Order by:

Aparana Kundi, Member

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant purchased a Health Insurance Policy "Family Floater Plan” bearing no.30660265202306 dated 07.04.2023 covering self and her husband. Accordingly, on dated 07.02.2024, the complainant was caught by illness and was got admitted to Dayanand College and Hospital Ludhiana on dated 07.04.2024 with the purpose to cure the said medical problem. During the treatment of complainant, initial the claim was sent for an amount of Rs.35915/- and subsequently final bill was raised for Rs.42,809.52/- with Opposite Party No.1, then the same has been refused/denied by the office of Opposite Party no. 1 by giving the remarks that “treatment traceable to child birth except ectopic pregnancy or towards mis-carriage (unless due to an accident) and lawful medical termination of pregnancy are not covered in the policy as per clause 6.18 of the policy”, vide letter dated 08.02.2024 and email dated 30.04.2024. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay the amount of insurance claim of Rs.42,809.52 under the name of Shruti Goyal for her diagnosis covered under the insurance policy alongwith 12% interest from the date of submission of first claim.  

b)      To pay a sum of Rs.1,00,000/- as compensation on account of mental tension and harassment alongwith 12% interest from the date of payment.

c)       To pay Rs.40,000/- as litigation expenses alongwith 12% interest from the date of payment.

d)      And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite Party No.1 appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complainant had approached this Commission with malafide and dishonest intention not only concealed the material facts but also twisted and distorted the same to suit her convenience and to mislead this Commission, the complaint does not disclose any cause of action for filling the present complaint against the answering Opposite Party. Submitted that the cashless facility was denied as per clause 6.18 and denial of cashless facility is not denial of the claim. The complainant was advised to submit the claim documents for reimbursement. However, the same has not been submitted by the complainant therefore the alleged claim has neither been accepted nor been rejected by the Opposite Party. Thus the present Complaint is a pre-mature Complaint; there is no deficiency in services on the part of the Answering Opposite Party; this Commission has no jurisdiction to try and entertain the present Complaint; the complainant has miserably failed to demonstrate any deficiency in services nor has been able to prove any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance.

          Submitted that the husband of the complainant Mr.Radhe Mohan Garg had submitted a duly filled application form alongwith the requisite documents and premium. On receipt of the application form, believing the information provided in the proposal form to be true and correct in all aspect, the policy was issued to Mr.Radhe Mohan Garg in which the name of the complainant was also included as insured member. Thereafter, the Answering Opposite Party received a cashless request from the complainant informing that she is being hospitalized in Dayanand Medical College and Hospital on 07.02.2024 for single spontaneous delivery and requested for cashless facility. Submitted that the complainant was diagnosed with single spontaneous delivery. As per terms and conditions of the policy medical treatment expenses traceable to childbirth except ectopic pregnancy or towards miscarriage (unless due to an Accident) and lawful medical termination of pregnancy are not covered in the policy. Therefore, the cashless facility was denied as per clause 6.18 of terms and conditions. In view of the above mentioned facts and circumstances, it is clear that the present complaint against the answering Opposite Party is meritless and legally not tenable. Submitted further that denial of cashless facility is not denial of claim. Hence, the complainant was advised to submit the claim documents for reimbursement. However, the same has not been submitted by the complainant therefore the alleged claim has neither been accepted nor been rejected by the Opposite Party. After receiving the re-imbursement claim and required documents, the claim and the documents will be scrutinized and then the Answering Opposite Party will decide whether or not to admit the Claim. The Complainant herein has jumped the entire process and has directly approached this Commission without providing an opportunity to the Answering Opposite Party to decide the Claim. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       Notice sent to Opposite Party No.2 was duly served, but despite service of notice, none appeared on behalf of Opposite Party No.2. Hence, Opposite Party No.2 was proceeded against exparte.

4.       In order to prove the case, complainant has placed on record her affidavit as Ex.C1 alongwith copies of documents Ex.C2 to Ex.C9.

5.       On the other hand, Opposite Party No.1 has placed on record affidavit of Sh.Sudhakar Anand Manager-Legal, Niva Bupa Health Ins. Co. Ltd. as Ex.OP1 alongwith copies of documents Ex.OP2 to Ex.OP4.

6.         We have heard the ld. counsel for both the parties and also gone through the record.

7.       It is admitted and proved on record that husband of the complainant namely Radhe Mohan Garg availed health insurance policy namely ‘Family Floater Policy’ bearing no.30660265202306 for the period 21.04.2023 to 20.04.2024 covering self and his wife Shruti Goyal i.e. complainant in the present complaint. It is also proved on record that during the policy coverage, the complainant got admitted in Dayanand Medical College & Hospital, Ludhiana on 07.02.2024 with complaints of ‘heavy menstrual bleeding’ and got discharged from the hospital on 08.02.2024. It is also proved on record, the complainant requested the Opposite Parties for cashless treatment, but cashless request of the complainant was rejected, vide letter dated 08.02.2024 placed on record as (Ex.OP4).

8.       We have considered the rival contents of ld. counsel for the parties and gone through the record. The main objection raised by Opposite Party No.1 is that complaint is pre-mature, as till date the complainant has not lodged any claim with them and complainant was advised to submit the claim documents for reimbursement, but the same has not been submitted by the complainant. While going through the reply placed on record by Opposite Party No.1, we came to know that after the rejection of cashless claim, the complainant directly approached this Commission and not prefer to lodge the claim with the Opposite Parties. Careful perusal of the record shows that complainant has not produced on record any document showing that after rejection of the cashless request, she ever lodged any claim with Opposite Party No.1 for the reimbursement of the expenses incurred by her on the treatment and there is no repudiation letter on record. However, the complainant has served a legal notice (Ex.C5) to Opposite Party, for which, the Opposite Party No.1 has not given any reply.

9.       In view of the above discussion, we are of the concerted view that being the complaint is premature, so it stands disposed of with a liberty to the complainant to lodge the claim with Opposite Parties and further liberty to the complainant to file fresh complaint, if not satisfied with the decision of Opposite Parties. Keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.

Announced in Open Commission