Chandigarh

DF-I

CC/193/2024

SHIVJI RAM GOYAL - Complainant(s)

Versus

MS NIVA BUPA HEALTH INSURANCE COMPANY LIMITED - Opp.Party(s)

ATUL GOYAL

03 Dec 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/193/2024
Date of Institution	:	10/4/2024
Date of Decision	:	3/12/2024

 

Shivji Ram Goyal S/o Jagan Nath Goyal resident of House No. 2161, Sector 21-C, Chandigarh-160022.

.Complainant

VERSUS

 

1.       M/s Niva Bupa Health Insurance Company Limited having its service branch at 2nd Floor, SCO 84-85, Sector 8-C, Chandigarh-160008 through its authorized representative/Branch Manager.

Opposite Party

 

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Sagar Kumar, Advocate proxy for Sh. Atul Goyal, Advocate for complainant
	:	Sh. Gaurav Bhardwaj, Advocate OPs.

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by the complainant under Section 35 of the Consumer Protection Act 2019 against the opposite parties  (hereinafter referred to as the OP). The brief facts of the case are as under :-
   1. It transpires from the averments as projected in the consumer complaint that the Complainant and his spouse have purchased a health insurance from the OP. The plan opted is Family Floater (hereinafter referred to be subject policy) and the policy is valid from 21.02.2023 to 20.02.2026 on payment of premium amount of Rs.1,65,926/- with sum insured of Rs.15.00 lakh. The copy of the Policy is annexed as Annexure C-1. On 24.10.2023, the Complainant was admitted at Shuddhi Ayurveda Panchkarma Hospital, Devinagar, Delhi Highway, Chandigarh, Dera Bassi an AYUSH Hospital specializing in AYUSH treatment and is accredited with NABH (hereinafter referred to be treating hospital) with the complaint of Dyaspnea, Nausea, Vertigo, ABD pain with acidity, Malena, Dysuria, Rt. Wrist Pain and was discharged on 07.11.2023 after remaining in Hospital for 15 days. The total amount charged by the Hospital for the entire treatment was Rs.1,68,000/-. The certificate for the period from 27.09.2021 to 26.09.2024 issued by NABH to the Hospital  is annexed as Annexure C-2 and copy of the invoice as Annexure C-3, the receipts dated 24.10.2023, 30.10.2023 and 03.11.2023 acknowledging the payments are annexed as Annexure C-4 (Colly) and the entire admission and discharge record and discharge summary dated 07.11.2023 are annexed as Annexure C-5 and C-6 respectively. On 29.11.2023 the treating hospital issued the certificate with respect to the line of treatment provided to the Complainant and the same is attached as Annexure C-7. The complainant raised the claim of Rs.1,68,000/- with the OP but the same was rejected  by the OP vide rejection letter Annexure C-8 dated 30.11.2023 on the ground  that as the patient was admitted for diagnostic and evaluation purpose, the claim is thus not payable as per Clause 4.1.4 of the policy. As per Clause 3.2 of the policy AYUSH treatment is covered if the insured is admitted for 24 hours or more. It is on record that the Complainant remained admitted in the AYUSH hospital for 15 days and as such the OP has wrongly rejected the claim of the complainant.  In this manner, the aforesaid act amounts to deficiency in service and unfair trade practice on the part of OP. OP was requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
   2. OP resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, cause of action jurisdiction. However, it is admitted that  the complainant and his spouse have purchased the subject policy from the OP valid w.e.f. 21.2.2023 to 20.2.2026  for the sum insured to the tune of Rs.15,00,000/-. It is further admitted that the complainant has raised the claim of Rs.1,68,000/-  but the same was repudiated as on scrutiny  of the claim it was found that the insured person was admitted primarily for investigation and evaluation purpose and there was no need for hospitalization.  Accordingly the claim of the complainant was rejected as per policy terms and conditions under Clause 4.1.4. On merits, the facts as stated in the preliminary objections have been re-iterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
   3. In rejoinder, complainant reiterated  the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.
2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments on record.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant and his spouse had purchased the subject policy  from the OP which was valid w.e.f. 21.2.2023 to 20.2.2026 with sum insured to the tune of Rs.5,00,000/-  and the complainant had taken treatment from  the treating Ayush hospital  and had raised a claim of Rs.1,68,000/- with the OP for the treatment taken in the treating hospital but the OP has rejected the claim of the complainant on the ground that the complainant was admitted primarily for investigation and evaluation purpose and there was no need for hospitalization, the case is reduced to a narrow compass as it is to be determined if the OP is unjustified in rejecting the claim of the complainant and the complainant is entitled for the relief as prayed for as is the case of the complainant or if the complaint of the complainant being false and frivolous is liable to be dismissed as is the defence of the OP.
   2. In the back drop of the foregoing admitted and disputed facts on record, it is clear that the entire case of the parties is revolving around  the subject policy Annexure C-1, medical record Annexure C-3 to C-7 and the repudiation letter Annexure C-8 and the same are required to be scanned carefully to determine the real controversy between the parties.
   3. The claim of the complainant was repudiated by the OP on the simple ground that the insured was admitted  primarily for investigation and evaluation purpose  and under Clause 4.1.4 of the policy the same is not covered. The relevant portion of Clause 4.1.4 is reproduced as under:-

“4.1.4 Investigation & Evaluation(Code-Excl04)

a. Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.”

.

4. However, Clause 3.2 specifically provides the expenses for treatment to the insured patient under Ayush treatment hospital  where a minimum 24 hours admission is there. The relevant portion of the said clause is reproduced as under:-

“3.2. Expenses during hospitalization (Hospital admission)

 

       a. We will pay the expenses incurred by you on treatment (Naturally this excludes expenses not linked to treatment like food, beverage, toiletries and cosmetics) if you were:

       *Admitted for 2 hours or more

       *NOTE: minimum 24 hours admission in      *AYUSH Hospital MUST for AYUSH treatment

         You had Dialysis (Hemo / Peritoneal), Radiotherapy or Chemotherapy for cancer

NOTE: Admission in a hospital happens in what is called wards or rooms of various categories, ICUS, CCUS, NICU etc or in Day care.”

 

5. As per case of the complainant he remained admitted in the treating hospital only when he was having severe pain condition and not able to walk properly and was having high infection only, on the advice of the treating doctor.
6. Perusal of discharge summary Annexure C-6 clearly indicates that the complainant remained admitted with the treating hospital from 24.10.2023 to 7.11.2023. Even Annexure C-7 the certificate issued by the treating  hospital clearly indicates that the insured patient needed proper hospitalization as he was in severe pain condition and not even able to walk and was having high infection and hospitalization was required  to keep the patient in observation under hospital and to do treatment by Ayurveda medicine and therapies. The relevant portion of the said certificate is reproduced as under:-

“Patient need proper hospitalization as patient was in sever pain condition and not able to walk properly and also infection was high. So we want to keep patient under observation in hospital and to do treatment by Ayurveda medicine and panchkarma therapies so patient could not be treated on day care or opd basis so we had to admitted patient in hospital and also it takes time for better prognosis in Ayurveda.

Line of treatment:- Ayurveda medicine/ Ayurveda therapies.”  

7. Thus, one thing is clear from the medical record having been relied upon by the complainant  and unrebutted by the OP that in fact Ayush treatment was given to the complainant through proper hospitalization  by the medical team of the treating hospital who found the complainant was in severe pain  and even not able to walk and was suffering from high infection for which the hospitalization was the only way to give the proper treatment to the complainant through Ayurvedic medicine and therapy and as such the case of the complainant is squarely covered  under clause 3.2 as discussed above as the complainant remained admitted more than 24 hours  especially when there is no evidence on record to show that the complainant was primarily admitted for diagnostic and evaluation purpose as is the defence of the OP.
8.  In view of the foregoing discussion, it is safe to hold that the OP has wrongly rejected the genuine claim of the complainant and the said act of OP amounts to deficiency in service and unfair trade practice on its part, especially when the entire case set up by the complainant in the consumer complaint as well as the evidence available on record is unrebutted by the OP. Hence, the instant consumer complaint deserves to be allowed.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP  is  directed as under:-
   1. to pay ₹1,68,000/- to the complainant(s) alongwith interest @ 9% per annum (simple) from the date of repudiation of the claim till onwards
   2. to pay ₹20,000/- to the complainant/s as compensation for causing mental agony and harassment;
   3. to pay ₹10,000/- to the complainant/s as costs of litigation.
5. This order be complied with by the OP within a period of 45 days from the date of receipt of certified copy thereof, failing which the amount(s) mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
6. Pending miscellaneous application(s), if any, also stands disposed off.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 3/12/2024			[Pawanjit Singh] President
mp
			[Surjeet Kaur] Member
			[Suresh Kumar Sardana] Member