Delhi

StateCommission

CC/533/2014

MR. UMESH KUMAR SAHDEV - Complainant(s)

Versus

THE MAX BUPA HEALTH INSURANCE CO. LTD. - Opp.Party(s)

25 Feb 2015

ORDER

IN THE STATE COMMISSION

(Constituted under section 9 of the Consumer Protection Act, 1986)

 

Date of Decision: 25.02.2015

 

Complaint Case No.-533/2014

 

Mr. Umesh Kumar Sahdev

S/o Har Krishan Lal Sahdev

R/o A-51, First Floor,

Gulmohar Park, New Delhi-49

                                                                                        ….Appellant

 

Versus

 

The Max Bupa Health Insurance Co. Ltd.

Through Director (Strategic and Development)

B-1/I-2, Mohan Cooperative Industrial Estate

Mathura Road,

New Delhi-110044

                                                                                   ....Respondent

 

CORAM

Justice Veena Birbal, President

Salma Noor – Member

N P Kaushik, Member (Judicial)

 

 

Salma Noor, Member

 

1.             Brief facts of the case are that the complainant purchased a Medical Health Policy namely “Heartbeat Platinum” for himself and his wife for Rs. 50 Lacs one adult commencing from 15.12.2013 to 14.01.2014. The complainant has paid a sum of Rs. 1,10,312/- towards the annual insurance premium for the said policy. The said insurance policy was with the stipulation that the payment shall be made directly to the hospital by the opposite party.

2.             The complainant suffered an acute health problem like extreme breathlessness and suffocation and on the advice of the respondent i.e. Insurance Company the complainant went to Max Super Specialty Hospital, where he was examined by Dr. Ajay Lall, Director-Respiratory Medicine and Senior Consultant who advised him certain medical tests to find out the cause of breathlessness and feeling of suffocation. As advised by Dr. Ajay Lall, X-Ray-Chest, Barium test, Stress Echo test, Echo Doppler test, Pulmonary function test, X-Ray soft Tissue Neck, Ultrasound KUB, Polysomnography test of the complainant were conducted.

3.             Thereafter, the complainant was discharged from the hospital on 19.12.2013. The total bill of different tests came to Rs. 91,562/-. Thereafter, the Max Super Specialty Hospital, Saket, New Delhi sent a requisition for preauthorization in respect of the complainant which was denied by the complainant on the ground that the case of the complainant fell within the exclusion clause of “Sleep apnea, snoring or any other sleep related disorder”. After being discharged from the hospital the complainant made representations to the Max Bupa Health Insurance Company stating that he was not treated for any of the disease falling in the exclusion clause of policy of Insurance. But Insurance Company rejected his representation and denied the claim.

4.                      Due to the denial of the claim by the OP the complainant suffered undue harassment, mental agony and distress. Thereafter, the complainant served a legal notice to the OP dated 13.05.2014 but the OP did not respond. Aggrieved by the conduct of the OP the complainant filed a complaint before this Commission with the following prayers:

           “It is most respectfully prayed that this Hon’ble Commission may be pleased to:

a.     initiate proceedings against the respondent for deficiency in service,

b.     award Rs. 91,562 (Rupees Ninety One Thousand Five Hundred and Sixty Two Only) being refund of medical bill along with 12% interest,

c.      award Rs. 85,00,000/- (Rupees Eighty Five Lacs Only) towards deficiency in service, harassment, inconvenience and losses in favour of the complainant and against the respondent.

d.     award present and future interest @ 12% on the above sums,

e.     award cost of Rs. 2,00,000/- including court fees, lawyer’s fees and other expenses,

f.      pass such other or further orders as this Hon’ble Commission may deem fit and proper in the interest of justice”.

5.             We have heard Sh. V.C. Rishi, counsel for the appellant at the admission stage and perused the prayer made in the complaint.

6.             On the perusal of the summary of the compensation claim for, we find that complainant in this complaint is seeking refund of Rs. 91,562/- of medical bills along with refund of 12% interest against the aforesaid actual amount paid or spent by the complainant. The complainant is seeking compensation to the tune of Rs. 85,00,000/- along with interest @ 12% towards deficiency in service, harassment, inconvenience and losses in favour of the complainant against the OP. Further, he is seeking 2,00,000/- as a legal expenditure .

7.                Under the provisions of the Consumer Protection Act, 1986 the original complaint can be filed in the District Forum or the State Commission or the National Commission depending the value of the cost of the goods/services. Section 11, Section 17 & Section 21 provides the pecuniary jurisdiction of the respective foras. Section 11 provides that District Fora shall have jurisdiction to entertain complaints where value of the goods of services and compensation, if any, does not exceed rupees Twenty Lakhs. According to Section 17, State Commission can entertain the complaints where the value of goods or services and compensation claimed exceeds rupees Twenty Lakhs but does not exceed one crore and if the said value is more than rupees one crore, jurisdiction to entertain the original complaint lies with the National Commission as provided under section 21 of the Act. Presently, no court fee on the claims preferred before the Foras concerned is payable. Therefore, tendency to defeat the hierarchy as per the scheme of the Act is always there. The Consumer Fora at various levels are required to guard against the inflated claims with malafide intentions to defeat the hierarchy of the Foras concerned. In the present complaint, the amount spent by the complainant is only Rs. 91,562/- but he has added disproportionate demand of Rs. 85,00,000/- towards deficiency of service and 2,00,000/- as legal expenses to bring this case within the jurisdiction of the State Commission. The above claim of the complaint is highly inflated, obviously, have been made to bring the complaint within the jurisdiction of this Commission. Thus, the complaint deserves to be dismissed with liberty to the complainant to file a fresh complaint on the same cause of action suitably reducing the claim amount before the appropriate Forum.

8)                 Accordingly, the complaint is dismissed with liberty reserved to the complaint to file a fresh complaint by suitably reducing the claim amount before the District Forum.

                    Complaint dismissed at the admission stage.

 

(Justice Veena Birbal)

President

 

(Salma Noor)

Member

(N P Kaushik)

Member (Judicial)

Rakeeba