Chandigarh

DF-II

CC/50/2020

Anil Sood - Complainant(s)

Versus

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

In Person

30 May 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	50/2020
Date of Institution	:	23.01.2020
Date of Decision	:	30.05.2022

 

                     

            

 

Anil Sood, 3185, Paradise Enclave, Sector 50-D, Chandigarh -160047.

                 ...  Complainant.

Versus

Max Bupa Health Insurance Co. Ltd., through Chandigarh Branch, SCO No.55, 56 & 57, Sector 8-C, Madhya Marg, Chandigarh -160009.

…. Opposite Party.

 

 

BEFORE:
	SMT.PRITI MALHOTRA,	PRESIDING MEMBER
	SHRI B.M.SHARMA	MEMBER
Argued by:-
	Complainant in person.
	Sh.Gaurav Bhardwaj, Adv. for the OP.

 

PER PRITI MALHOTRA, PRESIDING MEMBER

1.     Briefly stated, the facts of case as alleged by the complainant are that  he is having medical insurance policy from 1994 onwards from National Insurance Company for himself and his wife Mrs.Manisha Sood, which was later on ported to Max Bupa and the policy bearing No.30588174201600 having customer ID No.380428 was issued after conducting medical tests of the complainant and his wife. The complainant submitted the requisite documents and made the payment of the premium through credit card on 27.09.2016. On checking the policy documents, he found some major discrepancies and as such he sent an email to Mr.Anil Negi on 08.10.2016 for clarification as the questions were not asked by anybody and a complaint was registered by service request  regarding medical disclosure not asked by the agent.  On 24/25/10.2016, the complainant received a call from the Doctor who asked questions regarding his wife and relating queries and at the end of the call, he confirmed that the policy would continue and the complainant requested him to confirm the same by new updated policy but the doctor assured that there was no need for the same. It has further been averred that on 03.08.2017, his wife was operated on right eye after due intimation to the OP and the claim for Rs.41,329/- was raised vide Claim No.268003.   On 31.08.2017, he received notice by email for cancelation of the policy for non-disclosure of “bilateral L4/5 Laminecetomy, fececectomy and microdiscectomy with decompression in year 2004 with history of hypothyroidism since 2004.  Thereafter, the complainant received another e-mail dated 05.10.2017 to the same effect.  Vide e-mail dated 15.11.2017, he was informed that the claim was passed and policy was reinstated and the payment was transferred in the account on 23.11.2017. Vide e-mail dated 23.11.2017, the OP asked to renew the policy for 2017-18 before his claim No.268003 could be processed and the same was renewed on 07.12.2017.  It has further been averred that vide e-mail dated 14.04.2018, the complainant was informed that the claim for Rs.25,863/- out of Rs.40,726/- was passed and the remaining amount was deducted on account of reasonable and customary charges etc. It has further been averred that the OP has illegally deducted remaining amount from the claim amount and the same is payable as per the terms and conditions of the insurance policy. Alleging that the aforesaid acts of omission and commission on the part of the OP amount to deficiency in service and unfair trade practice, the complainant has filed the instant complaint.
2.     In its written statement, the OP while admitting the factual matrix of the case has submitted that the wife of the complainant was admitted for cataract surgery and claimed expenses of Rs.40,726/- out of which a sum of Rs.25,863/- were paid as per the terms and conditions of the policy and the remaining amount of Rs.14,863/- was declined as reasonable and customary deductions as per the clause of the terms and conditions of the insurance policy. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service on their part, a prayer for dismissal of the complaint has been made.
3.     We have heard the complainant in person, Counsel for the OP and have gone through the documents on record.
4.     The facts with regard to the issuance of the mediclaim policy in question to the complainant and his wife and submission of the claim for an amount of Rs.40,726/- on account of the treatment of complainant’s wife for cataract surgery have not been denied by the OP.  It has also not been denied that the OP had released the claim for Rs.25,863/- out of Rs.40,726/- and the remaining claim for Rs.14,863/- was declined/rejected on account of reasonable and customary deductions as per the alleged terms and conditions of the insurance policy. 
5.     On thorough perusal of the evidence on record and having considered the submissions made by the Counsel for the OP, we hardly able to come across any reasonable justification for deducting an amount of Rs.14,863/- from the claimed amount of Rs.40,726/- in the garb of alleged term “reasonable and customary deductions”. Apt to mention here that the OP in identical claim raised by the complainant had paid differently by not making any deduction in the garb of the alleged term “reasonable and customary deductions”. Thus, in this view of the matter, the OP has committed deficiency in service as also unfair trade practice by deducting Rs.14,863/- from the total claim amount of Rs.40,726/-.
6.          In view of the above discussion, the present complaint deserves to be allowed and the same is accordingly allowed with a direction to the OP to pay the remaining claim amount of Rs.14,863/- with interest @ 9% p.a. from 31.08.2017 till its actual payment. The OP shall also pay a sum of Rs.10,000/- to the complainant as compository compensation on account of mental agony and physical harassment for rendering deficient services coupled with unfair trade practice as well as for the unwarranted litigation. This order be complied with by the OP within 30 days from the date of receipt of its certified copy, failing which the OP shall pay an additional amount of Rs.5000/- to the complainant, apart from the above reliefs.
7.     Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

 

Announced 30/05/2022
	Sd/- (PRITI MALHOTRA) PRESIDING MEMBER
	Sd/-
	(B.M.SHARMA) MEMBER