainant purchased health insurance policy vide policy No. 31694946202100 for the period 29.4.2021 to 28.4.2022 and under the said policy the complainant and his wife was covered for a sum of Rs. 10 lakhs (Ex.C-2 & Ex.O.P1&2/3).  It is also admitted that wife of the complainant on 24.7.2021 got admitted in the said hospital and her operation was got conducted on the same day and was discharged in the evening of 25.7.2021. The case of the complainant is that he has spent an amount of Rs. 90,000/- on the entire treatment of his wife from his own pocket because the opposite parties No. 1 & 2 refused to provide cashless treatment on the ground that “as per policy clause 5.3 genitourinary surgery falls under 24 months waiting period hence rejected”.

14.              The allegation of the complainant is that no terms and conditions were ever supplied to the complainant alongwith policy/policy schedule by the opposite parties No. 1 & 2. On the other hand, the opposite parties No. 1 & 2 submitted that the terms and conditions were supplied to the complainant alongwith policy, but the opposite parties No. 1 & 2 have failed to place on record any evidence in order to rebut the above said allegation of the complainant. Moreover, we have perused the medical bill dated 24.7.2021 Ex.C-6 placed on record by the complainant which shows that an amount of Rs. 48,000/- has been spent by the complainant on the treatment of his wife Gagandeep Kaur. Further, in Ex.C-6 at Page No. 3 bill dated 25.7.2021 of Apollo Pharmacy shows that the complainant has spent Rs. 362.07 on the medicines. Further, in Ex.C-6 at page no.5 OPD receipt  dated 14.08.2021 which shows that complainant has deposited  Rs.500/-  and the total  comes to the tune of  Rs. 48,000/- + Rs. 362.07+Rs.500/- = Rs. 48,862.07.

15.              The complainant has placed on record the judgment of the Hon'ble Punjab & Haryana High Court, Chandigarh, (2008) 151 PLR 313, decided on 22.4.2008 in case titled New India Assurance Company Vs Usha Yadav And Others in which it is held that It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Company in such case reply upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy.

16.              The complainant further placed on record the another judgment of the Hon'ble High Court of Punjab and Haryana, Chandigarh, CWP No. 107 of 2020, date of decision January 07, 2020 in case titled Religare Health Insurance Company Limited Vs The Chairman, Permanent Lok Adalat and Another, in which it is held that Since the company itself is issuing policies for the tenure of 1 year then the company cannot claim that the company shall not pay any claim before the period of 2 years. There is no explanation as to how this clause justifies the issuance of policy for one year.

17.              So, we are of the view that the opposite parties No. 1 & 2 have failed to rebut the case of the complainant by producing on record any cogent and reliable evidence and there is clear cut deficiency in service on the part of the opposite parties by not giving the genuine claim of the complainant. We are also of the view that the insurance company has acted with pre-determined mind with the sole intention, to defeat the genuine claim of the complainant.

18.              As result of the above discussion and law laid down by the Hon'ble High Court of Punjab & Haryana, Chandigarh, the present complaint is partly allowed against the opposite parties No. 1 & 2 and the opposite parties No. 1 & 2 are directed to pay the claim amount of  Rs. 48,862/- to the complainant alongwith interest @ 7% per annum from the date of filing the present complaint till realization. The opposite parties No. 1 & 2 are further directed to pay Rs. 5,000/- as compensation on account of mental agony and harassment and Rs. 5,000/- as litigation expenses to the complainant.

19.              This order be complied with within a period of sixty days of receipt of copy of this order.

20.              The complaint could not be decided within the statutory time period due to heavy pendency of cases.

21.              Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance.

                    ANNOUNCED IN THE OPEN COMMISSION:

                                       25^th Day of April, 2024

 

                                       (Jot Naranjan Singh Gill)

                                                President

                                                

                                      (Sarita Garg)

                                      Member

 

                                      (Kanwaljeet Singh)

                                      Member