Haryana

Karnal

CC/280/2018

Raj Kumar - Complainant(s)

Versus

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

Sanjeev Kapoor

13 Jun 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 280 of 2018

                                                          Date of instt. 22.10.2018

                                                          Date of Decision 13.06.2019

 

Raj Kumar son of Shri Raghu Nath Sharma resident of House no.119, Gali no.7, Saini Colony, Model Town, Karnal.

                                                                         …….Complainant

                                                        Versus

 

1. Max Bupa Health Insurance Company Ltd; Corporate office Block B1/1-2, Mohan Cooperative Industrial Estate Mathura Road, New Delhi 110044 through its Managing Director.

2. Ashish Mehrotra, Managing Director and Chief Executive Officer, Max Bupa Health Insurance Company Ltd; corporate office Block B1/1-2, Mohan Cooperative Industrial Estate Mathura Road, New Delhi-110044.

3. Salini wife of Shri Harvinder Agent of Max Bupa Health Insurance Company Ltd. House no.18/1681, Gobind Nagar, near Old Sabzi Mandi, Karnal-132001.

 

                                                                   …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before   Sh. Jaswant Singh……President.  

      Sh.Vineet Kaushik ………..Member

            

 

 Present:  Shri Sanjeev Kapoor Advocate for complainant.

                   Shri Vikas Chauhan Advocate for opposite parties.

 

                   (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that the complainant had been insured of Group by Max Bupa Health Insurance Health Companion Variant 2 vide policy no.30685634201700m, ID no.2000313740, valid from 20.07.2017 to 19.07.2018, sum assured Rs.5,00,000/-. The complainant paid the premium of Rs.20,420/- for the said policy. The official of the OPs at the time of insurance assured that under this health policy the complainant and his family i.e. Smt. Geeta Sharma (spouse), Mr. Umang Sharma (son) are being insured. The official of the OPs also assured that the family members of insured person would get the mediclaim upto Rs.10.00 lacs. At the time of taking the policy all the members were healthy and there was no disease to any of the family member of the complainant. On 4.6.2018 suddenly the son of complainant had fell ill and complainant got his son admitted in Nishant Clinic Karnal and due to serious condition Dr. Sudarshan Kumar got the son of complainant admitted in the hospital and on 6.6.2018 patient was discharged. Complainant has spent a sun of Rs.8146/- on the treatment of his son. Thereafter, complainant approached the OPs for reimbursement of the claim and submitted all the relevant documents but OPs did not pay the claim and rejected the same. After rejection of the claim, the complainant applied in the office of Municipal Corporation Karnal and sought the details of Nishant Hospital and information supplied by the Executive officer, Municipal Corporation Karnal clear that the said hospital covers in the policy. Thereafter, complainant again asked the OPs for reimbursement of the mediclaim of the complainant but OPs did not bother to reimburse the claim of the complainant. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written version stating therein that complainant had approached the OPs for availing an insurance policy. As per information provided by the proposer/complainant to the telesales counselor on 13.07.2017 an insurance policy namely Health Companion Variant 2, bearing no.30685634201700 was issued to the proposer so as to extending an insurance cover for him, his wife and his son to an amount not exceeding Rs.5 lacs. It is further stated that the OPs received claim for reimbursement for the hospitalization of the complainant’s son in Nishant Hospital for treatment of fever during 4.6.2018 to 6.6.2018. Upon receipt the claim of the complainant, the company initiated an investigation whereby it came to the knowledge of the company that the hospital where the treatment was sought by the insured did not fulfill the criteria as mentioned in the policy terms and conditions and hence the claim is not payable.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C18 and closed the evidence on 10.4.2019.

4.             On the other hand, OPs tendered into evidence affidavit of Ms. Chandrika Bhattacharyya Ex.RW1/A and documents Ex.R1 to Ex.R5 and closed the evidence on  27.05.2019.

5.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.   

6.             The case of the complainant is that he had been insured of Group by Max Bupa Health Insurance from 20.07.2017 to 19.07.2018 for the sum assured of Rs.5 lakhs. At the time of taking the policy all the family members were healthy and there was no disease to any of the family member of the complainant. On 4.6.2018 son of the complainant namely Umang Sharma had fell ill and complainant got his son admitted in Nishant Hospital on the same day and he discharged on 6.6.2018. The complainant had spent a sum of Rs.8146/- for the treatment of his son. The complainant lodged the claim within stipulated period but the claim of the complainant was repudiated by the OP without any reason.

7.             On the other hand, the case of the OPs is that on 13.07.2017 the complainant purchased an insurance policy namely Health Companion Variant cover, for him, his wife and his son to an amount not exceeding Rs.5 lakhs. OPs received claim for reimbursement for the hospitalization of the complainant’s son in Nishant Hospital for treatment of fever during 4.6.2018 to 6.6.2018. Upon receipt of claim, the OP initiated an investigation whereby it came to knowledge of the OPs that the hospital did not fulfill the criteria as mentioned in the policy terms and conditions due to that claim of the complainant was repudiated.

8.             Admittedly, the complainant’s son had admitted in Nishant Hospital Karnal for treatment of fever during the subsistence of the policy. The claim for reimbursement for the hospitalization of the complainant’s son was repudiated by the OP only on the ground that the hospital where the treatment was sought by the insured did not fulfill the criteria as mentioned in the policy terms and conditions. But OP failed to prove on the file that what was the criteria and which criteria was not fulfilled by the said hospital. The counsel for the complainant relied upon the document Ex.C18 i.e. License Business, License u/s 331-Fresh of Haryana Municipal Corporation Act of 1994. Said letter has been issued by Municipal Corporation Karnal and as per Ex.C18 the license of the said hospital is valid for the year 2018-2019 for running of Nishant Clinic and Hospital. Hence, we are of the considered view that acts of the OPs amounts to deficiency in service and unfair trade practice.

9.             Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.8146/- to the complainant with interest @ 9% from the date of repudiation till its realization. We further direct the OPs to pay Rs.5500/-to the complainant for mental agony, harassment and towards litigation expenses. This order shall be complied with within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 13.06.2019

                                                                        President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

 

 

                     (Vineet Kaushik)   

                         Member