Chandigarh

DF-I

CC/395/2022

Bhupinderjit Kaur - Complainant(s)

Versus

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

Monisha Mahajan

11 Jun 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/395/2022
Date of Institution	:	29.3.2022
Date of Decision	:	11/6/2024

 

Bhupinderjit Kaur c/o Manmohan Singh Bajwa, resident of House No. 6173, Duplex Modern Complex, Mani Majra, Chandigarh 160101.

 

.....Complainant

Versus

 

Max Bupa Health Insurance Ltd.through its authorized representative registered office at Max house, 1 Dr. Jha Marg, Okhla, New Delhi-110020.

 

General Manager Claims, Max Bupa Health Insurance Ltd. Block BI- 1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi 110044.

New Address:-

Niva Bupa Health Insurance Company Limited (Formerly known as Max Bupa Health Insurance Company),

1. Having Corporate Office at:

14th Floor, Capital Cyberscape, Sector 59, Gurugram,

Haryana- 122001

2. Having Registered Office at:

C-98, First Floor Lajpat Nagar,

Part 1, South Delni, Delhi 110024.

3. Having Regional Office at: 2nd Floor, SCO 84-85, sector 8C, Chandigarh- 160003.

.....Opposite party

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR SURESH KUMAR SARDANA	MEMBER MEMBER

                       

ARGUED BY	:	Ms. Vanshika, Advocate proxy for Ms. Monisha Mahajan, Advocate for complainant.
	:	Sh. Gaurav Bhardwaj, Advocate for OP.

Per SURESH KUMAR SARDANA, Member

     Briefly stated the complainant availed a meical health policy from the OP  2000270132. The said policy commenced from 25.02.2017 and its validity extended up to 24.02.2018. The said policy was renewed on 25.02.2018 and its validity after the renewal extended up to 24.02.2020 vide policy no. 30638126201902. The complainant duly paid all the premiums. In  the month of October/ November 2019, the complainant had a severe ache and was referred to Fortis Hospital, Sahibzada Ajit Singh Nagar (Mohali), Punjab for medical investigation. Upon a medical examination, it was discovered that the complainant under risk was of developing Cancer and had been diagnosed with Cervix Biopsy  and  fractional curettage  and the complainant was accordingly admitted on 9.11.2019 and  discharged on 10.11.2019. Thereafter the complainant raised claim of Rs.2,61,514/-  but the same was redpudaited by the OP vide letter dated 19.2.2020 and also unilaterally cancelled the policy on the ground of suppression of material fact of pre-existing medical treatment: Parorysmal Superventricular Tachyeardia (PSVT) & RFA done in 2014 as per clause 9.2c(ii) at the time of applying for insurance policy. The complainant filed a complaint before the OMBUDSMAN which passed order dated 2.12.2020 in favour of the complainant and after order of the OMBUDSMAN the policy was reinstated  also the claim of surgery in 2019 was paid by the OP. However, did not pay payment towards the surgery in 2020 despite sending numerous lettes and reminders. Alleging the aforesaid act of Opposite Parties deficiency in service and unfair trade practice on their part, this complaint has been filed.

2. The Opposite Party in its reply stated that  in compliance of the order dated 02.12.2020 by the Insurance Ombudsman, the opposite party had already paid the sum of Rs.69,895/- along with non-payable of Rs.3940/- and had reinstated policyholder's policy with continuity benefit subject to receipt of renewal premium for the subsequent year.  Upon receipt of payment of premium the policy policy was reinstated with continuity benefits, subsequently upon reinstatement of the policy the complainant had filed for claim reimbursement for expenses during hospitalisation from 11.02.2020 to 15.02.2020 bearing no. 600318, the same was denied on the grounds of non-submission of mandatory documents as per policy T&C. The opposite party had issued missing info letter to the complainant and despite issuance of missing info letter and continuous reminders to the complainant for submission of mandatory document for processing of claim no response came from the complainant. As per clause 16 1 (i) of the Insurance regulatory and Development authority of India (protection of policyholders' interests) Regulations, 2017 an insurer shall settle the claim within 30 days from the date of receipt of last necessary document in accordance with the provision of regulation 27 of IRDAI (Health Insurance) Regulations, 2016. Upon which the claim was closed settled as denied upon non-submission of mandatory documents. All other allegations made in the complaint has been  denied being wrong.
3. Rejoinder was filed and averments made in the consumer complaint were reiterated.
4. Contesting parties led evidence by way of affidavits and documents.
5. We have heard the learned counsel for the contesting parties and gone through the record of the case.
6. The main grievance of the complainant is that inspite of having proper medical insurance cover her legitimate claim was not paid by the OPs.
7. On perusal of repudiation letter of OPs Annexure R-11, it is observed that the claim has been rejected on the ground of non submission of certain documents. However, the OP has failed to prove on record that the complainant has not supplied the requisite documents for the settlement of the claim.  
8. Even otherwise, on perusal of complaint, it is observed that the complainant has annexed all the required documents alongwith the complaint. We are of the view that if the  OP was interested in settling the claim then they could have used all the relevant required information annexed with the complaint but till date they did not do so. Thus non payment of legitimate claim of the complainant by the OP is deficiency in service and  the OP is indulged in unfair trade practice.  
9. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OP is directed as under:-

1. to pay Rs.61,514/-  with interest @9% P.A.from the date of repudiation i.e. 25.8.2022 till onwards.

 

2. to pay Rs.30,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay Rs.10,000/- to the complainant as costs of litigation.

10.      This order be complied with by the OP within 45 days from the date of receipt of its certified copy, failing which, it shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
11. Pending miscellaneous application(s), if any, also stands disposed off.
12.      Certified copies of this order be sent to the parties free of charge. The file be consigned.

			sd/- [Pawanjit Singh]
			President
			Sd/-
			[Surjeet Kaur] Member   Sd/-
11/6/2024			[Suresh Kumar Sardana]
mp			Member