District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 169/2022.
Date of Institution:30.03.2022.
Date of Order: 05.07.2023.
Surender Sharma S/o Shri Om Parkash Sharma R/o H.No.1107/8, Chamanpura, Rohtak, Haryana.
At present:
House No. 56, Block-1, First floor, Sector-10, Faridabad.
…….Complainant……..
Versus
Niva Bupa Health Insurance Office: C-98, Lajpat Nagar-1, New Delhi – 110 024.
…Opposite party
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Ms. Shailly Mudgil, counsel for the complainant.
Sh. Rakesh Dabaas, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant was beneficiary of cashless health policy issued by the opposite party vide policy No. 30537925202105, insurer ID 3299259 valid 17.6.2021 to 16.06.2022. The complainant developed symptoms of fever, cough, body ache etc. so in the emergency he had to be admitted in Park Hospital for treatment. Since the
symptoms were alluding to Corona Virus, therefore, samples were sent to examination and the same was confirmed with Crona positive to the complainant. Since the complainant was availing cashless policy from the opposite party company, therefore, he was resting assured that his treatment would not be denied due to financial crunch of the complainant ; however, to the dismay and grief of the complainant, the opposite party rejected cashless claim of the complainant vide their letter dated 07.01.2022 ref: No. 432248-799994. The complainant was very poor person who cannot afford treatment from private hospital, therefore, he got the policy from the opposite party but the opposite party behaving unprofessionally, unethically, illegally denied claim to the complainant leaving him at death bed. Since the complainant had no money in emergency and since the hospital was demanding prior deposit of atleast Rs.20,000/- prior starting treatment, then family members of the complainant had to mortgage some jewelry and got an amount of Rs.40,000/- which thoroughly spent for Covid treatment of the complainant. The complainant remained in Park Hospital from 07.01.2022 to 11.01.2022; the complainant had spent all of Rs.40,000/- but was not well recovered. Since the complainant had no further amount to deposit in hospital for treatment as the hospital was demanding further amount of around Rs.50,000/- and the treatment was likely to take around further one more week. The complainant, therefore, had to get discharge without getting proper treatment as the complainant had no money to pay. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) make payment of Rs.85,000/- alongwith interest @ 18% p.a. from the date of it became due till its final payment.
b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment .
c) make payment of Rs.50,000/- for the financial loss suffered by the complainant and litigation expenses incurred by him.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the complainant opted for the policy bearing No. 30537925201600 “Health Companion” from the period 17.06.2016 to 16.07.2017 for a base sum insured of Rs.5,00,000/- and the gross premium of Rs.15,854/-. It was pertinent to mention that complainant opted for portability and therefore, the policy bearing NO. 110103/11051/1000398518-02, Plan – of Company Apollo Munich Health Insurance Co. Ltd., was as per portability guidelines by the opposite party. The complainant renewed the aforesaid policy bearing No. 30537925202105 “Health Companion Variant No.2nd from the period 17.06.2021 to 16.06.2022 for a base sum insured of Rs.7,50,000/- alongwith no claim bonus of Rs,1,50,000/- and refill benefit of Rs.7,50,000/- against the gross premium of Rs.16,533/-. In pursuant to the aforesaid policy, the complainant submitted the cashless request No. 432248 for treatment of COVID 19 at Park Hospital. The aforesaid cashless claim bearing No. 432248 was rejected by the opposite party on account of the clause 6.15 of the policy and further the hospitalization was on account of physiotherapy, evaluations and investigations. The clause 6.15 of the policy terms and conditions provides for the hospitalization not justified in case of physiotherapy, evaluation, investigation, diagnosis or treatment not consistent with Standard treatment guidelines 2010) or Evidence Based Clinical Practices. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party–Niva Bupa Health Insurance with the prayer to: a) make payment of Rs.85,000/- alongwith interest @ 18% p.a. from the date of it became due till its final payment. b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment . c) make payment of Rs.50,000/- for the financial loss suffered by the complainant and litigation expenses incurred by him.
To establish his case the complainant has led in his evidence, Ex.CW!/1 – affidavit of Surender Sharma,Ex.C-1 – insurance policy,, Ex.CW-1/B – Cashless denial letter dated 07.01.2022,, Ex.CW1/C – discharge summary, Ex.CW1/D – legal demand notice, Ex.CW1/E – postal receipt.
On the other hand counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Shri Bhuwan Bhashker, Manager-Legal, M/s. Niva Bupa Health Insurance Company Limited, 2nd floor, plot No. D-5, Logix Infotech Park, Sector-59, Noida, Uttar Pradesh – 201301, Ex.R1 -Proposal form, Ex.R-2 – insurance policy bearing No. 30537925201600, Ex.R-3 – insurance policy bearing No.30537925202105, Ex.R-4 – Request for cashless hospitalization for medical insurance policy, Ex.R-5 – Cashless denial letter.
6. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite party is directed to process the claim of the complainant within 30 days from the date of receipt of the copy of
order and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite party is also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alognwith Rs.2200/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. File be consigned to the record room.
Announced on: 05.07.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
