District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 06/2022.
Date of Institution:04.01.2022.
Date of Order:15.05.2023.
Mrs..Tahira Azad wife of Shri Shaukat Azad, Resident of House No.. 637, Sector-37, Faridabad.
…….Complainant……..
Versus
1. M/s. Max Bupa situated at SCO 11, Ist and 2nd floor, above Canera Bank, near Green Channel Restaurant, Sector-16, Faridabad, Haryana – 121001 through its Branch Manager/Legal Advisor.
2. M/s. Max Bupa, Corporate & Registered office, B-1/1/2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi – 44 through its Regional Manager.
…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: Rafiq Mohd., counsel for the complainant.
Sh. Rakesh Dabaas , counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant was the member of Family Floater Insurance Health policy bearing o. 31560641202100 dated 14.2.2021 customer ID 2001119390 w.e.f. 14.2.2021 to 13.2.2022 from the opposite parties and the said policy was taken by the husband of the complainant. During the mediclaim policy, the complainant was admitted in 23.4.2021 in Shanti Devi Memorial Hospital Kheri More, Sector-89, Greater Faridabad and was discharged on 25.4.2021 and the hospital had raised the bill amount of Rs.82,500/- but the opposite parties not paid the bill amount and the complainant had paid the said bill amount from her own pocket and the complainant again admitted in Alfaa Health Care Hospital Main Farrukh Nagar Road, Near Canara Bank village Basai, Gurgaon dated 26.4.2021 and was discharged on 5.5.2021 and the hospital raised the bill amount of Rs.1,55,000/- and in this regard the complainant intimated to the representative of the opposite parties to make the said amount but the representative of the opposite parties ignored the legitimate request of the complainant and the complainant had to pay the said bill amount to the hospital from her own pocket. The complainant had sent all related documents regarding the treatment of the complainant as well as bill for getting the imbursement of the mediclaim amount no fruitful result came out. The complainant sent legal notice dated 06.10.2021 to the opposite parties through registered post 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 interest loss amount of Rs.2,37,000/- alongwith interest @
18% which was paid by the complainant from her own pocket during the mediclaim insurance period.
b) pay Rs.1,50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 22,000 /-as litigation expenses.
2. Opposite parties put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that the complainant failed to produce the required pending documents i.e (i) as per records submitted, patient was a known case of DM and HTN(ii) Please submit treating doctor certificate mentioning duration of the DM and HTN, all the treatment records including first consultation paper. (iii) kindly provide detail breakup of hospital final bill .(iv) kindly provide Covid-19 report, CRP, D Dimer, Ferritin, 1L6”. There were mandatory to process the claim, therefore in the absence of the pending required documents, the authenticity and accomplishment of documents for claim procedure not established, hence claim could not be paid, therefore, claim was repudiated under applicable policy terms and conditions. The opposite parties submitted that claims were paid by any insurance company out of the common pool of funds belonging to all policy holders of the company and insurance company had to check the admissibility of a claim before honoring it as such any payment as claimed in the complaint would be an undue discrimination with the other policy holders who were insured in same risk pool with identical health condition in which complainant claimed herself to be vide her proposal form. Opposite parties denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties–Max Bupa with the prayer to: a) make the interest loss amount of Rs.2,37,000/- alongwith interest @ 18% which was paid by the complainant from her own pocket during the mediclaim insurance period. b) pay Rs.1,50,000/- 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.CW1 – affidavit of Mrs. Tahira Azad, Ex.C-1 – Cash final bill, Ex.C-2 Discharge summary, Ex.C-3 – bill detail, Ex.C-4 – Discharge card, Ex.C-5 – policy schedule, Ex.C-5 - envelop
On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties Ex.RW1/A – affidavit of Manisha Rani, Senior Executive – Legal, Ms. Niva Bupa Health Insurance Company Limited, 2nd floor, Plot NO. D-5, Logix Infotech Park, Sector-59. Noida, Ex.R-1 – letter of authorization, Ex.R-2 – Porability Form, Ex.R-3 - Reassure Proposal Form, Ex.R-4(colly) – letter dated 17.02.2011, Ex.R-5 (colly) – discharge card, Ex.R-6 (colly)) – letter dated 20.07.2022 regarading missing information letter in respect of claim NO. 672747 Shokat Azad, Ex.R-7 – letter dated 15.06.2022 regarding member reimbursement statement for claim No. 672747.
6. In this case, the complainant obtained Family Floater Insurance Health policy bearing o. 31560641202100 dated 14.2.2021 customer ID 2001119390 w.e.f. 14.2.2021 to 13.2.2022 from the opposite parties and the said policy was taken by the husband of the complainant. The complainant was
admitted in 23.4.2021 in Shanti Devi Memorial Hospital Kheri More, Sector-89, Greater Faridabad and was discharged on 25.4.2021 and the hospital had raised the bill amount of Rs.82,500/- but the opposite parties not paid the bill amount and the complainant had paid the said bill amount from her own pocket and the complainant again admitted in Alfaa Health Care Hospital Main Farrukh Nagar Road, Near Canara Bank village Basai, Gurgaon dated 26.4.2021 and was discharged on 5.5.2021 and the hospital raised the bill amount of Rs.1,55,000/- . As per letter dated 20.07.2022 vide Ex.OP1/6(colly) in which it has been stated that:”as per records, submitted, patient was a known case of DM and HTN. Please submit treating doctor certificate mentioning duration of the DM and HTN, all the treatment records including first consultation paper.
- Kindly provide details breakup of hospital final bill.
- Kindly provide Covid 19 report –CRP, D Dimer, Ferritib IL6.
Opposite parties repudiated the claim of the complainant vide letter dated 15.06.2022 on the ground that “Non submission of mandatory claim documents, in absence of proper query reply after repeated reminders, the authenticity and accomplishment of documents for claim procedure not established hence claim cannot be paid, therefore claim stand repudiated under clause No. 7.3.
7. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order, subject to submission of documents as per required by the opposite parties and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite parties are also
directed to pay Rs.2200/- as compensation for causing mental agony & harassment alognwith Rs.2200/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. File be consigned to the record room.
Announced on: 15.05.2023 (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.
