Haryana

Kurukshetra

CC/291/2023

Vikas Sharma S/o Ganesh Chand - Complainant(s)

Versus

Niva Bupa Healrh Insurance Company - Opp.Party(s)

Himanshu Aggarwal

14 Aug 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISISON, KURUKSHETRA

 

Complaint No. 291 of 2023

Date of institution: 11.09.2023

                                      Date of decision: -14.08.2024

 

Vikas Sharma son of Shri Ganesh Chand Sharma resident of H. No.846/12, Azad Nagar Thanesar, Tehsil Thanesa, District Kurukshetra.                                                                                                                                                                                                                          …Complainant.

Versus

 

1.     Niva Bupa Health Insurance Company Limited (Formerly known as Max Bupa Health Insurance Company Limited) registered office: C-98, Lajpat Nagar 1, New Delhi-110024 (IRDAI Registration No.145) through its Managing Director.

2.     HDFC Bank Opposite Sector-5, Kurukshetra to Pipli Road Kurukshetra through its Branch Manager.

 

…Opposite parties

 

•  

NEELAM, MEMBER.

RAMESH KUMAR, MEMBER.

 

•  

Shri Karan Tanwar, Advocate for the OP No.1.

OP No.2 given up.

           

• :     

                This is a complaint under Section 35 of the Consumer Protection Act, 2019.

2.             Briefly stated, it is the case of the complainant that being allured by the OP No.1, complainant purchased Family Flotter Plan Health Medical Insurance Policy No.31595927202100 dt. 5.05.2021 from the OP No.1 and paid premium of the same for two years.  The complainant further averred that on 02.12.2022,  complainant visited the Sohana Hospital, Mohali for his treatment, where he was diagnosed of Chicken Pox, but due to non-availability of bed in ICU, he was referred to higher centre hospital.  In the testing of complainant, they charged Rs.10,000/- in cash from him and Sohana Hospital, Mohali intimated to OP No.1 in this regard.  Complainant admitted in the said hospital for his treatment where re rained admitted till 06.12.2022.  The said hospital intimated the OP No.1 regarding the treatment of him, but, OPs have illegally have rejected the cashless claim of complainant vide cashless claim NO.558030 dt. 06.12.2022 regarding spent on treatment of Rs.68,581/-.  The complainant sent legal notice dt. 31.03.2023, in reply to which the OPs demanded again all documents regarding the claim, and therefore, as per the Op No.1’s demand, the complainant sent all the requisite documents to the OP No.1, however, they did not pay any heed to the complainant.

3.             On notice, opposite party No.1 appeared and filed its written version while taking the preliminary objections with respect to the cause of action, jurisdiction, false and frivolus contended specifically by pleading  inter-alia that the patient/complainant Vikas Sharma was admitted primarily for diagnostic and evaluation purpose as there was no effective line of treatment and was admitted for medical management.  Therefore, we regret we are unable to extend cashless facility to this request under applicable policy clause.  It is crystal clear from the pre-auth form that the hospitalization was solely for evaluation, investigation and observation purpose only.

4.             Learned counsel for the complainant has tendered into evidence affidavit Ex.CW1/A and documents Ex.C-1 to Ex.C-64 and closed the evidence on 01.02.2024 by suffering separate statement.

5.             Learned counsel for the opposite party No.1 has tendered into evidence affidavit Ex.RW1/A and documents Ex.R-1 to Ex.R-6 and closed the evidence on 22.05.2024 by suffering separate statement.  OP No.2 had given up by the counsel for the complainant vide order dated 01.02.2024.

6.             We have heard the learned counsel for both the parties at length and have gone through the record available on the file carefully.

7.             Shri Himanshu Aggarwal, counsel for the complainant has argued that complainant purchased Family Flotter Plan Health Medical Insurance Policy No.31595927202100 dt. 5.05.2021 from the OP No.1 and paid premium of the same for two years.  The counsel for the complainant further argued that on 02.12.2022,  complainant visited the Sohana Hospital, Mohali for his treatment, where he was diagnosed of Chicken Pox, but due to non-availability of bed in ICU, he was referred to higher centre hospital.  In the testing of complainant, they charged Rs.10,000/- in cash from him and Sohana Hospital, Mohali intimated to OP No.1 in this regard.  Complainant admitted in the said hospital for his treatment where re rained admitted till 06.12.2022.  The said hospital intimated the OP No.1 regarding the treatment of him, but, OPs have illegally have rejected the cashless claim of complainant vide cashless claim NO.558030 dt. 06.12.2022 regarding spent on treatment of Rs.68,581/-. 

8.             Shri Karan Tanwar, Advocate for the OP No.1 has argued that complainant has not given the relevant documents which were acquisitioned by the OP for the final settlement of claim. 

9.             Rebutting his arguments, counsel for the complainant has argued that already all the documents mentioned in para No.4 of Ex. C-63 given to the OP company, but merely to harass the complainant again the documents are demanded by the OP Insurance Company. 

10.           Required documents are mentioned in Ex. C-63 in para No.4. At this stage,  counsel for the complainant has agreeable to provide again the copy of documents mentioned in Ex. C-63 within 10 days from today. 

11.           Hence, OP No.1 is directed to reimburse the medical expenses incurred by the complainant, as per the terms and conditions of Insurance Company issued by the OP No.1 within 45 days from today.

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 record room after due compliance.     

        Announced in open Commission:

        Dated: 14.08.2024

                                                                (Dr. Neelima Shangla)            

                                                                 President,

                                                                 DCDRC, Kurukshetra.

 

        (Neelam)                (Ramesh Kumar)

        Member.                 Member.