Punjab

Sangrur

CC/1190/2021

Judge Garg - Complainant(s)

Versus

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

Sh. Ritesh Jindal

17 Aug 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

 

                                                                        Complaint No. 1190

 Instituted on:   28.09.2021

                                                                        Decided on:     17.08.2023

 

Judge Garg aged about 32 years son of Sweet Kumar, resident of Jakhal Road, Balaji Colony, Near Hanuman Mandir, Near Dinesh Gupta Hospital, Sunam, Tehsil Sunam, Distt. Sangrur.

                                                         …. Complainant.     

                                                 Versus

1.             Max Bupa Health Insurance Company Limited, Branch Office: Sunami Gate, Street No.1, Block-A, Opposite Shahi Samadhan, Thales Bagh Colony, Sangrur through its Branch  Manager.

2.             Max Bupa Health Insurance Company Limited, Registered Office: Logix Infotech Park, Plot No.D-5, Sector 59, Gautam Budh Nagar (Noida) 201301 (UP) through its Managing Director.

                                                        ..Opposite parties.

 

For the complainant    :       Shri Ritesh Jindal, Adv.

For Opp.parties          :       Shri Sushil Kumar Ahuja, Adv.

 

 

Quorum                                           

Jot Naranjan Singh Gill, President

Sarita Garg, Member

                        Kanwaljeet Singh, Member

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT

 

1.             Complainant has preferred the present complaint against the opposite parties  on the ground that he obtained one online health insurance policy from the OPs bearing policy number 31760325202100 which was valid for the period from 30.5.2021 to 29.5.2022 for Rs.10,00,000/- after paying the requisite premium of Rs.7755/-. The policy in question was cashless and no other terms and conditions of the policy were ever issued to the complainant. The grievance of the complainant is that he felt fever on 26.7.2021 and was immediately taken to Mata Kaushalaya Memorial Centre and Poly Clinic, Sangrur for treatment and the doctor after diagnosing the case it was said to be a  case of dengue fever and the complainant remained admitted from 26.7.2021 to 31.7.2021 and the complainant paid an amount of Rs.62,000/- to the treating doctor for treatment. Thereafter the complainant lodged the claim with the OPs and submitted all the relevant documents, but OPs on 30.8.2021 repudiated the claim on the ground that 24 hours of hospitalization not completed. The OPs have repudiated the rightful claim of the complainant illegally and without any basis.  Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.62,000/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by OPs, preliminary objections are taken up on the grounds that the averments, allegations and claims made in the complaint are false, frivolous, vexatious and that the complainant has not produced any documents and the complaint should be dismissed. On merits, it is admitted that the complainant was insured under the policy in question and the policy terms and conditions were provided to the complainant at the time of insurance of the complainant. It is stated that the complainant is not entitled for any claim as he never remained admitted for 24 hours in the hospital. So, the claim has rightly been repudiated by the OPs. Lastly, the Ops have prayed that the complaint should

be dismissed with special costs.

 

3.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-28 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OP/1 to Ex.OP1/7 copies of documents and affidavits and closed evidence.

4.             We have gone through the pleadings put in by  the parties along with their supporting documents with their valuable assistance. 

5.             It is an admitted fact between the parties that the complainant  was insured with the OPs under the medical insurance policy. The contention of the complainant that during the subsistence of the insurance policy the complainant suffered dengue fever and remained admitted in Mata Kaushalaya Memorial Centre and Poly Clinic, Sangrur for treatment for the period from 26.7.2021 to 31.7.2021 where he spent an amount of Rs.62,000/-.  This fact is also proved from the copy of medical bills Ex.C-4 to Ex.C-12, whereas the discharge summary on record is Ex.C-13 wherein it has been clearly mentioned that the date of admission was 26.7.2021 and date of discharge was 31.7.2021 meaning thereby the complainant remained admitted in the hospital for treatment for six days. Ex.C-14 to Ex.C-24 are the copies of the clinic laboratory reports. Ex.C-26 to Ex.C-28 are the copies of the proforma submitted by the complainant to the OPs for settlement of the claim whereas all this evidence is supported by the affidavit of the complainant Ex.C-1.  On the other hand, though the stand of the OPs for repudiating the claim of the complainant is that the complainant did not complete 24 hours admission in the hospital, but this fact is not corroborated by any evidence on record. The OPs have produced Ex.OP/3 is copy of the insurance policy, Ex.OP/4 and Ex.OP/5 copy of the claim form etc. and Ex.OP/6 is the affidavit of one Bhuwan Bhashker, Senior Manager, wherein again it is mentioned that the claim of the complainant was denied on the substantial reason that 24 hours of hospitalization was not completed as claimed in the complaint, but we may mention that the OPs have miserably failed to prove that the complainant did not remain under treatment for less than 24 hours, whereas the complainant has clearly proved on record from the discharge summary Ex.C-13 which is duly sealed and signed by Dr. Mohit Goyal that he remained admitted in the hospital from 26.7.2021 to 31.7.2021 as mentioned above, where he spent an amount of Rs.62,000/- on his treatment during this period.  It is further worth mentioning here that by not settling the rightful claim of the complainant the OPs are deficient in rendering service to the complainant/consumer, who got himself insured under the policy by paying the requisite premium.

6.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

 

7.             Accordingly, in view of our above discussion, we allow the complaint and direct OPs to pay to the complainant the claim amount of Rs.62,000/- alongwith interest @ 7% per annum from the date of filing of the present complaint i.e. 28.09.2021 till realisation. Further the OPs are directed to pay to the complainant an amount of Rs.3500/- as compensation for mental tension, agony and harassment and further an amount of Rs.3500/- on account of litigation expenses. This order be complied with within a period of sixty days of receipt of copy of this order.

 

 

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

 

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

                        Pronounced.

                       August 17, 2023.