Haryana

Karnal

CC/254/2023

Rajbir - Complainant(s)

Versus

Niva Bupa Health Insurance Company Limited - Opp.Party(s)

Manoj Sachdeva

03 Jun 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No.254 of 2023

                                                        Date of instt.01.05.2023

                                                        Date of Decision:03.06.2024

 

Rajbir aged about 64 years son of Shri Genda Ram, resident of village Biana, District Karnal.

                                                                        …….Complainant.

                                              Versus

 

Niva Bupa Health Insurance Company Ltd. Formerly known as Max Bupa Health Insurance Co. Ltd. office at SCO no.209, 1^st floor, Sector-12, Urban Estate, Karnal through its Manager.

 

                                                                        …..Opposite Party.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Dr.  Suman Singh…..Member

 

 Argued by: Shri Tarun Virmani, counsel for the complainant.

                    OP exparte (vide order dated 17.07.2023)

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant purchased a health insurance policy bearing no.32589805202200, valid from 27.07.2022 to 26.07.2023, for the sum assured of Rs.7.50,000/-. The complainant and his wife are covered in the said policy. On 15.09.2022, the complainant fell ill as he was suffering from heart disease and due to which the complainant had been admitted in Rama Superspecialty Hospital, Karnal and he remained admitted from 15.09.2022 to 17.09.2022. Complainant applied for cashless facility to the OP and the surveyor of the OP also visited and inspected the complainant but at the time of making the payment of hospital charges, OP refused to pay the same. Hence complainant faced so many difficulties and had to arrange funds from others and then only paid the hospital bill of Rs.2,05,500/-. Complainant lodged the claim with the OP for reimbursement of the said amount but OP did not pay the same.  On 19.01.2023, complainant was again admitted in Rama Superspecialty Hospital, Karnal and remained admitted till 21.01.2023 and spent Rs.30,850/-. This time also OP did not pay the hospital charges and complainant paid the same from his own pocket. Complainant again approached the OP and requested to reimburse the abovesaid amount but OP denied to pay the same on the ground that complainant has concealed his old heart disease at the time of issuing the health policy.   

2.             It is further alleged that the complainant was admitted in Amritdhara My Hospital, Karnal from 01.09.2022 to 02.09.2022 and at that time OP paid the hospital charges of Rs.78,242/- . So, this time  the objection of OP for not releasing  the claim is totally illegal and unjustified. There is no concealment on the part of the complainant and after coming to know about the whole disease, the OP issued policy in favour of the complainant and received the premium amount of Rs.57,036/-. Then complainant sent a legal notice dated 13.04.2023 to the OP but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence this complaint.

3.             On notice, OP did not appear despite service and opted to be proceeded against exparte, vide order dated 17.07.2023 of the Commission.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy Ex.C1, copy of Rama Superspecialty Hospital Bills Ex.C2, copy of Amritdhara Hospital Bills Ex.C3, copy of legal notice Ex.C4, postal receipt Ex.C5, envelop of notice Ex.C6 and closed the evidence on 06.10.2023 by suffering separate statement.

5.             We have heard the learned counsel for the complainant and have gone through the record available on the file carefully.

6.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant purchased a health insurance policy from the OP. Complainant was admitted in Rama Superspecialty Hospital, Karnal twice and spent an amount of Rs.2,36,350/- on his treatment. The cashless request of complainant was denied by the OP. Complainant submitted his claim with the OP for reimbursement of the said amount and also completed all the required formalities but OPs did not pay the claim amount and denied to pay the same on the ground that complainant has concealed his old heart disease at the time of issuing the health insurance policy whereas complainant has no disease at the time of obtaining the policy and lastly prayed for allowing the complaint.

7.             The onus to prove his version was relied upon the complainant. To prove his version, complainant has placed on file his affidavit Ex.CW1/A, copy of insurance policy Ex.C1, copy of Rama Superspecialty Hospital Bills Ex.C2, copy of Amritdhara Hospital Bills Ex.C3, copy of legal notice Ex.C4, postal receipt Ex.C5, envelop of notice Ex.C6. To rebut the said evidence produced by the complainant, OP did not appear despite service and opted to be proceeded against exparte. Thus, the evidence produced by the complainant is unchallenged and unrebutted and there is no reason to disbelieve the same. Hence, the act of the OP while denying the claim of complainant amounts to deficiency in service and unfair trade practice.

8.               Complainant has claimed Rs.2,57,760/- but he has submitted the medical bills only for Rs.2,27,000/- Ex.C2. Hence, the complainant is entitled for the amount of Rs.2,27,000/- alongwith interest, compensation for harassment, mental pain and agony and towards the litigation expenses.

9.             Thus, as a sequel to abovesaid discussion, we partly allow the present complaint and direct the OP to pay Rs.2,27,000/-( Two lakhs twenty seven thousand only) to the complainant alongwith interest @ 9% per annum from the date of denial of the claim till its realization. We further direct the OP to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced
Dated: 03.06.2024 

  President,       

District Consumer Disputes

Redressal Commission, Karnal.

 

                  (Vineet Kaushik)              (Dr. Suman Singh)

                        Member                             Membe