Haryana

Kaithal

CC/175/2022

Ravinder Arora - Complainant(s)

Versus

Niva Bhupa Health Insurance Co Lt - Opp.Party(s)

Sh.Sukhdeep Singh

09 May 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAITHAL

 

                                                               Complaint Case No. 175 of 2022.

                                                               Date of institution:      13.07.2022.

                                                               Date of decision:       09.05.2024.

 

Ravinder Arora s/o Shri Shingara Singh, r/o R-II, HUDA, Cheeka, District Kaithal.

                                                                                      …Complainant.

                                                    Versus

 

1. Niva Bhupa Health Insurance Company Ltd., through its Director Operations and Customers Service having its office at C-98, Lajpat Nagar-1, New Delhi-110024.
2. Niva Bhupa Health Insurance Company Ltd., through its Branch Manager having its office at 2^nd Floor, Plot No.D-5, Sector-59, Gautam Budhnagar, Noida, Uttar Pradesh-201301.

...Opposite Parties.

 

          Complaint under Section 35 of the Consumer Protection Act

 

CORAM:   SMT. NEELAM KASHYAP, PRESIDENT.

                   SMT. SUMAN RANA, MEMBER.

                   SHRI SUNIL MOHAN TRIKHA, MEMBER.

                  

Present:       Shri Sukhdeep Singh Josan, Advocate for the complainant.   

                   Shri Ashok Tanwar, Advocate for the Opposite Parties.

 

                  

ORDER  -  NEELAM KASHYAP, PRESIDENT

          Complainant has filed this complaint under Section 35 of Consumer Protection Act, 2019, against the OPs.

2.                In the complaint, complainant alleged that he purchased a health policy from Star Health and Allied Co. Ltd. in the year 2010-11 and continuously renewing the same and about 3 years ago, cover of his and his family members increased upto Rs.10 lacs. That in the month of January 2022, he got ports his policy bearing No.P/21115/01/2021/007030 of Star Health into Niva Bhupa Health Insurance, who issued a policy No.32201632202200 dated 24.01.2022. That on 10.02.2022, his wife while doing household met with an accident and was having complaint of pain in her back and her MRI was conducted on 14.02.2022 and after that, he took her wife to Paras Hospital, Panchkula and then to Fortis Hospital, Mohali, who also advised for spine surgery. That on 03/04.03.2022 he along with wife went to Fortis Hospital, Mohali and gave their consent for surgery and he forwarded the necessary papers to OPs for availing cashless claim but OPs rejected his claim request No.446369 without assigning any reason. That somehow he managed the necessary expenses surgery was performed on 11.03.2022 and her wife remained admitted there till 15.03.2022. That thereafter, he made various representations to OPs to release the claim amount, but all in vain. That the above act of OPs, amounts to deficiency in service, on their part, due to which, he suffered huge physical harassment, mental agony as well as financial loss, constraining him, to file the present complaint, against the OPs, before this Commission.

3.             Upon notice of complaint, OPs appeared before this Commission and filed written statement, stating therein that the claim of complainant was duly paid to the tune of Rs.4,24,047/- on 25.07.2022 vide NEFT No.IN1ON22072504117. That there was a deduction of Rs.6218/- made on account of (Equipment Rs.500, warmer Rs.500, admission Rs.1500, safety lancet Rs.441, hand rub Rs.522, glove Rs.1150+312, urometer Rs.520, cover trolley Rs.33 ecg etc. Rs.63, three way Rs.450/-, gloves Rs.77, registration and Rs.150/-) as per terms and conditions of the policy. Hence, now nothing remains due qua OPs and prayed for dismissal the present complaint.

4.                To prove the case, complainant tendered into evidence affidavit Ex.CW1/A alongwith documents Annexure-C1 to Annexure-C25.

5.                On the other hand, OPs tendered into evidence affidavit Ex.RW1/A and documents Annexure R-1 to R-12.

6.                We have heard the learned counsel for the parties and perused the record carefully.

7.                Learned counsel for the complainant has argued that the complainant took a health insurance policy from the OPs. He further argued that wife of complainant got spinal surgery from Fortis Hospital, Mohali and spent total Rs.4,50,284/- and submitted the claim with the OPs, who paid only Rs.4,20,047/- against that amount and prayed that OPs be directed to pay the balance amount along with compensation amount and litigation expenses.

8.                Contrary to it, learned counsel for the OPs has argued that the complainant lodged the claim with the OPs, as such, claim amount of Rs.4,24,047/- has been paid to the complainant on 25.07.2022, vide NEFT No.IN1ON22072504117, after deduction of Rs.6218/- from that. Hence, now nothing remains due qua OPs and prayed for dismissal the present complaint.

9.                From the above pleadings of the parties, we found that now the dispute between the parties is with regard to balance claim amount. The complainant filed the present complaint, against the OPs, before this Commission on 13.07.2022, with a request to get release the total claim amount of Rs.4,50,284/- with compensation and litigation expenses. Contrary to it, the OPs had paid Rs.4,24,047/- to the complainant on 25.07.2022 i.e. after filing the complaint in hand. Moreover, the hospital concerned had sent the pre-authorization request to the OPs, which was denied by the OPs on 07.03.2022 Annexure C-5, due to that the complainant might have suffered huge physical harassment as well as mental agony and left with no other option except to knock the door of this Commission, by way of filing the complaint in hand on 13.07.2022, and when the OPs was in receipt of notice of this complaint, only then the OPs paid Rs.4,24,047/- to the complainant on 25.07.2022, against total amount of Rs.4,50,284/-. The above act and conduct of OPs, amount to gross deficiency in service, on their part. However, in order to support his above contentions, complainant produced medical bills of Rs.4,50,284/- as Annexure C6, C9 (3 pages), C10 (3 pages), C12 (2 pages), C13 (2 pages), C16 (3 pages), C17, C19 (3 pages), C20, C21 (4 pages) and C22 (3 pages), on the case file. Hence, after deducting Rs.6218 (necessary deductions as per policy in question) from Rs.4,50,284/-, the balance comes to Rs.4,44,066/-, which shall be paid, by the OPs, to the complainant. Since it is admitted fact that the OPs had already paid part payment of Rs.4,24,047/-, to the complainant, after deducting the said amount from Rs.4,44,066/-, the balance comes to Rs.20019/- (444066-424047), which shall be paid, by the OPs, along with compensation amount + litigation expenses, to the complainant.

10.              In view of our above discussion, we accept the present complaint and direct the OPs to pay the balance claim amount of Rs.20019/- along with compensation amount of Rs.5,000/- + litigation expenses of Rs.5,000/-, to the complainant. The OPs are further directed to make the compliance of this order, within a period of 45 days, from the date of preparation of certified copy of this order, failing which, the total award amount shall carry interest @6% simple per annum, from the date of filing the present complaint, till its actual realization.

11.              In default of compliance of this order, proceedings shall be initiated under Section 72 of Consumer Protection Act, 2019, as non-compliance of Court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. File be consigned to the records, after due compliance.       

Announced in open Commission:

Dt.:09.05.2024.

                                                                                      (Neelam Kashyap)

                                                                                      President.

 

(Sunil Mohan Trikha).             (Suman Rana).              

Member.                                  Member.

 

 

 

Typed by: Sham Kalra, SSS.