DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/43/2024
Date of Institution: 18.04.2024
Date of Decision: 05.12.2024
Gagandeep Sharma son of Sh. Harbans Lal Sharma resident of House No. B-1/662, Prem Nagar, Dhanaula Road, Barnala, Tehsil and District Barnala.
…Complainant
Versus
1. Niva Bupa Health Insurance Company Ltd., Unit No. 3, Plot No. 88, 2nd Floor, Kunal Tower, Mall Road, Opposite Axis Bank Ludhiana, Punjab-141001 through its Authorized Signatory.
2. Niva Bupa Health Insurance Company Ltd., Claims Department Logix Infotec Park, D-5, 2nd Floor, Sector 59, Near Sector 59 Metro Station, Noida-201301 through its Authorized Signatory.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Chamkaur Singh Adv counsel for complainant.
Sh. Dhiraj Kumar Adv counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Smt. Urmila Kumari: Member
3. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Niva Bupa Health Insurance Company Ltd., Unit No. 3, Plot No. 88, 2nd Floor, Kunal Tower, Mall Road, Opposite Axis Bank Ludhiana, Punjab-141001 through its Authorized Signatory & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant and his wife Devinder Sharma were insured with the opposite parties by way of Family Floater policy of Rs.5 lac vide policy No. 31354430202101 for the period from 14.09.2021 to 13.09.2022 which was later on renewed for the period from 14.09.2022 to 13.09.2023 for which the complainant paid insurance premium of Rs.17,289/- with the Ops and the premium was paid at Barnala through cheque No.000017 dated 10.10.2022 for a sum of Rs.17,289/- of Punjab & Sind Bank Branch Barnala Baba Ganda Singh School, Branch Dhanaula Chowk Barnala in favour of the Ops. It is further alleged that the complainant fell ill and he was admitted to Hearts Sanjivani Centre's Nectar The Cancer Institute on 06.04.2023 with the diagnosis of Coronary Artery Disease, Triple Vessel Disease and the doctor conducted various tests and the complainant was treated in the said hospital and he remained admitted in the said hospital and remained under treatment from where he was discharged on 09.05.2023. It is further alleged that the total expenditure on the treatment was Rs. 1,40,000/- for which the complainant could retain bills and intimation of the claim was given to the Ops, but later on the complainant received an email dated 22.06.2023 from the Ops to provide some additional information vide Claim ID 1360089 and again on 29.06.2023 for which the complainant being not known about the claim process and as such, the complainant replied to said email and thereafter as per the requirement of the Ops send all the requisite documents to the Ops on dated 03.07.2023 through DTDC Courier service vide Consignment No. T19434790. It is further alleged that after few days when the complainant did not receive any communication regarding the payment of the claim the complainant made enquiries from the Ops and the complainant was shocked to receive an email from the Ops stating that the claim of the complainant has not been approved due to the reason that "1.EECP is an OPD procedure (OPD treatment is not covered as per the policy, so claim not payable under Clause 6.30)." It is submitted here that neither the complainant had made any discrepancy in submitting the document nor has violated any provisions of insurance policy. It is further alleged that the complainant again contacted the Ops and requested the Ops to redress his grievance by releasing the amount of claim of the complainant but the Ops flatly refused to redress the grievance of the complainant. As such, the act and conduct of the opposite parties comes within the definition of the unfair trade practice as well as deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to pay the claim of complainant amounting to Rs. 1,40,000/- alongwith interest @ 12% from the date of filing the claim till realization.
- To pay Rs. 50,000/- as compensation towards mental tension and harassment and pay Rs. 11,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking preliminary objections on the grounds that the present petition is false, incorrect, malafide, the same has been filed before this Commission to waste the precious time of this Commission. The complainant has not approached this Commission with clean hands and has filed the present complaint while providing distorted, untruthful and intentional incorrect facts. It is most humbly submitted that the instant complaint lacks a cause of action and the complaint is based on mere surmises and conjectures. It is an established principle of law that the machinery of law cannot be invoked on the basis of mere conjectures. Therefore, this complaint is liable to be dismissed on want of the cause of action etc.
4. On merits, it is admitted in regard to the issuance of A Family Floater Reassure insurance policy bearing No. 31354430202100 for the duration from 14.09.2021 to 13.09.2022 for the basic sum insured of INR.5,00,000/- and policy being renewed No. 31354430202101 commencing from 14.09.2022 to 13.09.2023. It is further admitted that the complainant was admitted at Necter Cancer Institute, Bhava nagar, Mumbai Naka, Nashik, from 06.04.2023 to 09.05.2023 and was diagnosed with Coronary Artery Disease - triple vessel and had filed claim request bearing No. 1360089 for reimbursement of expenses incurred during the duration of hospitalization and post discharge the complainant had filed a claim reimbursement request for the total amount. But upon scrutinizing and investigation of the claim documents by the Opposite Parties, as per submitted documents, patient was admitted for EECP, which is an OPD procedure and the OPD treatment is not covered as per the policy terms and conditions. It is submitted that the claim was repudiated as per the terms and conditions of the policy. It is submitted that post discharge of the complainant a claim request bearing No. 1449339 for reimbursement of expenses incurred was received, and post receipt of the claim documents, investigation of the claim was done by the Opposite Parties to ascertain the authenticity of the claim, post scrutiny it was found that as per submitted documents, patient was admitted for EECP, which is an OPD procedure and the OPD treatment is not covered as per the policy terms and conditions, so claim not payable under clause 6.30 of the policy's terms and conditions. It is submitted that the opposite parties are not liable to pay any amount, hence the claim has been repudiated rightly. All other allegations are denied and prayed for the dismissal of complaint.
5. Ld. Counsel for the complainant has suffered the statement on 25.9.2024 that I do not want to file any rejoinder to the version of opposite parties.
6. The complainant tendered into evidence affidavit of complainant as Ex.C-1, copy of discharge certificate as Ex.C-2, copy of treatment chart as Ex.C-3 (8 pages), copy of patient data as Ex.C-4 (6pages), copy of prescription report as Ex.C-5, copy of examination of blood as Ex.C-6 (2 pages), and Ex.C-7 (15 pages), copy of receipt of claim as Ex.C-8, copies of emails as Ex.C-9 to Ex.C-11, copy of courier consignment as Ex.C-12, copy of email of non approval of claim as Ex.C-13, copy of bills as Ex.C-14 to Ex.C19, copy of policy Schedule as ExC-20 and closed the evidence.
7. Ld. Counsel for the opposite parties has suffered the statement on 5.12.2024 that I close the evidence on behalf of opposite parties.
8. We have heard the learned counsel for the parties and have gone through the record on the file.
9. It is admitted case of the opposite parties in regard to the issuance of A Family Floater Reassure insurance policy bearing No. 31354430202100 for the duration from 14.09.2021 to 13.09.2022 for the basic sum insured of INR.5,00,000/- and policy being renewed No. 31354430202101 commencing from 14.09.2022 to 13.09.2023. It is further admitted case of the opposite parties that the complainant was admitted at Necter Cancer Institute, Bhava nagar, Mumbai Naka, Nashik, from 06.04.2023 to 09.05.2023 and was diagnosed with Coronary Artery Disease - triple vessel and had filed claim request bearing No. 1360089 for reimbursement of expenses incurred during the duration of hospitalization and post discharge the complainant had filed a claim reimbursement request for the total amount.
10. Ld. Counsel for the complainant argued that the complainant fell ill and he was admitted to Hearts Sanjivani Centre's Nectar The Cancer Institute on 06.04.2023 with the diagnosis of Coronary Artery Disease, Triple Vessel Disease and the doctor conducted various tests and the complainant was treated in the said hospital and he remained admitted in the said hospital and remained under treatment from where he was discharged on 09.05.2023 (as per Ex.C-2). It is further argued that the total expenditure on the treatment was Rs. 1,40,000/- (as per Ex.C-14) for which the complainant could retain bills and intimation of the claim was given to the opposite parties, but later on the complainant received an email dated 22.06.2023 from the opposite parties to provide some additional information vide Claim ID 1360089 and again on 29.06.2023 (as per Ex.C-9) for which the complainant being not known about the claim process and as such, the complainant replied to said email and thereafter as per the requirement of the opposite parties sent all the requisite documents to the opposite parties on 03.07.2023 through DTDC Courier service vide Consignment No. T19434790 (as per Ex.C-12). It is further argued that after few days when the complainant did not receive any communication regarding the payment of the claim the complainant made enquiries from the opposite parties and the complainant was shocked to receive an email from the opposite parties stating that the claim of the complainant has not been approved due to the reason that "EECP is an OPD procedure (OPD treatment is not covered as per the policy, so claim not payable under Clause 6.30)". It is further argued that the complainant again contacted the opposite parties and requested them to redress his grievance by releasing the amount of claim of the complainant but the opposite parties flatly refused to redress the grievance of the complainant.
11. On the other hand, Ld. Counsel for the opposite parties argued that upon scrutinizing and investigation of the claim documents by the opposite parties as per submitted documents the patient was admitted for EECP which is an OPD procedure and the OPD treatment is not covered, so claim not payable under clause 6.30 of the policy's terms and conditions. It is further argued that the claim was repudiated as per the terms and conditions of the policy. It is further argued that the opposite parties are not liable to pay any amount, hence the claim has been repudiated rightly.
12. We have gone through the facts and evidence produced by the complainant. From the perusal of discharge summary i.e. Ex.C-2 it is established that on 6.4.2023 the complainant was admitted to Hearts Sanjivani Centre's Nectar The Cancer Institute with the diagnosis of Coronary Artery Disease = Triple Vessel Disease and the complainant remained admitted in the said hospital and was discharged on 09.05.2023 and the total expenditure on the treatment was Rs. 1,40,000/- (as per Ex.C-14) for which the complainant could retain bills and intimation of the claim was given to the opposite parties. Ld. Counsel for the complainant further argued that the complainant was shocked to receive an email i.e. Ex.C-13 from the opposite parties stating that the claim of the complainant has not been approved due to the reason that "EECP is an OPD procedure (OPD treatment is not covered as per the policy, so claim not payable under Clause 6.30)". Ld. Counsel for the complainant further argued that the claim of the complainant has been repudiated by the opposite parties on unreasonable and unjustified grounds. On the other hand, the opposite parties have failed to produce on record any evidence to prove the fact that EECP which is an OPD procedure and the OPD treatment is not covered, so claim not payable under clause 6.30 of the policy's terms and conditions. The opposite parties have taken specific ground for repudiation that EECP an OPD procedure and OPD is not covered as per policy. The complainant has produced the discharge certificate Ex.C-2 vide which it established that the complainant remained admitted in the said hospital from 6.4.2023 to 9.5.2023. The opposite parties failed to produce any evidence to support their version. So, we are of the view that the evidence produced by the complainant in support of his case is un-rebutted. Therefore, it is established that the opposite parties have repudiated the claim of the complainant on such flimsy grounds. Ld. Counsel for the complainant also relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims.
13. From the above discussion, it is proved that the claim of the insured/complainant was repudiated by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties.
14. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 1,40,000/- (as per Ex.C-14) alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties are further directed to pay Rs. 10,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainants. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
5th Day of December, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
(Navdeep Kumar Garg)
Member
