Chandigarh

StateCommission

A/47/2021

Manish Goyal - Complainant(s)

Versus

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

Shashank S. Sharma & Sukhmani Boparai Adv.

02 Jun 2022

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

Appeal No.	:	47 of 2021
Date of Institution	:	16.07.2021
Date of Decision	:	02.06.2022

 

Manish Goyal son of Surender Kumar Goyal resident of House No.618, Sector 18B, Chandigarh.

…Appellant/Complainant

V e r s u s

1. Max Bupa Health Insurance Company Limited, B-1, I-2, 90/2, Mathura Road, Mohan Cooperative Industrial Estate, New Delhi, Delhi 110044 through its Director.
2. Max Bupa Health Insurance Company Limited, SCO No.55, 56 & 57, Sector 8-C, Madhya Marg, Chandigarh 160009 through its Regional Manager

…..Respondents/opposite parties

BEFORE:              JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT.

                             MRS.PADMA PANDEY, MEMBER.

                             MR.RAJESH K. ARYA, MEMBER.

 

Present:-

                             Sh.Shashank S. Sharma, Advocate for the appellant.

          Sh.Gaurav Bhardwaj, Advocate for respondents.

 

PER JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT

                   This appeal has been filed by the complainant (now appellant before this Commission), feeling aggrieved by the order dated 05.03.2021 passed by the District Consumer Disputes Redressal Commission-I, U.T., Chandigarh (in short the District Commission), whereby the consumer complaint bearing no.624 of 2019 filed by him was dismissed, while observing as under:-

9. As per Annexure C-7, the order of the Hon’ble State Commission is dated 22.3.2018. Now the complainant states, he has submitted a claim of Rs.10,30,723/- on 29.5.2018. It is not made out to which period this claim pertained to. This plea is not substantiated with medical bills or any verification by the hospital concerned where the treatment was taken. The OPs have denied any such bill was received by them.  In which hospital such treatment was taken and what was the bill raised by them which was paid by the complainant has not been explained. If the claim was submitted then photocopies of the bills of medicines which were prescribed by the doctor and purchased by the complainant could have been annexed with the consumer complaint, but, these have not been annexed at all.
10. However, with the rejoinder one claim form is submitted which shows claim for post hospitalization expenses of Rs.10,30,723/- was raised. What were those post hospitalization expenses have not been detailed. At the cost of repetition, we may refer here, the bills so raised by the hospital have not at all been annexed with the present consumer complaint to fortify the claim made by the complainant which was submitted hardly 2-3 months after the decision by the Hon’ble State Commission and the Hon’ble State Commission had already rejected the said claim being premature. Complainant had the opportunity to get the copies if submitted before the Hon’ble State Commission or said file could have been got requisitioned in order to render corroboration and truthfulness to the claim submitted.  Thus, we are of the view the consumer complaint is in the air.
11. There was a direction for restoration of the policy which was already forfeited and as per the reply furnished by the OPs, it has been renewed till 2020 in compliance with the order of the Hon’ble State Commission…….”

2.           Review application bearing no.13 of 2021 filed by the appellant was also dismissed by the District Commission vide order dated 03.05.2021.
3.           The facts necessary for disposal of this appeal are that in the year 2011, the complainant/appellant purchased one health insurance policy named Family First Gold 2 lacs + 15 lacs and kept on renewing it from time to time till 2016, on payment of premium. The policy covered the family members of the complainant namely Ms. Darshan Goyal (mother), Mr. Surinder Kumar Goyal (father), Ms.Kajal Goyal (spouse), Mr. Rehan Goyal (son) and Mr. Viren Goyal (son). Further case is, Ms.Darshan Goyal, mother of the complainant was diagnosed with right mouth (Buccal Mucosa) carcinoma, squamous cell, Kertinizing type vide Surgical Pathology report dated 11.3.2016 of PGI, Chandigarh and was admitted in Lilavati Hospital and Research Centre, Mumbai. She remained admitted there for treatment for the period  from 25.03.2016 to 05.04.2016. However, the cashless facility was denied by the opposite parties, as a result whereof, the complainant had to pay the bills for the said treatment. When claim raised for the said treatment was rejected and at the same time the opposite parties also cancelled the policy and forfeited the premium paid, the complainant had approached this Commission by way of filing consumer complaint bearing no.234 of 2017, seeking directions to the insurance company for settlement of claim amount of  Rs.15,81,499/- alongwith interest and also prayed for restoration of the policy.  This Commission vide order dated 22.03.2018 restored the policy and granted the claim of Rs.7,00,023/- alongwith interest besides compensation of Rs.75,000/- and Rs.33,000/- as litigation expenses. However, liberty was granted to the complainant to submit the remaining claim separately. Relevant part of order dated 22.03.2018 is reproduced hereunder:-

“…For the reasons recorded above, this complaint is partly accepted, with costs, with following directions to the opposite parties:-

1. To restore the policy, in question, in favour of the complainant and his family members, referred to above, after adjusting the premium, if any, already paid by him and/or on receiving payment of premium, if due towards him.
2. To pay an amount of Rs.7,00,023/- to the complainant, alongwith interest @9% p.a. from the date of its repudiation.
3. To pay compensation, in the sum of Rs.75,000/- for causing mental agony and physical harassment to the complainant.
4. To pay cost of litigation to the tune of Rs.33,000/- to the complainant.
5. This order shall be complied within a period of 45 days, from the date of receipt of certified copy thereof, failing which the amount at Sr.No.(ii) above, shall further carry penal interest @12% from the date of default i.e. after expiry of 45 days and the amount at Sr.Nos.(iii) and (iv) shall carry interest @9% p.a. from the date of filing of this complaint till realization…”

4.           From the record, it reveals that thereafter the complainant, in May 2018, submitted claim for an amount of Rs.10,30,723/- with the opposite parties, for the post hospitalization treatment charges of her mother, yet, the same was not paid. It was averred by the complainant that the opposite parties have also accepted the premium amount of Rs.2,99,879/- on 07.03.2019 for the renewal of the policy starting from 2016 till 2019, but, the same was not renewed. Hence, consumer complaint was filed before the District Commission, which was dismissed vide order dated 05.03.2021 and review application bearing no.13 of 2021 filed by the appellant was also dismissed by the District Commission vide order dated 03.05.2021, resulting into filing of this appeal. 
5.           In the reply filed, the opposite parties/respondents, while admitting factual matrix of the case, contested the consumer complaint while taking numerous objections/pleas inter alia as under:-
   1. that the consumer complaint is not maintainable;
   2. that this Commission never gave liberty to the complainant to prefer a claim of Rs.8,81,476/-;
   3. that the order passed by this Commission was complied with and the amount which was due under the order was paid to the complainant;
   4. that the complainant did not raise any claim of Rs.10,30,723/-  with the opposite parties;
   5. that the claim of Rs.28,493/- raised on 31.5.2018 was repudiated by the opposite parties;
   6. that as many as 6-7 claims were already paid to the complainant in the year 2012, 2013, 2014, 2016 and 2018;
   7. that the parties cannot travel beyond the terms and conditions of the insurance policy; and
   8.  that the policy in question stood renewed till 09.10.2020. 
6.           In the rejoinder filed, the complainant reiterated all the averments contained in his complaint and controverted those, contained in written version of the opposite parties.
7.           The contesting parties led evidence before the District Commission.
8.           The District Commission after hearing the contesting parties and on going through the material available on record, dismissed the consumer complaint and also the review application, as stated above.
9.           Hence this appeal.        
10.           We have heard the contesting parties and gone through the material available on the record; including the written submissions/arguments filed on behalf of the appellant/complainant.  
11.           The basic facts of the case to the effect that in the year 2011, the complainant/appellant purchased the insurance policy in question, which was got renewed from time to time; that Ms.Darshan Goyal mother of the complainant was diagnosed with right mouth (Buccal Mucosa) carcinoma, squamous cell, Kertinizing type vide Surgical Pathology for which she took  treatment from Lilavati Hospital and Research Centre, Mumbai for the period from 25.03.2016 to 05.04.2016; that when cashless facility was denied by the respondents and also the policy was cancelled, the appellant had filed consumer complaint bearing no.234 of 2017 before this Commission; and that this Commission vide order dated 22.03.2018 restored the policy and ordered the respondents to pay the part claim amount of Rs.7,00,023/- alongwith interest besides compensation of Rs.75,000/- and Rs.33,000/- as litigation expenses, to the appellant; and that the appellant was granted liberty to submit the remaining claim of any amount separately with the respondents are not in dispute. It is also not in dispute that the order dated 22.03.2018 in respect of making part payment referred to above alongwith compensation etc. stood complied by the respondents in totality.

                   Thus, it is evident from the record that no dispute is left between the parties with respect to claim amount of Rs.7,00,023/- which arose in respect of the treatment taken by the mother of the appellant for the period from 16.03.2016 to 14.04.2016 at Lilawati Hospital.

12.           However, the present dispute is only with regard to nonpayment of remaining amount incurred by the complainant on post hospitalization charges of her mother at Max and Fortis Hospitals for the period from 10.04.2016 to 28.04.2018 i.e. Rs.8,81,476/- spent for the period from 10.04.2016 to 20.02.2017 and Rs.1,42,961/- for the period from 26.02.2017 to 28.04.2018.
13.           Counsel for the respondents contended with vehemence that since claim for the aforesaid amount Rs.10,30,723/- alongwith supported documents of the hospitals concerned was never  raised by the appellant, as such, question of non payment thereof did not at all arise; and that the claim of Rs.21,129/- raised on 31.5.2018 was repudiated by the respondents vide letter dated 01.06.2018, Annexure C-10, on the ground that treatment got done on 20.03.2018 did not fall under the coverage period from 10.10.2011 to 09.10.2016.

                   Perusal of contents of the order impugned also reveal that the District Commission has dismissed the consumer complaint, mainly on the following grounds:-

1.  that though the complainant stated that he had submitted a claim of Rs.10,30,723/- on 29.05.2018 with the opposite parties, yet, he failed to prove the fact as to for which period the said claim pertained to;
2. that medical bills or any verification by the hospitals concerned where the treatment was taken has not been proved;
3. that the complainant has failed to prove as to in  which hospital such treatment was taken by her mother and what was the bill raised by the said hospital, which was paid by the complainant; and
4. and that if the claim was submitted then photocopies of the bills of medicines which were prescribed by the doctor and purchased by the complainant has not been  placed on record.

On the other hand, counsel for the appellant contended that the appellant had raised claim in respect of the amount Rs.10,30,723/- incurred towards post hospitalization of mother of the complainant alongwith supported documents of the hospitals concerned but the respondents failed to reimburse the said amount; and that even the claim  of Rs.21,129/- was illegally repudiated by the respondents vide letter dated 01.06.2018, Annexure C-10 because they had already received premiums to the tune of Rs.2,99,879/- and Rs.3,44,787/- respectively, for the period starting from 10.10.2016 to 09.10.2020.

14.           Thus, under above circumstances, the moot question which falls for consideration before this Commission in this appeal is, as to whether, any claim in respect of post hospitalization of mother of the appellant, to the tune of Rs.10,30,723/- alongwith  requisite documents was submitted  with the respondents or not.

                   It may be stated here that perusal of record of the District Commission reveal that vide Annexure C-11, the appellant had submitted Claim Form (at page 107-C to 107-D) for reimbursement of amount of Rs.10,30,723/- for the post-hospitalization expenses incurred on her mother (Darshan Goyal) at Max Superspecaility Hospital, Mohali, for the period from 14.04.2016 to 28.04.2018.  It is further evident that alongwith this claim form, Claim Reimbursement Checklist dated 29.05.2018, Annexure C-11 was also submitted by the appellant, wherein following requisite documents have been mentioned to be handed over to the respondents on 30.05.2018 i.e. consent letter, age proof, original discharge summary, original laboratory investigation reports, original X-rays/MRIs etc., indoor case papers/OT notes, original final bill from hospital  with detailed breakup and paid receipts, original bills of medicines purchased and other documents  like CT/PET etc. cancelled cheque;  (running into 375 pages as mentioned therein).  Significantly, the respondents have acknowledged receipt of the said original documents alongwith other documents mentioned therein, on 30.05.2018, by affixing the stamp of their office. This document relating to acknowledgment of receipt of the aforesaid documents running into 375 pages has not been challenged by the respondents, by placing on record any contrary evidence nor it is their case that the receiving stamp of their company on the said  Claim Reimbursement Checklist dated 29.05.2018, Annexure C-11 is forged. Thus, it leaves no doubt with this Commission to hold that the appellant had submitted the claim form alongwith requisite documents on 29.05.2018, receipt whereof was acknowledged by the respondents on 30.05.2018, in the manner referred to above.

                   Significantly, there is another reason with this Commission to believe that the said claim documents,  Annexure C-11 collectively running into 375 pages were received by the  respondents and the said  reason  is  the email dated 14.10.2018 (at page 128-129 of the paper book of District Commission), wherein the appellant had requested the  respondents that his claim of Rs.10,30,723/- be settled immediately. Relevant part of the said email is reproduced hereunder:-

“…With reference to your trailing mail, you are kindly requested to go through the following:

1. My Claim pertains to the period April 2016 to May 2018 and not as stated in the mail (treatment done on 07 July, 2017).

2. My total claim is for Rs.10,30,723/- and however as per your enclosed letter, you are only in denial of claim of Rs.28493/ therefore the remaining amount should be immediately processed to my account.

3. Further, I have enclosed the Judgement of the State Consumer Forum for your reference which very clearly directs you to settle all my claims till date/future claims after receiving/adjusting any outstanding due from my end.

4. By denying me my rightful claim, you are clearly in Contempt of the Judgement passed by the Honorable Court.

5. Further, as per my experience with you in past, you are looking for all ways and means to DENY RIGHTFUL claims by giving all types of frivolous/false reasons; so it is totally incorrect on your part to state that 'At Max Bupa, it is our endeavour to pay all claims as per your policy plan and contract.

 

You are once again requested to process my claim and credit the entire amount along with the interest on DELAYED PAYMENT to my account on an urgent basis and STOP making a mockery of the claim process by giving false and frivolous reasons.

Thanks and regards

Manish Goyal…..”

 

In response to the said email, the respondents vide emails dated 15.10.2018, 29.10.2018, 08.11.2018 and 01.12.2018, Annexure C-9 informed the appellant that they acknowledge his concern and requested him to give some time to address the concern to his satisfaction. Relevant part of one of the emails sent by the respondents to the appellant, in response to email dated 14.10.2018 written by the appellant is reproduce hereunder:-

 

“…On 15-Oct-2018, at 6:21 PM, Grievance Redressal <Grievance Redressal@maxbupa com> wrote:

 

Dear Sir,

 

At the outset, we regret that the services at Max Bupa have not been to your satisfaction. We truly value your feedback as we work relentlessly towards constant improvement of services.

 

This is in reference to your e-mail appended below and our telephonic conversation dated 15th Oct '2018. As discussed. we would like to inform you that we acknowledge the receipt of your concern vide Complaint number #2899230 and we request you to please give us time till 22nd Oct 2018 for us to address the mentioned concern to your satisfaction.

 

Should you require any further assistance, we request you to call us on our Toll Free number 1800-3010-3333 or write to us at grievanceredressal@maxbupa.com / jyoti.mathur@maxbupa.com.

 

Assuring you of our best services.

 

Yours Sincerely,

 

Jyoti Mathur

 

Executive- Grievance Redressal

Max Bupa Health Insurance Company Limited,

B-1/1-2, Mohan Cooperative Industrial Estate

Mathura Road, New Delhi-110044…”

 

Thus, from the contents of email dated 15.10.2018 too, it can easily be seen that the parties were in contact with each other, after claim in the sum of  Rs.10,30,723/- was raised by the appellant vide Annexure C-11 aforesaid. Thus, the contention raised by the respondents to the effect that the appellant never approached them or contacted them in respect of claim of Rs.10,30,723/- is falsified from their own receipt of acknowledgment (dated 30.05.2018) on the claim form  alongwith requisite documents referred to above and also the contents of emails dated 14.10.2018 and 15.10.2018 reproduced above.

15.           However, we are surprised to note that despite the fact that the aforesaid document (Annexure C-11) clearly depicts  that the entire material information with regard to period of treatment/post hospitalization;  name of the hospital; original discharge summary, original laboratory investigation reports, original X-rays/MRIs etc., indoor case papers/OT notes, original final bill from hospital  with detailed breakup and paid receipt, original bills of medicines purchased and other documents  like CT/PET etc. cancelled cheque; running into 375 pages, were submitted by the appellant to the respondents on 30.05.2018 and emails aforesaid to this effect were also exchanged between the parties, yet, the District Commission fell into a grave error, while dismissing the consumer complaint by holding to the contrary. It appears that the District Commission has even failed to notice the contents of Annexure C-11 and also emails referred to above, as no mention thereof is found in the order impugned. Had the District Commission gone through the said document Annexure C-11 and had there been any doubt, in that regard, it could have easily directed the complainant to place on record the photocopies of the documents mentioned therein, but it failed to do so, and on the other hand, without commenting on the said documents, dismissed the consumer complaint, holding to the contrary.   
16.           Be that as it may, in this appeal, the complainant/appellant has again placed on record claim form and checklist (placed before the District Commission also) alongwith all the requisite documents mentioned therein,  to  prove that he has spent substantial amount of more than Rs.10 lacs  for the post-hospitalization expenses incurred on her mother (Darshan Goyal) for the period from 14.04.2016 to 28.04.2018.  Since,  the  said claim pertains to the years 2016 to 2018 and admittedly, the insurance policy in question has been renewed by the respondents for the said period, as such, we are of the considered view that if directions are given to the respondents/opposite parties to settle the claim of the appellant within a period of 90 days from the date of receipt of a certified copy of this order, it shall meet the ends of justice.   
17.           Keeping in view the above discussion, we are of the considered view that the orders passed by the District Commission, dismissing the consumer complaint and also the review application, being not based on the correct appreciation of evidence and law on the point, suffer from illegality and perversity, need interference of this Commission.  Consequently, this appeal stands allowed and the impugned orders stand set aside. The consumer complaint filed by the complainant/appellant stands partly allowed with following directions to the respondents/opposite parties, jointly and severally, as under:-
    1. To settle the claim filed by the appellant/complainant on 30.05.2018 within a period of 90 days from the date of receipt of a certified copy of this order. Any amount payable under the said claim shall be paid by them with interest @9% p.a. from 01.09.2018 (three months from the date of submission of claim) within a period of 30 days therefrom, failing which the assessed amount shall entail penal interest @12% p.a. instead of 9% p.a. till  realization
    2. To pay compensation to the tune of Rs.50,000/- to the appellant/complainant, for causing him mental agony, harassment and humiliation and also deficiency in providing service, negligence and adoption of unfair trade practice, by not settling his claim aforesaid and also cost of litigation to the tune of Rs.30,000/- within a period of 30 days from the date of receipt of a certified copy of this order, failing which the said amounts shall entail interest @ 9% p.a.  from the date of default till realization.
18.           Certified copies of this order be sent to the parties, free of charge.
19.           The concerned file be consigned to Record Room, after completion.

 

Pronounced

02.06.2022

Sd/-

[JUSTICE RAJ SHEKHAR ATTRI]

PRESIDENT

 

 

Sd/-

 (PADMA PANDEY)

          MEMBER

 

 

Sd/-

 (RAJESH K. ARYA)

MEMBER

Rg.