Haryana

Kurukshetra

CC/69/2019

Jai Naryana - Complainant(s)

Versus

Max Bupa Helath Ins - Opp.Party(s)

H.L.Jangra

11 Feb 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL  COMMISSION, KURUKSHETRA.

                                                               Complaint Case No.69 of 2019

                                                               Date of institution: 21.02.2019                                                                       

                                                                 Date of decision:11.02.2022

                              

Jai Narain aged 59 years, son of Shri Ram Kishan, resident of village Dayalpur, District Kurukshetra.                              …Complainant.

                                           Versus

1.The Managing Director, Max Bupa Health Insurance Company Limited B/1/1-2 Mohan Cooperative Industrial Estate, Mathura Road, New Delhi 110044.

2. Bajaj Finance Limited, SCO-44, Sector -17, Kurukshetra,3^rd Floor, Opposite Virk Hospital, Kurukshetra.              ….Opposite parties.

                   Complaint u/s 12 of the Consumer Protection Act.

Before:        Smt. Neelam Kashyap, President.

                   Ms. Neelam, Member.

                   Sh.  Issam Singh Sagwal, Member.

         

Present:      Sh.H.L.Jangra Advocate for the complainant.

Sh.Karan Tanwar Advocate for the OP No.1.

Sh.Shekhar Kapoor Advocate for the OP No.2.

ORDER

                   This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Jai Narain  against  The Managing Director, Max Bups Insurance Company  etc. the opposite parties.

2.                It is stated in the complaint that the complainant took personal loan of Rs.78,000/- from the OP No.2 and the OP No.2 got insured from OP No.1 vide cashless health policy bearing No.00207900201600 valid from 10.6.2016 to 9.6.2017 and the complainant had paid the entire required premium amount at the time of getting the Medical policy. The sum assured under the said policy was Rs.2,00,000.00.  At the time of obtaining of the insurance policy the age of the complainant was 58 years and he was hale and hearty.  It is further stated that unfortunately on 24.12.2016 the complainant suffered from heart attack and then he was immediately was taken to Ma x Health Care where he remained admitted from 25.12.2016 to 2.01.2017  where his ECG  and other tests were conducted and Bypass surgery of the heart of the complainant was conducted on 27.12.2016.  The Max Health Care, Anand Vihar, New Delhi was in the list of the prescribed hospitals covered under the insurance policy. An intimation regarding the ill health of the complainant was given to th3e OP No.1 and it assured that all the medical and treatment bills would be paid by the OP No.1 being insurer of the complainant as it was a cashless policy. When the complainant was admitted, his relatives on asking of hospital staff deposited an amount of Rs.1,95,000/- as a security amount and it was assured that as and when the insurance company would pay the actual medical expenses of the bill, then the amount would be refunded to the complainant. After discharge from the hospital, the complainant and his family members met the OP and asked for non payment, then the OP no.1 asked to submit the  bills and treatment record and assured that the amount would be refunded to the complainant but the OP No.1 failed to make the payment of the medical and treatment expenses to the complainant which amounts to deficiency in services on the part of the Ops. Thus, alleging deficiency in services on the part of the Ops, the complainant has filed the present complaint and prayed that the Ops be directed to make the payment of Rs.1,95,000/- alongwith compensation for the mental agony and harassment suffered by him alongwith litigation expenses.

3.                Upon notice, OP No.1 appeared and filed its written statement disputing the claim of the complainant. Obtaining of the insurance policy was admitted by the OP No.1. It is submitted that the policy under question is a group Health policy and was issued by the company wherein and group policy holders Bajaj Finance Limited. The risk inception date of the policy is 10.6.2016 and the risk expiry date is 9.6.2017.  It is further submitted that the complainant till date has not submitted the claim intimation-claimant’s statement form or any pre authorization request for the alleged claims of treatment at Max Health Care nor has submitted any requisite documents (Medical and other) hence, it is impossible for the OP company to process the case of the complainant and to put it under the process of payment without the knowledge of the claim or without receiving any document from the complainant. Whenever, the claim is submitted a thorough investigation has to be done regarding the same, the identity of the claimant has to be verified, the genuineness of the claim has to be verified, the status of the policy has to be checked and if it is in accordance with the policy terms and conditions, then only the claim can be processed. The complainant is advised to submit a proper claim under the policy as per the laid down procedure of the company and thereafter the OP company will take the appropriate decision with respect to the claim and intimate  the complainant accordingly. All other allegations made in the complaint have been denied specifically and it is submitted that there is no deficiency in services on the part of the OP no.1 and prayed for dismissal of the complaint.

4.                The OP No.2 also appeared and filed written statement disputing the claim of the complainant. It is submitted that the complainant availed a personal loan from OP on 10.6.2016 vide loan account No.510PST23932996,  The loan was to be repaid in 36 monthly installments of Rs.3441/- each.  For timely payment of EMIs the complainant has given the auto debit mandate/ECS mandate to clear the EMIs directly from his bank account. The complainant has defaulted in few payments of EMI No.1, 9 and 31 but subsequently the same was paid in cash by the complainant but the bouncing charges of Rs.500/- has been levied by the OP No.2 against the dishonored EMI(s and as on the date the total amount of Rs.1370/-  is due as on the date and the same is reflecting from the statement of account. The OP is a financing company and provides loan to all the needy persons thus the acceptance/rejection of the insurance solely depends upon the insurance partner/insurance company and hence the OP should not be accountable to be answered.  Therefore, complaint filed by the complainant is liable to be dismissed against the answering OP. Thus, it is submitted that there is no deficiency in services on the part of the OP and prayed for dismissal of the present complaint.

5.                The complainant in support of his case has filed his affidavit Ex.CW1/A and tendered documents Ex.C1 to Ex.C6 and closed his evidence.

6.                On the other hand, OP No.1 in support of its case has filed affidavit Ex.RW1/A and tendered documents Ex.R-2 to Ex.R-4 and closed its evidence.

7.                The OP No.2 in support of its case has filed affidavit Ex.RW1/A and tendered document Ex.R-1 and closed its evidence.

8.                We have heard the learned counsel for the parties and gone through the material available on the case file.

9.                The learned counsel for the complainant  while re-asserting the averments made in the complaint has argued that the complainant took personal loan of Rs.78,000/- from the OP No.2 and the OP No.2 got insured from OP No.1 vide cashless health policy bearing No.00207900201600 valid from 10.6.2016 to 9.6.2017. The sum assured under the said policy was Rs.2,00,000.00.  It is further argued that unfortunately on 24.12.2016 the complainant suffered from heart attack and he was immediately was taken to Max Health Care where he remained admitted from 25.12.2016 to 2.01.2017  and his ECG  and other tests were conducted and Bypass surgery of the heart of the complainant was conducted on 27.12.2016.   Intimation regarding the ill health of the complainant was given to th3e OP No.1 and it assured that all the medical and treatment bills would be paid by the OP No.1 being insurer of the complainant as it was a cashless policy. When the complainant was admitted, his relatives on asking of hospital staff deposited an amount of Rs.1,95,000/- as a security amount and it was assured that as and when the insurance company would pay the actual medical expenses of the bill, then the amount would be refunded to the complainant.  It is argued that after discharge from the hospital, the complainant and his family members met the OP and asked for non payment, then the OP no.1 asked to submit the original bills and treatment record and assured that the amount would be refunded to the complainant but the OP No.1 failed to make the payment of the medical and treatment expenses amounting to Rs.1,95,000/-  to the complainant which amounts to deficiency in services on the part of the Ops. Thus, alleging deficiency in services on the part of the Ops.

10.              On the other hand, it is argued on behalf of the OP No.1 that the policy under question is a group Health policy and was issued by the company wherein and group policy holders Bajaj Finance Limited. It is further argued that the  risk inception date of the policy was 10.6.2016 and the risk expiry date is 9.6.2017.  It is further argued that the complainant till date has not submitted the claim intimation-claimant’s statement form or any pre authorization request for the alleged claims of treatment at Max Health Care nor has submitted any requisite documents (Medical and other) hence, it is impossible for the OP company to process the case of the complainant and to put it under the process of payment without the knowledge of the claim or without receiving any document from the complainant. Whenever, the claim is submitted a thorough investigation has to be done regarding the same, the identity of the claimant has to be verified, the genuineness of the claim has to be verified, the status of the policy has to be checked and if it is in accordance with the policy terms and conditions, then only the claim can be processed. The complainant is advised to submit a proper claim under the policy as per the laid down procedure of the company and thereafter the OP company will take the appropriate decision with respect to the claim and intimate  the complainant accordingly. It is also argued that this Commission has got no jurisdiction to decide the present complaint and when this Commission has got no jurisdiction to decide the present complaint, this Commission should not have gone on the merits of this case. Reliance has been placed on the law laid down in the authorities Estate Officer, Greater Ludhiana Area Development Authority and others Vs. Jaswant Singh Law Finder Doc Id # 1634383, Sarvesh Kumar Singh and others Vs. Kailash Healthcare Hospitals Law Finder Doc Id # 1528956 and Religare Health Insurance Company Limited Vs.Subhash Chander Aggarwal Law Finder Doc Id # 885281.

11.              The learned counsel for the OP No.2 has argued that the OP No.2 had advanced the loan of Rs.78,000/- to the complainant and he has paid the entire loan amount and  there is no deficiency in services on the part of the OP No.2 and prayed for dismissal of the complaint qua OP no.2.

12.              The argument of the learned counsel for the OP No.1 that the Ops have no branch office at Kurukshetra and the policy was issued from Delhi office and the OP No.1 is having its office at Delhi is devoid of any force because the  complainant had availed loan facility at Kurukshetra office and the policy was issued to the complainant at Kurukshetra. Therefore, this Commission has got jurisdiction to entertain and decide the present complaint. The authorities cited on behalf of the Ops are not applicable to the facts and circumstances of the present case.

13.              The argument of the learned counsel for the Ops that the complainant has not submitted the claim form nor intimation was given to the Ops regarding the present claim is also not sustainable in the eyes of law and the present complaint is also barred by limitation. In this case the complainant suffered from heart attack on 24.12.2016 and he was discharged from the hospital on 2.01.2017. As per version of the complainant after discharge the complainant and his family members contacted the Ops and submitted the claim documents.  Even the complainant got served the legal notice  on 11.01.2019. The Ops have failed to reply the said legal notice.  The present complaint  has been filed on 21.02.2019  and the same is thus well within limitation. The Ops even after service of legal notice did not intimated that he is required to again submit the claim form.  Even after filing of the present complaint on 21.02.2019, the Ops even did not dare to assess and pay the claim of the complainant. Even during the pendency of the present complaint, the  Ops ought to have asked the complainant to complete the formalities again especially when the complainant has also done so. Thus, adverse inference is drawn against the Ops that they have knowingly and intentionally delayed the  payment of the claim to the complainant and thus deficiency in services on the part of the Ops is amply proved. Therefore, the OP No.1 is liable to pay the claim amount to the complainant. However, the complaint qua OP No.2 is liable to be dismissed as no deficiency on the part of the OP No.2 is made out.

14.              So far as quantum of claim amount is concerned, vide bill Ex.P-3 the complainant has made the payment of Rs.1,95,000.00 to the Max Heathcare Hospital and Rs.4461/- has been paid by the complainant for his treatment vide bills  at pages 12 to 16. Therefore, the complainant is entitled to claim amount of Rs.1,95,000+ Rs.4461/- = Rs.1,99,461/- besides the compensation for the mental harassment and agony caused to him and for the litigation expenses.

15.              In view of our above discussion and findings, we accept the present complaint against OP No.1 and direct the OP No.1 to make the payment of Rs.1,99,461/-  alongwith interest @ 6% per annum from the date of this order, till its actual realization.  The OP No.1 is further directed to pay Rs.10,000/- to the complainant as compensation for the mental harassment caused to him and Rs.5000/- for the litigation expenses. The OP No.1 is further directed to make the compliance of this order within a period of 30 days from the date of this order, failing which the complainant shall be entitled to initiate proceedings u/s 25/27 of the Consumer Protection Act. The complaint qua OP no.2 stands dismissed. Certified copy of this order be supplied to the parties concerned as per the rules and the file be consigned to the record room after due compliance.

 

Announced in the open Commission.

Dated: 11.02.2022.                                                                President.

 

                              Member                         Member.