Chandigarh

DF-I

CC/587/2022

Parul Gupta - Complainant(s)

Versus

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

Devanshu Aggarwal

12 Jun 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

Parul Gupta @ Parul Aggarwal wife of Mr.Devanshu Aggarwal, aged 31 years, R/o H.No.126, Sector 28-A, Chandigarh-160002. (UID:274596102770).

… Complainant

V E R S U S

M/s Niva Bupa Health Insurance Co. Ltd., CIN: U66000DL2008PLC182918 (formerly known as Max Bupa Health Insurance Co. Ltd.) through Managing Director, Ramachandran Krishnan, having its registered office at C-98, 1^st Floor, Lagpat Nagar, Part-1, New Delhi 110024 and also at SCO No.55-57, 2^nd Floor, Sector 8-C, Madhya Marg, Chandigarh 160009.

Email: … Opposite Party

Per Suresh Kumar Sardana, Member

1.      Averments are that the complainant and her husband had purchased a policy from the OP through their registered agent effective w.e.f. 11.11.2021 to 10.11.2022 for herself and her husband being the insured persons under the said policy for a total sum of Rs.10,00,000/-. The complainant had paid a gross premium of Rs.12,810/- towards the policy in question (Annexure C-1). The complainant had been planning to start a family and had thus visited a gynaecologist on 15.01.2022 for routine checkup. As per the advice of the doctor, the complainant had undergone the advised tests (annexure C-4 to C-6) respectively. It is submitted that while conducting internal investigation the doctor had there and then conducted a minor surgery of Hymenectomy upon the complainant. After conducting the said minor surgery, the complainant was discharged on 08.02.2022 (Annexure C-7). The complainant had submitted her claim to the tune of Rs.33,134- alongwith all relevant documents to the OP (Annexure C-11). It is further submitted that insurance agent had assured that the claim of Rs.33,134/- would be sanctioned and released within a period of 15 days from the date of lodging of the claim (Annexure C-12). The complainant had checked the mobile application on 7.4.22, showed that the claimed has been rejected without assigning any reason and without even providing any rejection letter to that effect. Thereafter, the complainant had written an email on 07.04.2022 to OP. Whereby OP had admitted that it had been negligent in providing services. The OP had then specified that the reason for rejection of claim and had stated that the claim has been rejected as per clause 6.2. It is also submitted that vide letter dated 8.4.2022 OP’s have rejected the claim of the complainant by citing Diagnosis/Treatment as Fever, whereas, the complainant had been treated with Hymenectomy which relates to gynae problem and has no relation with fever in any manner. The complainant is running from pillar to post to get the entire claim amount reimbursed as per the claim form and insurance policy. Hence, is the present consumer complaint.
2.     OP contested the consumer complaint, filed its written reply and stated that it was found that the had taken treatment for Portal Vaginal atresia for which she had undergone a Hymenectomy. As per the terms and conditions of the policy, there was a 24 months waiting period that had to be served for treatment of certain illnesses. It is clearly spelt out in the said clause that 24 months of continued coverage has to be there for covering the specified illnesses except if the illness is due to an accident or cancer. The Complainant had a corrective surgery of her vagina i.e., hysterectomy which falls under the list of illness for which specific waiting period under clause 6.2 is applicable i.e., 6.2 (xiv) Surgery of Genito urinary system unless necessitated by malignancy. Therefore, the claim was denied as per the terms and conditions. Denying all other allegations made in the complaint a prayer for dismissal of the complaint has been made.
3.     Rejoinder was filed and averments made in the consumer complaint were reiterated.
4.     Parties led evidence by way of affidavits and documents.
5.     We have heard the learned counsel for the parties and gone through the record of the case.
6.     On perusal of the complaint, it is observed that the main grievance of the complainant is that inspite of having proper health insurance cover, her legitimate claim was rejected without any basis.
7.     On perusal of the reply of the OP, it is observed that the claim of the complainant has been rejected on the basis that corrective surgery undergone falls under the list of illness for which specific waiting period under Clause 6.2 (xiv) is applicable. We reproduce here below:-

Clause 6.2. (xiv) of the terms and conditions of the policy.

6.2 Specified disease/procedure waiting period-Code Exl02

“a. Expenses related to the treatment of the listed conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an Accident (covered from day 1) or Cancer (covered after 30-days waiting period).”

b.xxxxx

c.xxxxx

d.xxxxx

e.xxxxx

“f. List of specific diseases/procedure:

1. Xxxxx
2. xxxxx
3. xxxxx
4. xxxxx
5. xxxxx
6. xxxxx
7. xxxxx
8. xxxxx
9. xxxxx
10. xxxxx
11. xxxxx
12. xxxxx
13. xxxxx
14. Surgery of Genito urinary system unless necessitated by malignancy.” 

    It is observed that the complainant has undergone “Hymenectomy” which is not covered under the above clause 6.2 (xiv).

8.     Hence, in view of above discussion, we are of the concerted view that the claim of the complainant has been wrongly repudiated & the OP have indulged in unfair trade practice & is also deficient in providing service and the complainant has been made to run from pillar to post & finally to this Commission for redressal of his grievance.
9.     In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OP is directed as under :-

1. to pay an amount of ₹33,134/- to the complainant alongwith interest @ 9% per annum from the date of filing of this complaint till realization.
2. to pay an amount of ₹5000/- to the complainant as compensation for causing mental agony and harassment to her;
3. to pay ₹7,000/- to the complainant as costs of litigation.

10.     This order be complied with by the OP within thirty days from the date of receipt of its certified copy, failing which, it shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
11.     Certified copies of this order be sent to the parties free of charge. The file be consigned.