Chandigarh

DF-I

CC/587/2023

SATINDER SINGH - Complainant(s)

Versus

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

DEVINDER KUMAR

01 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/587/2023
Date of Institution	:	18.12.2023
Date of Decision	:	01/07/2024

 

Satinder Singh son of Late Sh. Ram, aged 47 years, resident of H.No. 139, GH-28, Mansa Devi Complex, Sector 5, Panchkula.

Complainant

 

VERSUS

 

 

1. NivaBupa Health Insurance Company Limited, SCO No. 84-85, Sector Floor, Sector 8-C, Madhya Marg, Chandigarh through its Branch Manager.

2. NivaBupa Health Insurance Company Limited, 1st Floor, EagleFlight, Western Expressway, Near WEH Metro Station Andheri Kurla Road, Adnheri East, Mumbai- 400093 through Managing Director.

Opposite Parties

3.       Raffels Hospital, Sector 14, Panchkula through its Managing Director/Proprietor/Authorized Signatory.

Proforma Opposite Party

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Devinder Kumar, Advocate for complainant
	:	Sh.Gaurav Bhardwaj, Advocate for OPs No.1&2.
	:	Sh. Mohit Shukla, Advocate for OP No.3

 

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 OPs). The brief facts of the case are as under :-

1. It transpires from the averments as projected in the consumer complaint that in the year 2020 the agent of OPs No.1&2 approached the complainant and explained the features of health insurance policy  and on the assurances of the said agent, the complainant agreed to purchase the health policy for himself and his family members. Accordingly, the complainant obtained the health insurance policy from the OPs No.1&2 covering the complainant his wife Raj Rani, daughter RitikaMaurya and son AnoopMaurya and got the same renewed continuously by paying requisite premiums. In the year 2023, the complainant under the directions  of the OP No.1 and 2 paid a sum of ₹33,174 and the Ops No.1&2 issued two health insurance policies bearing No.31133960202303  and 33096643202300  valid from 18.3.2023 to 17.3.2024. Under the first policy  Annexure C-1 (hereinafter to be referred as subject policy) the complainant and his wife and daughter were covered whereas  under the second policy Annexure C-2 the complainant and his son AnoopMaurya were covered. From the date of inception of policy  in the year 2020 till  February 2023  the complainant did not raise any claim  with the OPs No.1&2. On 10.1.2023  when the son of the complainant namely AnoopMaurya while playing suffered pain in right arm therefore, the complainant visited the OP No.3 hospital (hereinafter referred to be as treating hospital) for check up and on the directions of the doctors of the hospital X-ray was conducted and the doctor diagnosed the problem to be comminuted fracture right Hummerus shaft and advised operation.  The copy of medical slip is annexed as Annexure C-3. The son of the complainant was admitted in the treating hospital on 10.1.2023 and was operated upon on11.1.2023  by the treating doctor of OP No.3 and discharged on 12.1.2023. The treating hospital raised bill of ₹95,000/- for payment and informed the complainant that the claim will be submitted to Ops No1&2 directly and the same will be released to him. The copy of discharge summary is annexed as Annexure C-4. In addition to the amount of ₹95,000/-, the complainant also paid an amount of ₹2927/-  on pre and post hospitalization and paid a total sum of ₹97,927/- to the treating hospital for the treatment of his son and the copies of bills and payment receipts are annexed as Annexure C-5 to C-14. Later on the hospital had submitted the claim of ₹97,927/- alongwith documents with the Ops No.1&2 and it was assured by the Ops No.1&2 that the claim will be processed and released shortly. However, instead of releasing the genuine claim of the complainant, the OPs No.1&2  through their website/app intimated that the claim of the complainant has been rejected as per clause 7.2 XII-C on the ground that the supporting documents have not been submitted by the complainant and the copy of website/app details is annexed as Annexure C-15.   Thereafter the complainant approached OP No.3  and asked about the documents  and the complainant was informed by the OP No.3 hospital that the requisite documents have already been submitted with OPs No.1&2 and on the persistent requests of the complainant, the OP No.3 had again provided X-ray film for submission of the same to the insurance company and accordingly he submitted the same with OPs No.1&2 vide letter dated 18.8.2023 and sent the same through DTDC  courier and the copy of letter is Annexure C-16 and dispatch proof is Annexure C-17.  However, despite of the fact that the complainant submitted all the requisite documents, Ops No.1&2 repudiated the genuine claim of the complainant. The aforesaid act amounts to deficiency in service and unfair trade practice on the part of OPs No.1&2. OPs No.1&2 were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs No.1&2 resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action, jurisdiction and concealment of facts and also that the complainant has not complied with the terms and conditions of the subject policy. On merit it is admitted that the subject policy Annexure R-2 was issued by the answering OP to the complainant. The complainant has obtained variant 2 individual insurance policy and variant 2 family floater policy which were valid from 18.3.2023  to 17.3.2024. It is further admitted that the answering OPs received the claim from the complainant for reimbursement of expenses incurred by the complainantduring  AnoopMaurya’s hospitalization at the OP -3 hospital from 10.1.2023 to 12.1.2023. The discharge summary and other claim documents are annexed as Annexure R/4(colly). It is further alleged that in fact as the complainant had not submitted the requisite documents  despite of repeated reminders, hence, the claim of the complainant was rejected as per clause 7.2-XIII-C. The denial letter is annexed as Annexure R-5.  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. OP No.3 resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, misjoinder of party, cause of action, locus standi. On merits, admitted that  the son of the complainant was admitted in the hospital  on 10.1.2023  and operation was conducted on 11.1.2023 and was discharged on 12.1.2023 and the complainant was asked to pay ₹95,000/- and later on the answering OP had submitted the claim for reimbursement to the tune of ₹97,927/-alongwith requisite documents with Ops No.1&2. It is alleged that the answering OP has submitted X-ray films and all the requisite documents to the complainant as required by him. 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
4. In replication, 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.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the son of the complainant AnoopMaurya was covered under the subject policy Annexure C-2  which was valid  w.e.f. 18.3.2023 to 17.3.2024 and the son of the complainant AnoopMauryainsured suffered pain while he was playing and thereafter he was brought to treating hospital OP No.3 where he was diagnosed with comminuted fracture right Hummerus shaft and surgery was advised by the treating doctor and accordingly he was admitted in the hospital of OP No.3 on 10.1.2023 and surgery was conducted on 11.1.2023 and he was discharged on 12.1.2023  as is also evident from discharge summary Annexure C-4and thereafter the treating hospital OP No.3 submitted the claim of the complainant  with Ops No.1&2 but the claim of the complainant  was repudiated by the Ops No.1&2 vide  repudiation letter Annexure C-18/R-4  on the ground  that requisite documents have not been  submitted by the complainant or by the treating hospital,   the case is reduced to a narrow compass as it is to be determined if  the Ops No.1&2 are unjustified in repudiating the claim of the complainant and the complainant is entitled for relief as prayed for as is the case of the complainant or if the Ops No.1&2 had rightly repudiated the claim of the complainant and the complaint of the complainant is liable to be dismissed  as is the defence of the OPs.
   2. In order to prove his case, the complainant proved on record the letter dated 18.8.2023 Annexure C-16 which clearly indicates that the complainant had addressed the said letter to OP No1 and intimated that  though the requisite documents have already been submitted with the Ops No.1&2 by the hospital  but the complainant had again sent the pre and post X-ray films with the said letter as is also evident from dispatch proof issued by the DTDC Annexure C-17but, the OPs No.1&2 had repudiated the claim of the complainant vide Exhibit R-4 dated 14.1.2024, intimating the complainant that the claim has been rejected as the requisite documents have not been submitted by the complainant.  However the defence of the Ops No.1&2  stands falsified from the written reply filed by the treating hospital OP No.3  as in its written version the treating hospital OP No.3 categorically alleged that all the requisite documents alongwith claim form weresubmitted by it to the OPs No.1&2 for processing the claim.Moreover, the OPs No.1&2 havenot led any evidence to rebut the allegations of OP No.3 as well as to the letter Annexure C-16 & DTDC receipt Annexure C-17 vide which the complainant had again submitted the requisite documents to OPs No.1&2, making it clear that the  treating hospital has submitted all the requisite documents with Ops No.1&2 and despite of that the OPs No.1&2 repudiated the claim of the complainant on flimsy ground and the aforesaid act of OPs No.1&2 amounts to deficiency in service and unfair trade practice on their 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 OPs. Hence, the instant consumer complaint deserves to be allowed.
   3. So far as the claim amount is concerned, as the complainant has already proved on record medical bills/receipts Annexure C-5 to C-14 indicating that the complainant has spent an amount of ₹₹97,927/- which fact has also been affirmed by OP No.3 the treating hospital, it is safe to hold that the complainant is entitled for ₹97,927/- .

 

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPsNo.1&2 are directed as under :-

 

1. to pay ₹₹97,927/- to the complainant alongwith interest @ 9% per annum (simple) from the date of repudiation i.e. 14.1.2024 till onwards.
2. to pay an amount of ₹10,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/- to the complainant/s as costs of litigation.

 

5. This order be complied with by the OPs No.1&2 jointly and severally 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. Complaint qua OP No.3 stands dismissed.
7. Pending miscellaneous application(s), if any, also stands disposed off.
8. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 01/07/2024 mp			Sd/- [Pawanjit Singh] President
			Sd/-
			[Surjeet Kaur] Member