Chandigarh

DF-II

CC/455/2021

Rajbir Singh - Complainant(s)

Versus

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

Devinder Kumar Adv.

31 May 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	455 OF 2021
Date  of  Institution	:	19.07.2021
Date   of   Decision	:	31.05.2022

 

 

 

 

Rajbir Singh son of Sh.Harkirat Singh, aged about 36 years, H.No.1714/3, Near Kwality Sales Corporation, Shimlapuri, Ludhiana, Punjab.

             …..Complainant

 

Versus

1]  Max Bupa Health Insurance Company Limited, SCO No.36-37-38, Sector Floor, Sector 8-C, Madhya Marg, Chandigarh through its Branch Manager.

2]  Max Bupa Health Insurance Company Limited Corporate Office: Block B1/1-2, Mohan Cooperative Industrial Estate, Mathura road, New Delhi 110044 through Managing Director

   ….. Opposite Parties

 

BEFORE:  SMT.PRITI MALHOTRA    PRESIDING MEMBER 

                    SH.B.M.SHARMA                 MEMBER

 

 

Argued by :-  Sh.Devinder Kumar,Advocate for the complainant.

   Sh.Gaurav Bhardwaj, Advocate for OPs

 

PER PRITI MALHOTRA, PRESIDING MEMBER

 

         Briefly stated, the complainant obtained health insurance from OPs valid from 17.08.2016 to 16.08.2017 covering complainant’s father Sh.Harkirat Singh and mother Smt.Parminder Kaur and got it renewed from time to time upto 16.8.2021 (Ann.C-1).  It is averred that the father of the complainant remained admitted in PGI, Chandigarh for treatment of Cancer and operated upon during the currency of insurance policy.  It is stated that complainant spent an amount of Rs.5,81,558/- on the treatment of his father Sh.Harkirat Singh from 5.5.2019 till his death on 12.3.2021.  It is also stated that the expenditure on medical treatment/medicines has been done strictly as per prescription of the doctors at PGI, Chandigarh.  It is submitted that the complainant, as per procedure, submitted claim for reimbursement of medical expenses with all complete details/bills on 4.3.2021 with OP Insurance Company and submitted the documents again as per the demand of the OPs on 1.4.2021, but the OPs, without assigning any reason, approved partial claim of the complainant to the tune of Rs.2,60,457/- (Ann.C-7).  Thereafter, the complainant requested the OPs to pay the remaining claim amount of Rs.3,21,101/- but to no avail. 

         It is averred that earlier also the complainant lodged a claim of Rs.2,74,889/- towards medical expenses till 9.5.2019 incurred on the treatment of his father, which the OPs had repudiated against which complainant preferred complaint, which was allowed by District Forum-I, UT, Chandigarh on 13.8.2019 (Ann.C-6) and the appeal preferred against that order by the OPs was also dismissed by Hon’ble State Commission, UT, Chandigarh, whereupon the OPs paid the amount in compliance to order dated 13.8.2019. 

         Alleging the partial settlement of claim and denying the remaining claim amount as deficiency in service on the part of OPs, hence this complaint has been preferred.

 

2]       The OPs have filed joint reply and while admitting the factual matrix of the case, stated that out of the claim of Rs.5,81,588/-, the OP Company has already paid Rs.2,60,457/- on 12.4.2021, as admitted, to complainant as per terms & conditions and other claims were under process at the time of filing the present complaint. It is submitted that after scrutinizing the medical record and investigation, the OPs are ready and willing to pay an amount of Rs.2,30,733/- as per the policy terms.  It is also submitted that as far as the remaining claim of Rs.90,398/- is concerned, the complainant has not filed any medical bills with respect to said amount and in the absence of medical bills, the OP Company is not in a position to scrutinize the same.   Denying other allegations and pleading no deficiency in service, the OPs have prayed for dismissal of the complaint. 

 

3]       Replication has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of the OPs as in their reply.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and perused the entire record.

 

6]       Admittedly, the complainant obtained health insurance policy from OPs on 4.8.2016 valid from 17.08.2016 to 16.08.2017 covering his father Sh.Harkirat Singh and mother Smt.Parminder Kaur and got it renewed upto 16.8.2021 by paying hefty premiums respectively.  It is undisputed that father of the complainant remained admitted in PGI, Chandigarh for treatment of Cancer and operated upon during the currency of insurance policy.

 

7]       The complainant’s claim for reimbursement of Rs.5,81,558/- incurred on the treatment of his father Sh.Harkirat Singh was filed with OPs which was not paid in full and only an amount of Rs.2,60,457/- was paid.  The reason assigned by the OPs for not honouring the claim of complainant in toto is not sustainable in light of the facts that all the bills & documents were duly submitted to the OPs.  Arbitrarily they failed to consider the genuine bills for the reason best known to them. 

 

8]       The record reveals that the OPs on an earlier occasion also repudiated the claim filed by the complainant on 9.5.2019 under the policy period from 17.8.2018 to 16.8.2019 and for getting the genuine claim, the complainant was forced to undergo litigation to get his claim which was allowed by the District Commission-I, UT, Chandigarh and was also confirmed in an appeal filed by the OPs.  In the present case also, the OPs paid only partial claim of Rs.2,60,457/- out of claimed amount of Rs.5,81,588/- citing the reason vide Annexure C-7 that the deductions, if any, are based on the terms and conditions of the policy. To the utter surprise, when the claim for the balance payment was filed vide present complaint, the OPs offered to pay another amount of Rs.2,30,733/- which further was short of Rs.90,398/-.  It has been so observed that the acts & conducts of the OPs reflect the arbitrary functioning of the OPs who did not bother to honour the genuine claim which they undertakes to indemnify under the policy issued by them after having the hefty premiums for the same. This arbitrary functioning of the OPs needs to be curbed.

 

9]       Apt to mention that during the course of arguments, it is submitted by the ld.Counsel for the complainant that the OPs have now paid/credit an amount of Rs.2,30,733/- in the account of the complainant whereas an amount of Rs.2,60,457/- was already paid, out of total claim of Rs.5,81,558/- and now only an amount of Rs.33,735/- is left to be paid by the OPs against the said claim.  There is no cogent evidence on record from the side of Opposite Parties as to why an amount of Rs.33,735/- has been deducted by them from the total claim amount of the complainant.  Therefore, we are of the opinion that the act & conduct of the OPs in denying/deducting the genuine claim of the complainant not only amounts to deficiency in service but also an example of unfair trade practice resorted to by them. Observed further that functioning arbitrarily, the Insurance Company/OPs even failed to consider the plight of the family of the insured which suffered not only for the untimely death of their dear one but their harassment got increased multifold when were forced to indulge into the unwarranted litigation to get their genuine claim.

 

10]     Taking into consideration the above discussion and findings, the present compliant is allowed against the OPs with directions to the OPs as under:-

a)  To reimburse the remaining/balance medical claim of Rs.33735/- to the complainant;

 

b)  To pay a compository amount of Rs.50,000/- to the complainant towards compensation for causing harassment and mental agony to the complainant due to their deficient services coupled with unfair trade practice, along with litigation cost of Rs.15,000/-.

        

         This order shall be complied with by the OPs within a period of 30 days from the date of its receipt, failing which they shall be liable to pay additional cost of Rs.20,000/- apart from the above relief.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

31^st May, 2022                                                                                                                                                                      

Sd/-

 (PRITI MALHOTRA)

PRESIDING MEMBER

 

Sd/-

(B.M.SHARMA)

MEMBER