Chandigarh

DF-I

CC/757/2015

Achla Goswamy - Complainant(s)

Versus

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

Rajiv Sharma

04 Nov 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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Consumer Complaint  No	:	757 of 2015
Date  of  Institution	:	10.11.2015
Date   of   Decision	:	4.11.2016

 

 

 

 

 

Achla Goswamy w/o Shri Praveen Goswamy r/o H. No. 1285 Sector 42B, Chandigarh. 

 

….Complainant

Vs.

 

1.   M/s Max Bupa Health Insurance company ltd. B-1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi 110044 through authorized officer.

2.   M/s Max Bupa Health Insurance Company Ltd. SCO No.55-56-57, Second floor, Sector 8-C, Madhya Marg, Chandigarh 16009 through authorized officer.

3.   Shri Vivek Narula, Agent, Max Bupa Health Insurance Co. Ltd. SCO No.55-56-57, Second floor, Sector 8-C, Madhya Marg, Chandigarh 160009.

 

…… Opposite Parties 

 

BEFORE:  

 

MRS.SURJEET KAUR                  PRESIDING MEMBER

SH. SURESH KUMAR SARDANA          MEMBER

 

 

 

For Complainant	:	Sh. Rajiv Sharma, Adv.
For OP	:	Sh. Gaurav Bhardwaj, Adv.

 

 

PER SURESH KUMAR SARDANA, MEMBER

 

 

 

                The facts, in brief, are that the complainant purchased health policy from OP No.1 through OP No.2 in 2012 and got the same renewed from year to year by making payment of premium annually. The policy was renewed for the year 2015 as well.  According to the complainant he was assured cashless treatment since 2012 at any of hospitals approved by Max Bupa Company. It is stated that in the year 2015 the complainant also got his policy renewed w.e.f 6.2.2015.  It is alleged that the complainant in the year 2015 submitted a medical claim amounting to Rs.5,54,498/- with OP No.1 but it rejected the same on the ground  that the date of admission is prior to date of payment of premium.  It is  pleaded that the complainatn paid the premium in time howerever the OPs due to previous dispute  did not accept the cheque and took time  whether to accept the premium or not. Thus the Ops arbitrarily rejected the claim of the complainant.         Alleging that the aforesaid acts amounted to deficiency in service and unfair trade practice on the part of the opposite parties, the complainant has filed the instant complaint.

2.           Notice of the complaint was sent to Opposite  Parties, seeking their version of the case
3.           The OPs No.1&2  filed written statement stating therein that the answering OP received premium on 10.3.2015 whreeas the complainant was admitted in the hospital on 7.2.2015 and discharged on 15.2.2015. Therefore, no claim is payable as per clause 6 of general information Section III of the terms and conditions of the policy proposal form, submitted by the complainant at the time of inception of the policy.  As per clause 6 of the general information Section III the policy will come into force only after receipt of the fulll  receipt of the premium chargeable.  Thus no claim is payable as the premium was received late after admission of the complainant in the hospital as such the claim was rightly repudiated. The remaining allegations were denied, being false. Pleading that there is no deficiency in service on its part, a prayer for dismissal of the complaint has been made.
4.  The OP No.3 had adopted the reply  and evidence filed by the OPs No.1&2  on 24.5.2016 as has been reflected in the order of the same date.
5.           The complainant has filed a rejoinder, wherein he has reiterated all the averments, contained in the complaint, and repudiated those, contained in the written version of Opposite Parties.
6.           Parties were permitted to place their respective evidence on record, in support of their contentions.
7.           We have heard the learned counsel for the parties and have perused the record, along with the written arguments filed on behalf of both the sides.
8.           We have perused the document Annexure C-1 produced by the complainant which is a premium receipt issued by the OPs on 13.3.2015.  A further perusal of the said documents reveals that the commencement of the policy in question is shown as 6.2.2015 and expiry date is shown as 5.2.2016 .  whereas  the complainant has fallen sick on 7.2.2015 and was discharged on 15.2.2015, which is evident from Annexure C produced on record by the OPs. Meaning thereby the complainant was duly covered under the health policy in question  though the OPs with a malafide intention issued him receipt of premium at a later date i.e. after complainant’s falling sick.  Hence we find deficiency on the part of OPs who though issued the policy w.e.f. 6.2.2015 to 5.2.2016 yet with  a malafide intention and to frustrate the claim of the complainant showed the date of premium receipt as 13.3.2015 and refused the claim of the complainant on that sole ground. Hence the OPs are liable to reimburse the claim of the complainant
9.           In the light of above observations, we are of the concerted view that the Opposite Parties are found deficient in giving proper service to the complainant and having indulged in unfair trade practice. Hence, the present complaint of the Complainant deserves to succeed against the Opposite Parties, and the same is allowed, qua them. The Opposite Parties are, jointly and severally, directed  to:-

 

[a]  To reimburse the claim amount of
Rs 5,54,498/- to the complainant.

 

[b]  To make payment of Rs.50,000/- to the complainant towards compensation for causing mental and physical harassment.

 

[c]  To make payment of Rs.10,000/- to the complainant as litigation expenses.

 

 

         

 

         

 

Announced

4.11.2016                                             sd/-

 (SURJEET KAUR)

PRESIDING MEMBER

 

Sd/-

 (SURESH KUMAR SARDANA)

MEMBER

p>

 

Announced

8.11.2016                                             sd/-

 (PRITI MALHOTRA)

PRESIDING MEMBER

 

Sd/-

 (SURESH KUMAR SARDANA)

MEMBER