Haryana

Kurukshetra

CC/553/2019

Anuradha - Complainant(s)

Versus

Max Bupa - Opp.Party(s)

Ashok Kaushik

19 Sep 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KURUKSHETRA

 

                                                                    Complaint No.:    553 of 2019.

                                                                   Date of institution:         23.12.2019.

                                                                   Date of decision: 19.09.2022

 

Anuradha Devi w/o Shri Dinesh Sharma, r/o village Sikanderpur, Indri, District Karnal.

                                                                                                …Complainant.

                                                      Versus

 

Max Bupa Health Insurance Company Limited, SCO No.101-103, 2^nd Floor, Batra Building, Sector-17D, Chandigarh, through its Manager.

...Respondent.

 

CORAM:   NEELAM KASHYAP, PRESIDENT.    

                   NEELAM, MEMBER.

                   RAMESH KUMAR, MEMBER.

 

Present:       Shri Ashok Kaushik, Advocate for the complainant.

                   Shri Karan Tanwar, Advocate for the Opposite Party.

 

ORDER:

 

1.                This is a complaint under Section 12 of the Consumer Protection Act, 1986.

2.                It is alleged in the complaint that the complainant purchased a Family Medicare Policy No.30898226201900 on 18.02.2019 valid from 18.02.2019 to 17.02.2020 and paid Rs.2237/- to OP. Under this policy, four members including complainant was covered. On 28.10.2019, complainant was going to Kurukshetra from his village on the motorcycle with his husband and when they reached near Pipli, the motorcycle was suddenly slipped and received multiple injuries on various parts of body. She was got admitted to Apna Hospital, Kurukshetra, where remained admitted from 28.10.2019 to 13.11.2019 and paid Rs.43000/- as hospital charges and also spend Rs.45000/- approx. on purchase of medicines etc. She filed her claim with OP vide claim No.475635 and completed all the formalities and supplied the requisite documents demanded by OP vide letter dated 16.12.2019. She approached the OP various times to release the claim amount, but it refused to do the needful. The above act and conduct of OP amounts to deficiency in service, causing her mental agony, harassment and financial loss, constraining her to file the present complaint against the OPs, before this Commission.

3.                Upon receipt of notice of complaint, OP appeared and filed its written statement stating therein that policy No.30898226201900 was issued by OP on the basis of information provided by the Assured in the online application form. The claim has been repudiated on the ground that the claim is not genuine on account of various misrepresentation based in the treatment which was undertaken by the Insured. As per investigation report, it was revealed that ICP shows no any surgery done, only Patient kept on medical management that IV Antibiotic & Antacid etc. which has no role in injury yet kept on same for 17 days, no indication of same justified. Lab Report done in Arya Medical Laboratory & reports done by Mr. Ved DMLT no pathologist attached. Lab report not valid, also no any X-ray film or reports submitted while insured informed submitted and yet ICPs suggest no any facture, so only for Laceration hospitalization for 17 days not justified. Hence, on the grounds of misrepresentation of facts and discrepancies, the claim was rejected and communicated to the complainant vide letter dated 25.02.2020. There is no deficiency in service on the part of OP and prayed for dismissal the present complaint.

4.                In support to support her case, complainant tendered affidavit Ex.CW1/A along with documents Ex.C-1 to Ex.C-31 and closed the evidence.

5.                On the other hand, OP, in its evidence, tendered affidavit Ex.RW1/A along with documents Ex.R/A, Ex.R-1 to Ex.R-5 and closed the same.

6.                We have heard the learned counsel of the parties and carefully gone through the case file.

7.                Learned counsel for the complainant argued that the complainant purchased a Family Medicare Policy No.30898226201900 on 18.02.2019 valid from 18.02.2019 to 17.02.2020 and paid Rs.2237/- to OP. Under this policy, four members including complainant was covered. On 28.10.2019, complainant was going to Kurukshetra from his village on the motorcycle with his husband and when they reached near Pipli, the motorcycle was suddenly slipped and received multiple injuries on various parts of body. The complainant was got admitted to Apna Hospital, Kurukshetra, where remained admitted from 28.10.2019 to 13.11.2019 and paid Rs.43000/- as hospital charges and also spend Rs.45000/- approx. on purchase of medicines etc. The complainant filed her claim with OP vide claim No.475635 and completed all the formalities and supplied the requisite documents demanded by OP vide letter dated 16.12.2019. The complainant approached the OP various times to release the claim amount, but it refused to do the needful. The above act and conduct of OP amounts to deficiency in service.

8.                The learned counsel for OP argued that policy No.30898226201900 was issued by OP on the basis of information provided by the Assured in the online application form. The claim has been repudiated on the ground that the claim is not genuine on account of various misrepresentation based in the treatment which was undertaken by the Insured. As per investigation report, it was revealed that ICP shows no any surgery done, only Patient kept on medical management that IV Antibiotic & Antacid etc. which has no role in injury yet kept on same for 17 days, no indication of same justified. Lab Report done in Arya Medical Laboratory & reports done by Mr. Ved DMLT no pathologist attached. Lab report not valid, also no any X-ray film or reports submitted while insured informed submitted and yet ICPs suggest no any facture, so only for Laceration hospitalization for 17 days not justified. Hence, on the grounds of misrepresentation of facts and discrepancies, the claim was rejected and communicated to the complainant vide letter dated 25.02.2020. There is no deficiency in service on the part of OP and prayed for dismissal the present complaint.

9.                There is no dispute between the parties that the complainant had obtained Family Medicare policy from OP for a period w.e.f. 18.02.2019 to 17.02.2020 after paying Rs.2237/- vide policy document Ex.C-2.

10.              Learned counsel for the complainant alleged that on 28.10.2019, complainant received multiple injuries on various parts of body in a roadside accident and she remained admitted in Apna Hospital, Kurukshetra from 28.10.2019 to 13.11.2019 vide Discharge Summary Ex.C-6 and paid Rs.43000/- there vide receipt Ex.R-5 and Rs.45,000/- on other expenses, total Rs.83,000/-. She filed her claim with OP vide claim No.475635 Ex.C-4 and completed all the formalities and supplied the requisite documents demanded by OP, but OP failed to release the claim amount. The OP repudiated claim of complainant vide letter dated 25.02.2020 on the ground: “As per received document and investigation done by us, it was found, misrepresentation of facts observed in claim documents, hence claim repudiated as per policy clause 10.21”.

11.              Since OP insurance company repudiated the claim of the complainant, therefore, the onus to prove the same, was upon the OP.

12.              Learned counsel for the OP firstly contended that in the Discharge Summary Ex.C-6, there is mentioned by the concerned doctor that patient admitted on 28.10.2019 with multiple injuries (lacerated wounds), but there is no document on the case file, vide which, it can be gathered that any surgery of the complainant was done by the OP. From the perusal of entire record, we found no such document on the case file. He further contended that in the complaint, complainant admitted that she suffered multiple injuries in that accident and remained admitted in the hospital for 17 days and certainly the doctor concerned conducted the X-ray/surgery on the complainant in this regard, but from the receipt Ex.C-5, it is clear that no such X-ray or Surgery was conducted by the doctor concerned. From receipt Ex.C-5 we found that there is not mentioned any charges for X-ray or surgery etc. and in this regard, plea taken by the OP is plausible. He further contended that from the treatment record Ex.C25, it is clear that the doctor concerned had given various antibiotics injection/medicines to the complainant, which has no concern with injury, meaning thereby, the complainant had not suffered any multiple/serious injuries in the alleged accident, as such, there was no need for remaining indoor patient in that hospital and the doctor concerned had given only antibiotics to the complainant during her treatment.    

13.              He further contended that there is no MLR on case file. As per complainant, she remained admitted in Apna Hospital from 28.10.2019 to 13.11.2019 i.e. about 17 days i.e. 7 days indoor patient, meaning thereby, the complainant might have suffered serious injuries in that accident, due to which, she was remained admitted in the hospital for about 17 days and the concerned doctor might have certainly prepared MLR in this regard, but it is strange that no such MLR was produced on the case file by the complainant, which raises serious doubt to the story of the complainant. Furthermore, there is no DDR/FIR on the case file. In this way, this Commission reaches to the conclusion that the complainant alleged that she received multiple injuries in the accident in question and that’s why she remained admitted in the hospital for about 17 days (7 days indoor patient) and spent total Rs.83,000/- in this regard, but from the perusal of entire record, we found that the complainant failed to produce any MLR/DDR/FIR or X-ray report or Surgery detail on the case file, vide which, it can be gathered that there was need for remaining admitted by the complainant in that hospital for about 17 days. Moreover, during that treatment, complainant was given antibiotics and antacid, which has no concern with the injury in question, which is clear cut misrepresentation of material facts, by the complainant, from OP, as such, claim of complainant was rightly repudiated by OP on this very ground. It seems that the complainant in connivance with the said hospital concocted the false story of her admission just to extort money from the OP insurance company.

14.              Keeping in view the above facts and circumstances of the case, we are of the considered view that OP has not committed an error while repudiating the claim of the complainant on the ground of misrepresentation of material facts, by the complainant, from the OP. Hence, we found no deficiency on the part of OP. Complaint is devoid on merits and is liable to be dismissed on this very ground.

15.              Hence, due to the reasons stated hereinbefore, we found no merit in the present complaint and dismiss the same, it being devoid on merits, leaving the complainant to bear his own costs of litigations. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the records, after due compliance.

Announced in open Commission:

Dated:19.09.2022.

    

 

                                                                                       (Neelam Kashyap)               

(Ramesh Kumar)                     (Neelam)                        President,

Member.                                  Member.                         DCDRC, Kurukshetra.           
 

 

 

 

 

Typed by: Sham Kalra, Stenographer.