DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. NO. 297/2021

Date of Institution: 06.08.2021

Judgment Reserved on: 12.12.2023

Judgment Passed on: 19.12.2023

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms. Rashmi Bansal (Member)

Judgment By: Sh. S.S. Malhotra (President)

JUDGMENT

By this judgment the Commission would dispose off the complaint of the complainant alleging deficiency in service in not reimbursing the medical bill/claim by the OP.

1. Before coming to the facts it is brought on the record that complaint has initially filed the complainant against Max Bupa Health Insurance Company but subsequently an application was filed alongwith the amended memo of parties as the name of the OP was change from Max Bupa Health Insurance Company Ltd. to Niva Bupa Health Insurance Company. Therefore the name of the OP has been shown as per amended memo of parties in the cause title.
2. Brief facts stated by the complainant in the complaint are that she was having a group insurance mediclaim policy valid from 04.11.2016 to 03.11.2017 which included the diabetes as a pre-existing disease and the same was duly incorporated in the policy documents of the OP, for a sum assured of Rs.5,00,000/- and it was renewed from i.e. 04.11.2017 to 04.112018 and then even next year up to 04.11.2019. However, on 13.12.2019 during the valid and effective policy, the complainant felt a small boil under her cheek which did not disappear with medication for couple of days and then she observed that size of the boil was increasing and it also become painful then and she visited the local physician who suggested that the complainant should visit some specialist of that field and gave no prescription/medicine. The complainant then was taken to max super specialty hospital and as per the advice of the doctor required hospitalization sensing the seriousness of the situation and accordingly the surgery was performed with respect to small boil on 21.12.2019 and complainant submitted the policy details for cashless mediclaim and even approval of cashless authorization to the extent of Rs.58,275/- was received in the hospital but on next i.e. 20.12.2019 another letter was received from the OP seeking additional information from the hospital about the past treatment and soon thereafter the earlier approval given on 19.12.2019 was rejected and previous authorization was also cancelled. The complainant in the circumstances on discharging on 24.12.2019 had to pay entire amount of the treatment i.e. Rs.3,06,578/- to the hospital. Thereafter, when the complainant visited the hospital for regular post surgery check up on 26.12.2019, the treating doctor has suggested that a grafting procedure is required to further cover-up the area which had damaged due to boils. Then complainant being financially stressed as the cashless claim has already been rejected by the OP, and considering all these facts, and also the financial burden of grafting on the wounded area, visited Aryan Hospital at Gurugram and consulted further on 07.01.2020 where she was advised for hospitalization for further investigation for surgery and as such she was admitted in  Aryan Hospital on 07.01.2020 and remained hospitalized up to 10.01.2020 where the said procedure was done and another amount of Rs.80,665/- was spent/paid to Aryan Hospital, Gurugram, Haryana and in totality she had spent an amount of Rs.3,87,203/- on the treatment. She submitted the bill/claim were filed physically with OP on 04.09.2020 including details of all invoices, documents, payment receipts, investigation reports, prescription, which was duly received by OP and she even received the mail on 26.11.2020 acknowledging the same as ID No.576277, and it was assured that claim will be provided within 15 days. However, vide email dated 28.11.2020 the OP rejected the claim for the reason that some documents have not been received and the OP required additional information from the complainant to submit the documents duly certified by the treating doctor about the exact duration of Necrotizing Fasciitis Left Cheek, Heart Disease and Hypertension and also first consultation paper when it was diagnosed.  The complainant again received similar mail on 05.12.2020 from OP and complainant then responded to the above said mail on 06.12.2020 and answered the queries raised by the OP stating that complainant has never been treated or diagnosed by any physician earlier and local physician only suggested that the complainant had to visit some multy-specialist hospital without prescribing any medicine and then the complainant have visited the Max Hospital where from all the documents have already been submitted and also clarified that the complainant was not suffering from any hypertension nor had taken any regular medicine but surprisingly the mail was not delivered to the OP rather bounced back on 06.12.2020 itself with the comment that “your massage can’t be delivered” because delivery to this address is restricted and when complainant tried to re-send the mail, same result happened and similar result happened with respect to mails received on 14.12.2020, 19.12.2020, 26.12.2020, 02.01.2021, 09.01.2021 which all were duly replied but all were bounced back and the net result is that OP never gave any heed to the repeated replies/explanation and ultimately complaint received an e-mail on 13.01.2021 where the claim was rejected on the ground that further information has not been given by the complainant. It is further stated that this conduct of the OP in not receiving the reply, and allowing mails to bounce back, and further not reimbursing the amount of the bill of Rs.3,87,203/- to the complainant, amounts to deficiency in service and accordingly she filed the present complaint thereby claiming Rs.3,87,203/- with interest @12% p.a. from the date of repudiation till payment with compensation of Rs. 2,00,000/- and litigation Rs.55,000/-.
3. The OP has filed its reply through Mr. Bhuwan Bhasker the authorized representative of the OP and has taken the preliminary objection that complainant is not entitled to any relief as she is guilty of suppressing material facts, the complainant has not provided documents which were mandatory for processing the claim, the claim was rejected because the authenticity and accomplishment of documents for claim procedure was not established, the complainant has not replied the e-mails dated 28.11.20, 05.12.20, 12.12.2020, 14.12.2020, 19.12.2020, 26.12.2020, 02.01.2021, 09.01.2021 by which complainant was requested to provide the documents with respect to certificate of the doctor, exact Necrotizing Fasciitis Left Cheek, Heart Disease and Hypertension, first consultation paper when it was diagnosed and since the complainant failed to provide these document, the claim was closed, therefore complainant claim be dismissed with cost.
4. On merits it is stated that the present complaint is an abuse of the process of law as there is no deficiency on the part of OP rather the complainant has failed to provide the requisite document which is in violation of the terms and conditions of the policy and therefore complaint case be dismissed. As far as policy is concerned the same is not disputed but it is submitted that policy kit containing all relevant documents were duly sent to the complainant and believing the abovesaid declaration with respect to terms and condition of the policy, the policy was issued from time to time and as per policy, request was received by the opposite party from the hospital of the complainant with provisional diagnosed Esteomyelaties Mandible and Facial Necrotizing Fasciitis, estimated stay of 5 days and estimate cost of Rs.1,64,750/- and initially a sum of Rs.58,275/- was even sanctioned but after perusing the same certain additional documents were asked for, with respect to past treatment record etiology of contailment scan report and films, the past report of Necrotizing Fasciitis Left Cheek, Heart Disease and Hypertension but since there documents were not provided the cashless was subsequently denied and when complainant submitted the claim for reimbursement of Rs.387203/- toward medical expenses incurred during the hospitalization period from 19.12.2019 to 24.12.2019 and follow up surgery in Aryan Hospital, Gurugram, the OP regularly had been writing e-mail/reminder to the complainant thereby demanding certain document as mentioned in the preliminary objections but since the was not done and even the investigating team reported and recommended for rejection of the claim on the basis of non-discloser of patient’s history with respect to respiratory failure, non critical CAS and HTN prior to policy the claim was rejected. It was further recommended that as per consultation paper dated 26.10.2019 patient was a follow up case of Necrotizing Fasciitis Left Cheek, Heart Disease and Hypertension and as per the son of the patient, patient has Necrotizing Fasciitis Left Cheek, Heart Disease and Hypertension since 03 to 05, prior to hospitalization in Max Hospital and son of the patient was hiding the exact duration of Necrotizing Fasciitis Left Cheek, Heart Disease and Hypertension. It is further submitted that thereafter various letters were written which were not responded to by the complainant and as such claim was finally repudiated and as such complaint be rejected.
5. Complainant has filed evidence by way of her own affidavit where as OP has filed evidence of Shri Bhuwan Bhasker its constituted attorney. The complainant has also filed written arguments, OP has not filed any written argument. The Commission has heard the arguments and perused the record/documents filed by both the parties.
6. The fact in nutshell are that the complainant suffered certain aliment with respect to her cheek for which she visited a local doctor who advised her to go to expert where after complainant took treatment from Max Hospital where despite initially approving the cashless treatment on 19.12.2019, they withdrew their approval thereby demanding some more documents particularly with respect to pervious history and complainant had to spent an amount to Rs.306578/- for her treatment and Max Hospital and for further treatment she had spent Rs.80665/- at Aryan Hospital, Gurugram which was not reimbursed by the OP and she filed the present complaint. The main contention of the OP is that the documents which had been placed on record suggest some previous history, particularly at Page No.99 of the WS where the OPD consultation paper dated 26.12.2019 suggests that it is as a follow up case and then certain more documents were sought from the complainant. Those documents were never supplied and the claim was rejected for non supplying of documents.
7. The counsel for complainant has argued that the document which is being relied upon by the OP dated 26.12.2019 as a documents which is post surgery documents and that document is dated 26.12.2019 whereas the surgery has already been done on 20.12.2019 and this document is of the time when complainant had re-visited the hospital after the surgery i.e. on 26.12.2019 and the attending the doctor/physician mentioned it as a follow up case’s and infact this document is not prior to the treatment of the cheek Fasciitis. It is further argued that the OP definitely asked for certain documents but for all the six times when the complainant had received the e-mails from the OP, she responded to the OP through emails and every times the emails got bounced, and it is argued that it was a foul play on the part of OP by mismanaging its system so that no mail would reach to the OP pertaining to this case.
8. The Commission has perused the record and the contention of complainant is corroborating to the facts that mail got bounced. Not only this, when this was specifically enquired from the Ld. counsel for OP as to why the e-mails were bouncing back, he was not in position to explain as to why the emails as sent by complainant were bounced back and even in the WS of the OP, there is no corresponding denial of the respective para where the complainant has mentioned the fact of bouncing all the emails. The fact that complainant sent reply and it got bounced back, sufficiently proves that deficiency in the system of OP, in receiving the mails and as such OP now cannot rely that complainant has not supplied the documents, rather it is OP who shut his e-mails window thereby denying the access of emails to its system. Further, the contention of OP that complainant had been suffering from this ailments even prior to getting the policy has also not been proved by the OP and quite surprisingly the OP has rejected the claim on the basis of report given by the investigation team. The said report is being reproduced her and above
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9. The Commission has perused the record and is of the opinion that this said investigator either intentionally or mischievously has mentioned the follow up case on 26.10.2019 in its report where the actual date is 26.12.2019. This investigator has not taken any pain to confirm this date from the hospital’s record as there is no documents dated 26.10.2019 on court record. Rather the documents which perhaps is being stated by the investigator is 26.12.2019 and that particular documents is a documents which definitely is a ‘follow up case’ after surgery which has been done on 20.12.2019 by the concerned doctor at Max Hospital. Further, the said investigator has also given the reference of the son of the patient where the son has allegedly told the investigator with respect to left cheek Fasciitis and has allegedly stated that it is around 3 to 5 year back. There is no affidavit of the said investigator filed on record so that such version could be appreciated. Such report of the investigator upon which the OP has rejected the clam appears to be a tutored report of the OP and has been accepted by the OP without asking anything in writing from the investigator in support of his alleged observation as it was favouring OP and therefore the commission is of the opinion that the OP rejected the claim unlawfully.  
10. This Commission is also of the opinion that had the OP would have asked some documents from the investigator like OP is asking documents from the complainant, then OP would not have rejected the claim and it appears that not only there is the deficiency in service by the OP in repudiating the claim of the complainant on this half hearted investigation by the investigator rather there appears to be a callusion in between the insurance company and the investigator and this Commission reserves its right for taking action against such investigator by reporting to the appropriate authority about such conduct of the investigator. The irony is that even the name of the investigator or the report of the said investigator has not been placed on record and above all the name of the son of the complainant who allegedly told the said investigator is also not on record/file. Further there is not even a single documents placed on record by the OP which may somehow show that complainant had been suffering from any previous ailment with respect to the left cheek Fasciitis and it appears to the Commission that the OP has rejected the claim unlawfully and as such it is held liable for deficiency in service towards complainant.
11. Accordingly the commission hereby order the OP to pay Rs.3,87,203/- with interest @12% per annum with effect from the date of filing the complainant till actual realization alongwith compensation of Rs.30,000/- including litigation charges.
12. This whole amount is payable within 30 days failing which this amount would carry the interest @ 18% per annum from the date of filing of complaint till is actually paid.
13. Copy of the order be supplied/sent to all the parties free of cost as per rules.

 Announced on 19.12.2023.

File be consigned to Record Room.