District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.587/2021.
Date of Institution: 16.11.2021.
Date of Order: 11.01.2023.
Roshan Lal son of late Shri Richh Pal, resident of village Bhaisrawali Post Office Tigaon, Tehsil Ballabgarh, District Faridabad. Mobile No. 9990849071.
…….Complainant……..
Versus
1. M/s. Max Bupa Health Insurance Co. Ltd. D-5, 2nd floor, Logix Infotech Park, Opp. Metro Station, Secator-59, Noida, Uttar Pradesh – 201301 through its authorized person.
2. HDFC Bank Ltd., HDFC Bank House, Senapati Bapat Marg, Lower Parel (W), Mumbai – 400013. Phone 91(22)5652 -1000, 91(22) 5652-1000.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Complainant in person.
Sh. Rakesh Dabaas, counsel for opposite party No.1.
Sh. Rajiv Rana, counsel for opposite party No.2.
ORDER:
The facts in brief of the complaint are that the complainant purchased a accidental policy bearing No. 31455467202000 dated 30.11.2020 from opposite party No.1 through opposite party No.2. The policy was for the period of 3 years meaning thereby the expiry of the policy in question was 29.11.2023. The complainant struck with an accident and received multiple injuries in his body on dated 8.7.2021 and he was admitted in the hospital i.e. SSB Hospital and Multi Specialty, Ajronda Chowk, Faridabad. The complainant remained under treatment and his left patella was operated as the patella was broken up. At the time of admission in the hospital the opposite parties were duly informed about the accident and the complainant also demanded for the policy in question again and also requested to take the cashless treatment from the hospital on the basis of Accidental Insurance Policy. But the opposite party totally failed to do so and the opposite arties also refused the complainant that the medical bills were not covered under the policy. It was also stated by the opposite parties that as per the policy the opposite parties can avail Rs.10,000/- per week on account of bed rest period including the hospital treatment days. At the time of discharge of the complainant the concerned doctors of the hospital advised rest for a period i.e. 10.07.2021 to 7.08.2021 and the same was again repeated for further period i.e. 08.08.2021 to 28.08.2021 and also advised by the doctor to check up from the physiotherapist. The complainant thereafter take treatment from the physiotherapist and still under treatment as the complainant was not well due to the accidental injuries. At the time of purchasing the policy the opposite parties assured the complainant to avail cashless treatment from the hospitals, the name of hospitals were annexed with the policy and also assured to give Rs.10,000/- for the date of accident till the recovery of the patient. Now the opposite parties were going back out from his commitment/assurance. It seems that the opposite parties sold his policies on false assurances by making foolish to the customer with their bad intention or to grave the hard earned money of the opposite parties. The complainant submitted his claim to the opposite parties and the opposite parties did
not honour to the complainant and the opposite parties also honour the request of the complainant by sending a objectable letter dated 02.09.2021 through email which hardly heart to the complainant. The complainant sent legal notice to the opposite parties but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) make the payment of Rs.1,00,000/- and bound to pay Rs.10,000?- weekly to the complainant during the treatment period and advised rest period to the complainant alongwith other benefits to the complainant forthwith.
b) pay Rs. 15,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 22,000 /-as litigation expenses.
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the complainant opted for the policy bearing NO. 31455467202000 “Individual” from the period 30.11.2020 to 29.11.2023 with a base sum insured of Rs.25,00,000/- and the gross premium was Rs.10,238/-. The complainant moved an claim reimbursement application for an amount of Rs.40,000/- with respect to the treatment for fracture of Patella at SSB Heart and Multispecialty Hospital from the period 08.07.2021 to 09.07.2021. On the receipt of the aforesaid claim application, the opposite party No.1 generated claim bearing NO. 717305 and further review the application and medical documents of the complainant. After the perusal of the documents, the opposite party gave the following observations in compliance with terms and conditions of the policy:
“…….Non disclosure: patient was having H/o Loss of Vision prior to
policy the Medical conditions was not disclosed to us at the time of policy inception therefore, rejected as per policy T &C clause def 10….”
The complainant was wasting the previous time of the Hon”ble Commission on account of fact that there was non disclosure of pre existing medical conditions i.e. H/o Loss of Vision prior to policy the medical conditions on the part of the complainant. The statements/details in the online proposal form re future loss to the applicant. On the other hand, the complainant did not disclose the pre-existing medical illness/conditions and had filed the complaint. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Opposite party No.2 put in appearance through counsel and filed written statement wherein Opposite party No.2 refuted claim of the complainant and submitted that the answering opposite party had acted only as referral agent of the insurance company and the policy should have been issued by the Insurance company post completing the necessary formalitis towards and the Insurance Company was relevant party to provide clarification in this regard. It was imperative to mention that post issuance of policy, there was a separate contract between the complainant and the insurance company and in case of any dispute relating to the insurance policy, the complainant shall directly take up the matter with the insurance company i.e opposite party No.1 MAX Bupa Health Insurance Company Ltd. It was further submitted that the complainant had filed the present false complaint on the basis of distorted and fabricated facts with a view to extract money from the answering opposite party. The complainant had completely failed to prove any deficiency in service on the part of the opposite party bank. The Hon’ble Supreme Court of India vide it’s judgment dated 06.10.2021 passed in the
matter of SGS India Ltd. Vs. Dolphin International Ltd. Held that “Onus of proof of deficiency in service was on the complainant under the Consumer Protection Act”.
Opposite party No. 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties–Max Bupa Health Insurance Company Ltd. & another with the prayer to: a) make the payment of Rs.1,00,000/- and bound to pay Rs.10,000?- weekly to the complainant during the treatment period and advised rest period to the complainant alongwith other benefits to the complainant forthwith. b) pay Rs. 15,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 22,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW-1 – affidavit of Roshan Lal, Ex.C-1 –Depict type of injury The Pictorial Diagram , Ex.C-2 & C3 – Medical & fitness Certificate, Ex.C-4 – Final Bill of supply detail (Credit), Ex.C-5 -& 6 – Discharge summary, Ex.C-7 – letter regarding endorsement related to policy No. 31455467202000, Ex.C-8 – report of CT scan,
On the other hand counsel for the opposite party No.1 strongly
agitated and opposed. As per the evidence of the opposite party No.1 – affidavit of Shri Bhuwan Bhasher, sEnior Manager – Legal, M/s. Niva Bupa Health
Insurance Company Limited, 2nd floor, Plot NO. D-5, Logix Infotex Park, Sector-59, Noida, Uttar Pradesh, Ex.R1 – letter dated 30.11.2020, Ex.R2 – Discharge summary, Ex.R3 (Colly) – letter dated 10.12.2021.
As per evidence of opposite party No.2 Ex.RW2/A – affidavit of Hasmita Sagar, Legal Manager and authorized representative of M/s. HDFC Bank Limited having its office at First floor, Tower-a, Plot NO. 31, Nazafgarh Industrial Area, Shivaji Marg, Moti Nagar, New Delhi, Ex.R-1 – Board of Resolution, Ex.R-2 – application form, Ex.R-3 – EasyEMI Credit Card Statement
7. In this case, the complainant has obtained a Special Category Policy T.D.S (Temporary Total Disability) in which the complainant can claim 1% of the sum assured. It is evident from Medical & Fitness Certificate vide Ex.C- 3 in which it has been mentioned that “Roshan Lal aged 44 years was suffering from/operated for ORIF (Tension Band Wiring) left patelia and he was admitted from 08.07.2021 to 09.07.2021 and further he was advised rest for a period of 28 days from 10.07.2021 to 07.08.2021. As per Medical & Fitness Certificate vide Ex.C-2 in which it has been mentioned that “Roshan Lal aged 44 years was suffering from/operated for ORIF (Tension Band Wiring) left patelia and he was admitted from 08.07.2021 to 09.07.2021 and further he was advised rest for a period of 21 days from 08.08.2021 to 28.08..2021. It means he was admitted for 2 days and advised rest for 7 weeks. As per the T & C of the policy, the complainant can claim Rs.10,000/- per week i.e. 7 week x Rs. 10,000/- = Rs.70,000/-. The complainant has filed the complaint and prayed for Rs.. 1,00,000/-. As per Final Bill of Supply Details dated 09.07.2021 for Rs.61,216/- vide Ex. C-4 which does not cover under the policy.
8. After going through the evidence led by both the parties, the Commission is of the opinion that the complaint is allowed as per T &C of policy i.e. 7 weeks x Rs.10,000/- = 70,000/-.
9. The opposite party No.1 is directed to pay Rs.70,000/- alongwith interest @ 9% p.a. from the date of filing of complaint till its realization. Opposite party No.1 is further directed to pay Rs.3300/- as compensation on account of mental tension, agony and harassment alongwith Rs.3300/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of order. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 11.01.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
