Haryana

Karnal

CC/15/2022

Sh. Sameer Malik - Complainant(s)

Versus

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

Shakuntla Dagar

12 May 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.15 of 2022

                                                        Date of instt. 10.01.2022

                                                        Date of Decision:12.05.2023

 

Shri Sameer Malik aged about 38 years son of Shri Ranu Malik, resident of house no.1, Club Lane, Karnal.

                                                                        …….Complainant.

                                              Versus

 

1.     Max Bupa Health Insurance Company Limited now named as Niva Bupa Health Insurance Company Limited, SCO no.55-56-57, Second floor, sector 8-C, Madhya Marg, Chandigarh-160018 through its authorized representative.

 

2.     Max Bupa Health Insurance Company Limited now named as Niva Bupa Health Insurance Company Limited B-1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi-110044 through its Chief Operating Officer.

 

                                                                      …..Opposite Parties.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before      Shri Jaswant Singh……President

                Shri Vinneet Kaushi……Member

                Dr. Rekha Chaudhary…….Member

                   

Argued by: Smt. Shakuntla Dagar, counsel for complainant

                   Shri Lalit Chopra, counsel for the OPs.

 

                  (JASWANT SINGH, PRESIDENT)

ORDER: 

       

                The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant has been purchasing health insurance policy since 2012 regularly from New India Assurance Company Ltd. However, one of the agent of OPs Shri Deepak Dua has represented that OPs are providing better services than any other health insurance company. Thus, on the assurance of the agent of the OPs, complainant ported his and his family members’ health insurance policy on 27.02.2018 with the OPs, vide policy no.30742077201800. The policy was effective from 27.02.2018 to 26.02.2019 and basic sum assured was Rs.30,00,000/- on payment of premium of Rs.19,654/-. At the time of porting of the policy the OPs got done medical examination of the complainant and his family members. In the month of November 2018, the complainant has gone for Alumini Meet in his college in Pune. There he developed some problem like ringing sensation in his right ear all of a sudden, so he contracted Dr. Mil;lind Kirtane, ENT Surgeon, in Breach Candy Hospital, Mumbai on 19.11.2018 who did minor procedure in the right ear on 21.11.2018 of the complainant after getting some tests done on 20.11.2018 and complainant was discharged on the same day. It is further averred that in the year 1998 operation of left ear of the complainant had to be got done because while swimming water has entered int he middle part of his left ear which caused infection. The complainant was just a child at that time and thereafter complainant never had any problem in his left ear or his right year post his operation in 1998. Moreover, complainant has also contacted the surgeon in the year 2011 before getting any health insurance policy for general checkup as advised by the doctor who has performed the surgery stating that he should consult a doctor after becoming major. On checkup, the doctor told that everything is fine and there is no problems in the ears and nothing needs to be done ever. The complainant has spent a sum of Rs.26,815/- for this procedure of his right ear which has been done on 21.11.2018. So, he applied for claim under the health policy for reimbursement of the said amount. Complainant submitted the original bills as well as prescription and discharge slip of the doctor alongwith original policy. Meanwhile, the health policy has also been renewed by the OPs on 27.02.2019 on payment of Rs.25,533/- as premium and adding the daughter of complainant Ms. Samiha Malik. It is further averred that OPs sent 30 days notice dated 29.05.2019 for cancellation of his family health insurance policy through email that during processing of his claim, it has been noticed that there has been non-disclosure of pre-existing disease. The said notice is totally false and is on wrong facts. The complainant has no problem in any of his ears after the operation in 1998 for about 20 years. So, it is not a case of pre-existing ailment at all. Inspite of this notice and email dated 07.01.2020 no premium charged for renewal of policy amounting to Rs.25,5233/- on 27.02.2019 is refunded by the OPs so far.

2.             Thereafter, the agent of the OPs Mr. Deepak Dua, bearing ID CHD0128217 through whom the complainant ported his family health insurance policy also informed the OPs via email dated 04.06.2019 about the wrongful denial of the claim of the complainant. Complainant sent email dated 14.09.2019 and 17.12.2019, but to no avail. The cancellation notice dated 29.05.2019 issued to complainant is clear cut case of gross deficiency in service on the part of the OPs. OPs, vide email dated 07.01.2020 via email reverted back stating that the claim of complainant stands cancelled and turned down on account of non-disclosure of pre-existing illness at the time of applying for health policy. Then complainant sent a legal notice dated 31.01.2020 to the OPs but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

3.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action and concealment of true and material facts. On merits, it is pleaded that complainant approached the OPs for the purchase of New India Floater Mediclaim Plan having sum insured of Rs.8,00,000/- and consequently a policy was issued bearing no.35360134162800000133 originally commencing from 26.02.2016. However, in the year 2018 the complainant intended to port his policy in some other product as the complainant found the latter product better. Accordingly, the complainant had chosen a product by the name of “Heart Beat Family First Silver” having base sum insured of Rs.5,00,000/- for each insured and floater sum insured of Rs.15,00,000/- , annual premium of Rs.25,533/- for a policy of one year. Consequently, a policy bearing no.30742077201800 was issued covering the family members of the complainant as well. It is further pleaded that the complainant submitted the claim with the OPs on 22.04.2019 for an amount of Rs.26,815/-. The claim was duly investigated by the OPs and ultimately the claim was denied by the OPs on the ground that the treatment was taken on OPD basis and OPD treatment is not covered under the policy, therefore, claim was not payable as per the terms and conditions of the policy. It is further pleaded that policy documents delivered to the complainant provided him a period of 15 days within which he could have return the policy to OP by stating the reason thereof. The act and conduct of the complainant in not returning/surrendering the policy within the given time signified his acceptance to the terms and conditions mentioned in the policy documents. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

4.             Parties then led their respective evidence.

5.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of consultation slip of Dr. Milind Ex.C1, test advice by the doctor Ex.C2, medical bill dated 20.11.2018 Ex.C3, receipt for amount charged by doctor of Rs.3500/- dated 19.11.2018 Ex.C4, copy of payment receipt of Rs.20375/- Ex.C5, bill of Rs.20,375/- Ex.C6, notice of cancellation of policy dated 29.05.2019 Ex.C7, representation by agent Deepak Dua to OPs dated 04.06.2019 Ex.C8, copy of letter of complainant to agent Deepak Dua Ex.C9, copy letter dated 14.09.2019 sent by complainant Ex.C10, copy of notice dated 17.12.2019 sent to OPs Ex.C11, copy of letter dated 07.01.2020 of the OPs Ex.C12, copy of insurance policy no.30742077201800 alongwith terms and conditions Ex.C13, copy of insurance policy no.30742077201901 alongwith terms and conditions Ex.C14, copy of insurance policy covering period 26.02.2014 to 25.02.2016 of New India Assurance Company Ex.C15, copy of insurance policy covering period 27.02.2017 to 26.02.2018 of New India Assurance Company Ex.C16, copy of treatment slip of mother in law of sister of complainant Ex.C17, resident permit of sister of complainant in U.K. Ex.C18, notice dated 31.01.2020 Ex.C19, copy of health Forever insurance policy of Royal Sunderam Ex.C20 and closed the evidence on 02.08.2022 by suffering separate statement.

6.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Bhuwan Bhasker, Senior Manager Ex.OP1/A, certificate of change of name of company Ex.OP1, letter of authorization Ex.OP2, copy of rules of IRDA Ex.OP3, copy of proposal form Ex.OP4, copy of policy dated 17.12.2018 Ex.OP5, payment detail Ex.OP6 and closed the evidence on 01.12.2022 by suffering separate statement.

7.             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.

8.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant

complainant had purchased a health insurance from the OPs. On 21.11.2018, complainant did minor procedure in the right ear in Breach Candy Hospital, Mumbai and spent Rs.26,815/- on his treatment. After discharged from the hospital, complainant submitted the claim form with the OPs for reimbursement of the said amount and got completed all the formalities. The complainant requested the OPs several times for reimbursement of claim amount but OPs inspite of the releasing the claim amount has cancelled the policies and also not refunded the premium amount with regard to renewal of the policy. Now the complainant has purchased the insurance policy from the other insurance company and wants to refund the premium amount alongwith claim amount and lastly prayed for allowing the complaint.

9.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that the  complainant had taken the treatment on OPD basis and OPD treatment is not covered under the policy, therefore, claim was not payable as per the terms and conditions of the policy and prayed for dismissal of the complaint.

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

11.           Admittedly, complainant purchased a health insurance policy from the OPs and same was effective from 27.02.2018 to 26.02.2019. It is also admitted that complainant on 21.11.2018 complainant had gone under minor surgery in his right ear and he discharged on the same day.

12.           Complainant had spent a sum of Rs.26,815/-on his treatment. Complainant applied for claim under the policy for reimbursement of the said amount but claim of the complainant has been repudiated by the OPs on the ground that the treatment was taken on OPD basis and OPD treatment is not covered under the policy. The claim was not payable as per terms and conditions of the policy Ex.OP4. The relevant clause is reproduced as under:-

Clause 2.5 Day Care Treatment

We will indemnify the Medical Expenses incurred on the insured person’s Hospitalization for any day care treatment during the policy period following an illness or injury that occurs during the policy period provided that:

a.     The Day Care Treatment is medically necessary and follows the written advice of a Medical Practioner.

b.     The Medical Expenses insured are reasonable and Customary charges for any procedure where such procedure is undertaken by an insured person as Day Care Treatment.

c.      The following procedures will be covered as Day Care Treatment under this benefit as they each require a period of specialized observation care after completion of the procedure:

        i. Stereotactic radiotherapy, chemotherapy and immunotherapy for cancer (approved immunosuppressant drugs will be payable only if administered as a part of these procedure.

        ii. Renal dialysis/Erythropoietin for chronic renal failure will be payable only if administered as a part of this procedure.

d.     We will not cover any OPD treatment and Diagnostic Services under this benefit.

13.           The claim of the complainant has been denied by the OPs on the ground that treatment taken by him is not payable as per condition no.2.5(d). But in the present case, complainant has not taken the treatment in OPD rather he has taken the treatment  in Day Care basis, which is covered under the clause 2.5 (a) of the policy. Hence, the plea taken by the OP has no force.

14.           The complainant has taken the treatment on 21.11.2018 and spent Rs.26815/-. Not only, the claim has been repudiated by the OPs, also cancelled the both the policy of complainant. The complainant had got renewed the policy in question from 27.02.2019 to 26.02.2020 by paying the renewal amount of Rs.25,333/-.  But OPs have not refunded the premium amount on cancellation of the policy in question. Hence the act of the OPs is also illegal, arbitrarily and unjustified.

15. 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.

16.           Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OPs while repudiating the claim of the complainant amounts to deficiency in service and unfair trade practice. 

17.           The complainant has spent Rs.26,815/- on his treatment and in this regard he has placed on record medical bills Ex.C1 to Ex.C6. The said bills have not been rebutted by the OPs.  Further, OPs have not refunded the Rs.25,533/- as premium amount. Hence, the complainant is entitled for Rs.52348/- (Rs.26815+Rs.25533) alongwith interest, compensation for mental harassment and litigation expenses etc.

18.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.52348/- (Rs. fifty two thousand three hundred forty eight only) to the complainant alongwith interest @ 9% per annum from the date of repudiation/cancellation of the policy till its realization. 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. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:12.05.2023                                                                   

                                                               

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 

 (Vineet Kaushik)       (Dr. Rekha Chaudhary)

                          Member                           Member