Delhi

North

CC/167/2021

RAMAKANT TRIPATHI - Complainant(s)

Versus

NIVA BUPA HEALTH INSURANCE - Opp.Party(s)

AJAY TYAGI & VIPIN TRIPATHI

02 Feb 2024

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

Phone: 011-23969372; 011-23912675 Email: confo-nt-dl@nic.in

Consumer Complaint No. 167/2021

In the matter

Sh.Ramakant Tripathi

S/o Sh.Anand Narayan Tripathi

R/o H.No.83, Gali No.3,

Bhagwan Park, Jharoda

Majra, Burari, Delhi-110084                                                                             ...Complainant                                                                                       v/s

Niva Bupa Health Insurance Co.Ltd.

Through its directors

Registered office at:-

C-98, First floor, Lajpat Nagar, Part-I, Delhi-110024                             

 

Corporate office at:-

14th floor, capital Cyberscape

Golf course extension Road

Sector-59, Gurugram-122101, HR                                                                        ... Opposite  party

ORDER

          02/02/2024

Ms.Harpreet Kaur Charya, Member

1. Facts necessary for the disposal of the present complaint are that, the complainant Sh.Ramakant Tripathi got his Health Insurance Policy (since 2016) with New India Insurance Company ported to Niva Bupa Health Insurance Co.Ltd. , Opposite Party (hereinafter OP).  The complainant was convinced by the executive of OP to get the policy ported by assuring that the benefits of the previous policy will continue with zero waiting periods and coverage of all pre-existing disease.
2. Health Insurance policy bearing No.31267934202000, Customer ID 1000067167 for period 14/07/2020 to 13/07/2021 with coverage of Rs.5,00,000/- was issued by 
OP. A total premium of Rs.20,428/- was paid on 02/07/2020.  As per the policy documents the specific waiting periods and 30 days waiting period were waived.  
3. One 21/08/2020, Smt Kamla Devi Tripathi, the wife of the complainant and also the insured visited Mata Ram Kirti Devi Sanwadia Hospital with the complaint of itching in the right ear.   Since, there was no relief, she visited Sant Parmanad Hospital on 15/09/2020 and met Dr. Ankit Jain (MBBS, MS ENT), where she was prescribed some medicines for a week.  As there was no relief the above-said doctor after conducting some tests found some injury in the ear and suggested surgery. 
4. Cashless claim was denied on the ground of “Gross non-disclosure of material facts CSOM since 6 months”.  The complainant has stated that the period of 06 months was inadvertently written by the treating doctor to which ,Dr. Ankit Jain issued a letter dated 25/09/2020 admitting the error and clarified it was ‘01 month’ and not ‘06 month’. Again an email requesting reconsideration of cashless claim vide Pre-auth. /reimbursement claim request ID 315418 was written on 28/09/2020 which was replied by OP at 19:45 hours with the heading ‘Applied exclusion for policy No.31267934202000’ asking the complainant to accept the exclusion clause within 30 days and also threatened in case the consent is not received the policy will be cancelled after 30 days.
5. On 29/09/2020, the wife of the complainant was hospitalized and underwent surgery and discharged on 30/09/2020.  Total expenses of Rs.56,985/- apart from hospitalization charges and additional pre and post hospitalization expenses of Rs.10,000/- were paid by the complainant. 
6. Notice dated 30/09/2020 was served upon OP requesting to pass the medi-claim within 15 days but all in vain. An email dated 30/09/2020 at 15.07 hrs. was written to OP at gro@maxbupa.com and grievanceredressal@maxbupa.com with the copy to IRDAI at complaints@irdai.gov.in  was also written.  
7.     On 06/10/2020, at 13.25 hrs. the complainant received an email confirming the registration of the complaint vide No.5152632.  On 29/10/2020 the complaint received 02 mails instructing him to file claim for reimbursement on the pretext that it was not possible to ascertain the liability at this juncture and would require further verification. It was also assured that post receipt of the documents case of the complainant will be reviewed as per policy terms and conditions. As per the instructions of the grievance Redressal Cell, the complainant furnished ‘Acceptance of exclusion’ by formal letter.
8. On 18/11/2020, the claim of the complainant was rejected and the policy was cancelled on the ground that OP had not received the consent letter for applying exclusion.  Complainant approached the IRDAI on 15/12/2020 disputing the decision of OP vide grievance No.2448712, however, the same has not been decided till date.   
9. The complainant has alleged that non-reimbursement of expenses incurred on the treatment of his wife has not only caused physical but mental harassment which amount to deficiency in services on part of OP.  
10. Legal Notice dated 03/02/2021 was served upon OP calling them to reimburse the expenses of Rs.70,000/- alongwith interest @2% per month from the date of submission of claim till realization and compensation  of Rs.5,00,000/- on account of mental tension , pain.  The said notice was not replied however, the complainant was again asked to accept the exclusion clause. 
11. Feeling aggrieved by the rejection of his claim and cancellation of the policy the complainant has prayed for direction to OP to pay Rs.70,000/- alongwith interest @24% p.a. from the date of submitting the claim till realization; Rs.5,00,000/- as compensation towards mental trauma, physical harassment and financial losses and Rs,22,000/- as cost of litigation.
12. The complainant has annexed the policy documents dated 11/07/2020, premium receipt dated 11/07/2020, prescription of Mata Ram Kirti Devi Sanwadia Hospital dated 21/08/2020, prescription of Sant Parmanand Hospital dated 15/09/2020, discharge summary dated 30/09/2020 alongwith test results and bills from 19/09/2020 to 30/09/2020; cashless denial letter 22/09/2020, certificate issued by the treating doctor alongwith  affidavit, emails  for the period  from 28/09/2020  to 06/10/2020, registration of complaint with IRDAI dated 30/10/2020, consent letter dated 23/10/2020, emails exchanged with OP from 29/10/2020 to 05/03/2021; guidelines on migration and portability of health insurance policy dated 01/01/2020 issued by IRDAI; policy terms and conditions  and copy of the   Aadhar Card of the complainant.
13. Notice of the present complaint was issued to the OP.
14. Written statement was filed on their behalf where, they have taken several preliminary objections such as the complaint was premature as the cashless pre-authorisation was rejected and no claim for reimbursement had been received as per the terms and conditions. On 29/10/2020 the complainant vide an email was requested to file claim for reimbursement. As per the pre-authorisation, it was suggested that the patient had adverse medical condition due to which the liability could not be ascertained at that juncture as the patient was suffering from CSOM since 06 months.  Thus, it was suppression of material facts.
15. They have denied that there was deficiency in services and the claim of the complainant and cancellation of the policy was incorrect. It has been submitted that the complainant had obtained reimbursement of his claim of Rs.75,000/- for dengue and typhoid in the year 2017 and had got the policy ported from New India Insurance Co. Ltd. in July, 2020 . The complainant had signed and submitted the form after going through the policy terms and conditions.
16. Since, no objection was received from the complainant; therefore, the complainant was bound by the policy terms and conditions.  Receipt of pre-authorisation cashless claim form dated 21/08/2020 (sic) and its denial vide letter dated 22/09/2020 has been admitted.  It has been submitted by the OP that they decided to apply exclusion for suppurative and unspecified otitis media, which, was informed to the complainant and the consent was sought towards the same, however, the policy was cancelled as the required consent was not received.  Claim for reimbursement was also not filed by the complainant.  Rest of the contents of the complaint have been denied with a prayer for dismissal of the complaint with cost.
17.   OP has annexed the letter of authorisation dated 24/02/2022 as Annexure R1; Health Companion proposal Form of the complainant as Annexure R2; copy of policy terms and conditions as Annexure R3; Pre-Authorisation Form (Cashless) as Annexure R4 ;copy of denial of authorisation letter bearing no.315418 as Annexure R5 with their written statement. 
18. Rejoinder to the written statement to the OP was filed by the complainant where it has been submitted that the complainant had filed a claim for reimbursement vide email dated 03/11/2020 and same was rejected vide email dated 26/12/2020.  Rest of the contents of the written statement have been denied. 
19. Evidence by way of affidavit was filed by the complainant.  the contents of the complaint and rejoinder have been reaffirmed.  He has relied on the documents annexed with the complaint. 
20. OP has got examined Sh.Bhuwan Bhashker, authorised representative of OP. He has also deposed on oath the contents of the written statement. He has got exhibited the copy of authority Letter dated 25/02/2022 as Ex.RW1/1, copy of online application as Ex.RW1/2, copy of policy terms and conditions as Ex.RW1/3; copy of pre-authorisation form received from Sant Parmanand Hospital as Ex.RW1/4; copy of denial of authorisation as Ex.RW1/5.  He has also relied upon email dated 28/09/2020 filed by the complainant.  Copy of reimbursement claim alongwith document has been exhibited as Ex/RW1/6, copy of the reply dated 20/09/2021 of the legal notice as Ex.RW1/7.
21. We have heard the arguments of Ld. Counsel for the complainant and Ld. Counsel for OP.   We have also perused the material placed on record.  Though OP in its Written statement has denied the filing of claim of reimbursement by the complainant but in Para 11 of their evidence same has been admitted by them. Thus, the claim for reimbursement is not in dispute, similarly portability is also not in dispute.To ascertain the liability of OP,  we  need to look at Annexure-R-3 (the policy document), which states:-
“Thank you for choosing Max Bupa as your preferred health insurance partner through portability, we wish to intimate you that your policy 31160034192800000340 of Company (optional) The New India Assurance Co.Ltd. and Date of initiation 04/07/2016 has been ported as per Portability Guidelines.”
22.    Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016 F. No. IRDAI/Reg/17/129/2016 defines Portability:
m. “Portability” means the right accorded to an individual health insurance policyholder (including family cover), to transfer the credit gained for pre-existing conditions and time bound exclusions, from one insurer to another or from one plan to another plan of the same insurer.
23. Therefore, in the light of above regulation, for the purpose of determining waiting period for pre-existing conditions and time bound exclusions, the date of inception of the health insurance policy will be 04/07/2016.  As per the same document corresponding to the column pre-existing disease and personal waiting period, it bears-specific waiting periods (waived)’30 day waiting period (waived) and None respectively.  So, even from this document it is substantiated that the there was no waiting period for pre-existing disease.
24. OP had rejected Pre auth/cashless treatment for CSOM on the ground of pre-existing disease. This rejection is based on information provided by the treating doctor, Dr. Ankit Jain, MS, ENT in the form, where it has been written 06 months ® CSOM, however, the same doctor has again on his letterhead endorsed that it was due to some misunderstanding and mis-communication, it should have been 01 month and not 06 months.  An affidavit dated 26/11/2020 has also been given by him to that effect.  OP has not disputed the affidavit given by the treating doctor.  Even, in prescription dated 21/08/2020 of Mata Ram Kirti Devi Sanwadia Hospital, it is seen that the complainant had visited with the complaint of itching right ear and pain; it implies that complainant was not aware of the CSOM disease. Even on that basis it cannot be said that there was concealment of pre-existing disease by the complainant.
25. OP vide e-mail dated 28/09/2020, has sought complainant’s consent for accepting exclusion for “Suppurative and unspecified Otitis Media” within 30 days.  In case the exclusion was not agreeable to the complainant, the policy would be cancelled.  This act of OP amounts to pressurising the complainant to agree to the exclusion clause.   Despite, receiving the consent from the complainant, the policy was still cancelled by OP on 18/11/2020, thereby, leaving the complainant and other beneficiary without any medical health cover.  The cancellation of the policy by OP on arbitrary ground has also deprived the complainant from the benefits of continuous coverage since 2016. 
26. The act/ omission on the part of OP in denial of Pre Authorisation/ cashless treatment, rejection of the claim for reimbursement on the ground of concealment of Pre- Existing disease and ultimately cancellation of the policy definitely amounts to deficiency in services and Un-fair trade practice.
Therefore, in the facts and circumstances of the present complaint we direct OP to pay:
i. Rs.70,000/- on account of reimbursement of the claim.
ii. Interest @ 9% per annum from the date of filing of the present complaint (11/10/2021) till realisation.
iii. Compensation of Rs.30,000/- on account of mental harassment and agony&
iv. Rs.20,000/- as litigation expenses.
In case of non-complaince of this order within 30days, OP shall be liable to pay interest @ of 9% per annum on (i+iii) from the date of order till realisation.
Office is directed to supply the copy of this order to the parties as per rules. Order be also uploaded on the website.  Thereafter, file be consigned to the record room.

 

 

 (Harpreet Kaur Charya)

             Member

          

         

                    (Divya Jyoti Jaipuriar)

                                                      President

 

     

 

 

   
 

 

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