Haryana

Karnal

CC/673/2023

Tarsem Kumar - Complainant(s)

Versus

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

Jitender Barchinerl

04 Dec 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.673 of 2023

                                                        Date of instt 01.12.2023

                                                        Date of Decision: 04.12.2024

 

Tarsem Kumar, aged 39 years, son of Shri Jai Bhagwan, resident of house no.917, Banso Gate Dayal Pura, Karnal. Aadhar no.2747 7144 0957.

 

                                                                        …….Complainant.

                                              Versus

 

1.  Niva Bupa Health Insurance Company Limited, (formerly known as Max Bupa Health Insurance Company Limited through its Branch/Divisional Manager, 1^st floor C-98, Lajpat Nagar, Delhi: 110 024.
2. Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Company Limited through its Branch/Divisional Manager, near Deepanshu Chapwala, Urban Estate, Sector-12, Karnal.

…..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

      Ms. Sarvjeet Kaur…..Member

 

Argued by:  Shri Jitender Barchipal, counsel for the complainant.

                    OP No.1 exparte, vide order 21.05.2024.

                    OP no.2 exparte, vide order dated 18.03.2024.

                   

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant had purchased a health insurance policy i.e. Health Suraksha Policy (Silver Plan) bearing no.2952201525609900000, valid from 15.10.2016 to 14.10.2022 and approximately paid Rs.60,000/- as premium regularly. Previously the said policy was purchased from HDFC Ergo General Insurance Company, lateron the said policy was got ported with the OPs as per the Portability guidelines and the policy was effected from 15.10.2022 to 14.12.2023. The sum assured under the policy was Rs.10,00,000/-  and a sum of Rs.24,788/- was paid as premium to the OPs regarding the said policy and the policy product name was re-assure and the policy name is 3277313920200. The policy is family pakage policy including the complainant, wife Mrs. Monika Rani, son Mr. Vansh and daughter Ms. Vanshika covered under the said policy. At the time of purchasing the policy, the complainant was asked to sign various blank and printed papers by the agent of the OPs. However, no terms and conditions were explained to the complainant by the agent of the OPs at the time of signing the abovesaid papers. Prior to obtaining the said policy, the wife of the complainant had got not any type of disease or ailment. On 01.12.2023, the wife of complainant suffered fever and she went to the Amritdhara Hospital, Karnal for examination and after necessary lab test the hospital diagnosed that AFI Viral, age with dehydration thrombocytopenia, where she was admitted and treated and a sum of Rs.34026/- was spent by the complainant and a sum of Rs.30,000/- was passed by the OPs, thereafter the doctor advised the wife of complainant to consult with Nephrologists Specialist and then the complainant booked the appointment at Medanta Hospital Gurgaon In Nephrologists Department, where she was admitted and diagnosed the chronic kidney diseases, for which she remained admitted there from 27.02.2023 to 01.03.2023 for treatment and the doctors advised her for complete bed rest. After discharge from the hospital, Mrs. Monika wife of the complainant again visited the hospital as an OPD patient. A sum of total Rs.1,03,532/- was spent on the necessary test, investigation, treatment and medicine etc. as the authorization request was rejected by the OPs, vide cashless claim no.599118 dated 01.03.2023. The complainant informed the OPs in this regard and submitted all the original bills alongwith claim form as per directions of the officials of the OPs. the officials of the OPs assured the complainant that the mediclaim amount will be paid as early as possible but OPs did not pay any claim and lastly repudiated the claim of complainant, vide letter dated 18.04.2023 on the false and frivolous ground and also cancelled the policy of complainant and forfeited the premium amount illegally. Due to this act and conduct of OPs, complainant has suffered mental pain, agony and harassment as well as financial loss. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence complainant filed the present complaint seeking direction to the OPs to pay Rs.1,03,532/- alongwith interest @ 24% per annum from the date of treatment till its realization, to revalidate the policy of complainant, to pay Rs.1,00,000/- as damages on account of mental pain, agony as well as harassment and to pay Rs.25,000/- as litigation expenses.

2.             On notice, OPs no.1 and 2 did not appear despite service and opted to be proceeded against exparte, vide order dated 18.03.2024 and 21.05.2024 respectively of the Commission.

3.             Learned counsel for the complainant has tendered into evidence affidavit of Tarsem Kumar Ex.CW1/A, copy of insurance policy of HDFC Ergo Ex.C1, copy of insurance policy of Niva Bupa Health Insurance Ex.C2, copy of forwarded letter from hospital Ex.C3, copy of medical bill Ex.C4, copy of discharge summary Ex.C5, copy of cashless authorization letters dated 19.02.2023 Ex.C6 and Ex.C7, cop of tax invoice/bill of supply Ex.C8, copy of payment receipt Ex.C9, copy of doctor’s certificate dated 17.03.2023 Ex.C10, copy of cashless denial letter Ex.C11, copy of notice of cancellation of policy Ex.C12 and closed the evidence on 17.09.2024 by suffering separate statement.

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

5.             Learned counsel for the complainant, while reiterating the contents of complaint, has vehemently argued that of complainant purchased a Health Insurance Policy from the OPs for the sum insured of Rs.10,00,000/- under the portability scheme. In the said policy complainant, his wife and dependent children were covered. During the subsistence of the policy, wife of complainant has taken the treatment from Amritdhara Hospital, Karnal and spent an amount of Rs.34026/- but OPs paid only Rs.30,000/-. Thereafter, the wife of complainant had taken treatment from Medanta Hospital, Gurgaon and spent an amount of Rs.1,03,532/-.  Complainant lodged a claim with the OPs for reimbursement of the said amount and submitted all the required documents to settle the claim, but OPs did not pay the claim amount and repudiated the claim of complainant on the false and frivolous ground and also cancelled the policy of complainant on the false and frivolous ground and lastly prayed for allowing the complaint.

 6.            The onus to prove his case was relied upon the complainant. To prove his case, complainant has placed on file copy of insurance policy of HDFC Ergo Ex.C1, copy of insurance policy of Niva Bupa Health Insurance Ex.C2, copy of forwarded letter from hospital Ex.C3, copy of medical bill Ex.C4, copy of discharge summary Ex.C5, copy of cashless authorization letters dated 19.02.2023 Ex.C6 and Ex.C7, cop of tax invoice/bill of supply Ex.C8, copy of payment receipt Ex.C9, copy of doctor’s certificate dated 17.03.2023 Ex.C10, copy of cashless denial letter Ex.C11, copy of notice of cancellation of policy Ex.C12. It has been proved from the abovesaid documents earlier complainant purchased the health insurance policy from HDFC Ergo General Insurance Company from 15.10.2016 to 14.10.2022 and thereafter ported the same in the OPs company from 15.10.2022. The wife of complainant has taken the treatment during the subsistence of the insurance policy.  Moreover, to rebut the evidence produced by  the complainant, OPs despite service did not appear and opted to be proceeded exparte. Hence, the evidence produced by the complainant goes unchallenged and unrebutted and there is no reason to disbelieve the same. Thus, the act of the while denial of the claim and cancellation of the insurance policy of the complainant amounts to deficiency in service and unfair trade practice.

7.             The complainant has spent an amount of Rs.1,03,532/- on the treatment of his wife and in this regard he has placed on file Tax invoice Ex.C8 and payment receipt Ex.C9 issued by Medanta Hospital, Gurgaon. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental pain, agony and harassment and litigation expenses etc.

8.             Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.1,03,532/- (Rs. one lakhs three thousand five hundred thirty two only) alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization to the complainant. We further direct the OPs to regularize the policy in question on receipt of pending premium amount from the complainant from the date of its cancellation. We further direct the OPs to pay Rs.25,000/- 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.

Dated:04.12.2024

         President,

      District Consumer Disputes                            

      Redressal Commission, Karnal.

 

                                 (Sarvjeet Kaur)

                                     Member