Chandigarh

DF-I

CC/943/2022

VARINDER JINDAL - Complainant(s)

Versus

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

VISHAL MADAAN

20 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/943/2022
Date of Institution	:	24/11/2022
Date of Decision	:	20/10/2023

 

1. Varinder Jindal, Age 56 years, S/o Sh.Om Parkash Jindal
2. Raghav Jindal, Age 29 years, S/o Sh.Varinder Jindal
3. Vrinda Jindal, Age 25 years, D/o Sh.Varinder Jindal

     All resident of # C-802, Royal Mension, Peer Muchalla Road, Dhakoli, Zirakpur, Mohali.

… Complainants

V E R S U S

1. Niva Bupa Health Insurance Co. Ltd. formerly known as Max Bupa Health Insurance Co. Ltd., through its Manager, SCO No.55-56-57, Second Floor, Sector-8C, Madhya Marg, Chandigarh.
2. Niva Bupa Health Insurance Co. Ltd. formerly known as Max Bupa Health Insurance Co. Ltd., through its Managing Director/Director/General Manger 14^th Floor, Capital cyberscape, Golf Course Extension Road, Sector 59, Gurugram, Haryana-122011.
3. Alchemist Hospital through its Director/MD Registered Office: Sector 21, Panchkula.

… Opposite Parties

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR	MEMBER
	SURESH KUMAR SARDANA	MEMBER

 

                                                

ARGUED BY	:	Sh.Varinder Jindal, Complainant No.1 in person, being father of complainant No.2 & 3.
	:	Sh.Gaurav Bhardwaj, Advocate for OP No.1 & 2.
	:	Sh.T.S.Khaira, Advocate for OP No.3 (OP No.3 already ex-parte).

Per Suresh Kumar Sardana, Member

1.     Averments are that Smt. Czarina Jindal (diseased) wife of complainant No.1 purchased a health insurance policy in the year 2015 from the OP No.1 & 2 for the period 9.1.2015 to 8.1.2016. The said policy was renewed every year since its purchase by paying the requisite premium of policy. During the month of June 2021 Smt. Czarina Jindal wife of complainant No.1 and mother of complainant No.2 & 3 suffered from the problem of meningiomas (brain tumour) again for which she got treatment from Alchemist Hospital i.e., OP No.3 and also from Fortis Hospital, Mohali for one time. Meanwhile OP No.3 got three security cheques from complainant No.3 till settlement of insurance claims by OP No.1 & 2. But OP No.1 & 2 repudiated the claim dated 7.10.2022 & 22.10.2022 towards bills totaling of Rs.11,09,547/- on the grounds for non-disclosure of disease (Annexure C-7 & C-8). It is further stated that Smt.Czarina Jindal filed a consumer complaint No.CC/440/2016 before the District Consumer Forum-I, U.t., Chandigarh and the same was allowed vide order dated 3.1.2017 (Annexure C-2). Thereafter a legal notice dated 31.10.2022 was served upon complainants by the OP No.3 as three cheques mentioned aforesaid given as security were dishonoured (Annexure C-11). Unfortunately, Smt. Czarina Jindal expired on 20.10.2022. It is crystal clear that the OP No.1 & 2 are negligent and deficient in their service and liable for unfair trade practice by failure to pass treatment expenses of Smt. Czarina Jindal. Hence, is the present consumer complaint.
2.     OP No.1 & 2 contested the consumer complaint, filed their written reply and stated that the policyholder was admitted at Alchemist Hospital for the duration from 3.5.2022 to 23.05.2022 wherein the claim request was filed for the expenses borne for the duration of hospitalization. Upon scrutiny of claim and investigation done the claim was denied due to non-disclosure of history of Gamma knife surgery done in 2005, the claim request was denied in accordance with clause 6.1.12 of the policy T&C. It is further stated that Gamma Knife radio surgery is a type of radiation therapy used to treat tumors, vascular malformations and other abnormalities in the brain. This is fact was not disclosed by the insured/policyholder at the time of taking the policy (Annexure OP/5) colly. It is also stated that the disputed claims of CC/943/2022 has been denied on a different ground i.e., non-disclosure of gamma knife surgery done in 2005 (Annexure OP-7). On these lines, the case is sought to be defended by the OP No.1 & 2.
3.     Notice of the complaint was sent to the OP No.3 seeking its version of the case. However, nobody appeared on behalf of OP No.3 despite following proper procedure, therefore it was proceeded ex-parte on 08.02.2023.
4.     No rejoinder filed by the complainants.
5.     Parties led evidence by way of affidavits and documents.
6.     We have heard the learned counsel for the parties and gone through the record of the case.
7.     On perusal of the complaint, it is gathered that the main grievance of the complainants is that the legitimate claims in respect the treatment of the deceased (wife of complainant No.1 and mother of complainants No.2 & 3) were not paid inspite of having proper insurance cover.
8.     The ground on which the claims have been rejected is reproduced from Annexure C-9 as below:-

Reason of Rejection:-

         “The claim id 156068 was paid after waiving ND. In other claim 9693 have found non-disclosure of Gamma Knife surgery (different non-disclosure against preview claim (156068) prior to policy.”

        On perusal of documents submitted by the complainants, it is observed that the policies were renewed in respect of the deceased insured continuously and the OPs were aware of the pre-existing disease. The fact of the same has been deliberated in the case No.CC/440/2016 decided by this Commission. Moreover, the OPs have already paid 4 claims out of 6 claims submitted by the complainants for the treatment of same disease.

         Hon'ble High Court of Punjab and Haryana at Chandigarh in Khursheed's case (supra) also was pleased to observe as under:-

         "Insurance Companies are charging hefty premium for insuring the vehicles. Once the question of liability arises, the companies resort to one technical objection and the other. These Companies really chase people and literally promise everything at the time of selling policy. It is usual to see people struggle to run after agents and surveyors to get their rightful claims. Such agents then look other way and make insurers to make rounds to Company offices. Insurers are then made to approach the Courts and are even dragged to this Court on one technical plea or the other. No one really is made to read the terms while making him to sign on the printed forms for selling policies. This attitude must change. At least, the Courts should not be burdened with this uncalled for litigation." 

9.     From written arguments, filed by the OP No.3, it is observed that it has taken a stand that “a civil suit under Order XXXVII of the CPC for recovery of money from the complainants will be filed as they have not cleared the bills in lieu of the medical service provided to the Smt. Czarina Jindal wife of complainant No.1.”
10.     In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OP No.1 & 2 are directed as under :-

1. to pay the claim No.969310 dated 27.06.2022 for an amount of ₹9,06,714/- and claim No.1084820 dated 13.10.2022 for an amount of ₹2,02,833/- to the complainants alongwith interest @ 9% per annum w.e.f the dates of repudiation till realization, to enable the complainants to pay the same to the OP No.3.
2. to pay an amount of ₹30,000/- to the complainants as compensation for causing mental agony and harassment to them.
3. to pay ₹10,000/- to the complainants as costs of litigation.

11.     This order be complied with by the OP No.1 & 2 within 45 days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
12.     The consumer complaint qua OP No.3 stands dismissed with no order as to costs.
13.     Pending miscellaneous application, if any, also stands disposed of.
14.     Certified copies of this order be sent to the parties free of charge. The file be consigned.

			Sd/-
20/10/2023			[Pawanjit Singh]
Ls			President
			Sd/-
			[Surjeet Kaur]
			Member
			Sd/-
			[Suresh Kumar Sardana]
			Member