Haryana

Ambala

CC/365/2021

Satish Kumar - Complainant(s)

Versus

Max Bupa Helth Insurance Co Ltd - Opp.Party(s)

G.S.Ahluwalia

09 Jun 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	365  of 2021
Date of Institution	:	02.12.2021
Date of decision	:	09.06.2023

Satish Kumar son of Shri Babu Ram, resident of village Ganouli, Post office Ambli, Tehsil Naraingarh, District Ambala.

…..Complainant

versus

 

Niva Bupa Health Insurance Company Limited, (formerly known as Max Bupa Health Insurance Co. Ltd.) SCO No.55, 56 & 57, 2nd Floor, Sector 8-C, Madhya Marg, Chandigarh through its Authorized Signatory.

….…. Opposite Party

Before:       Smt. Neena Sandhu, President.

                             Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:      Shri Gurmit Singh Ahluwalia, Advocate, counsel for the    complainant.

                   Shri Sunil Sharma, Advocate, counsel for the OP.

Order:        Smt. Neena Sandhu, President.

1.                Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to it:-

1. To release the health claim amounting to Rs.1,53,052/- along with interest @ 18% per annum.
2. To pay Rs.50,000/- as compensation on account of unnecessary harassment caused to the complainant.
3. To pay Rs.22000/- as litigation expenses
4. Grant any other relief, which this Hon’ble Commission may deems fit.

 

2.             Brief facts of this case are that the complainant availed health insurance policy bearing No.31616688202100, valid from 19.03.2021 to 18.03.2022 by paying its premium from the OP. At the time of purchasing the above said policy by the complainant, the OP assured the complainant that he and his family members are included in the benefits against the said health policy and that all the benefits of the said policy will be started from the day of its purchase. It was also assured by the OP that the said policy is cashless policy and as and when the complainant will submit claim, the same will be released to him immediately without any delay. The wife of the complainant namely Mamta Rani in the month of July 2021 suffered some problem in her uterine and due to covid- 19 she took treatment as per the guidelines through online but she could not recover from her ailment and was advised by the concerned doctor to visit the hospital physically for her complete check up. Accordingly, after informing the OP and as per the directions of the OP, the complainant got admitted his wife-Mamta Rani in the recognized hospital of the OP i.e. Paras Hospital, Panchkula on 07.09.2021, where she was medico legally checked up by the concerned doctor and the disease was diagnosed as "Uterine Sarcoma". The concerned doctor advised surgery for the aforesaid disease and accordingly the complainant informed the OP regarding the disease of his wife as well as the treatment suggested by the concerned doctor, upon which the OP assured the complainant that the said disease is very much covered under the aforesaid health policy; the said policy is cashless one and that the entire payment of the said hospital will be paid by the OP. Accordingly as per the assurances of the OP, the complainant got treated his wife from the recognized hospital of the OP and surgery for removal of Uterine. She was discharged from the hospital on 14.09.2021 and the hospital charged Rs.1,53,052/- from the complainant at the time of discharge of the patient from the hospital and issued receipt/bills to the complainant. Though it was assured by the OP that the entire treatment charges will be paid by the insurance company directly to the hospital, but when the complainant at the time of discharge of his wife from the hospital informed the OP regarding the payment of treatment charges, the OP asked the complainant, first to pay the treatment charges to the hospital from his own pocket on the pretext that it will take some time for scrutiny of the bills by the insurance company. The OP also assured the complainant that after receipt of bills of the hospital, the OP will immediately release the health claim to the complainant as per the said bills. As such, as per the assurances of the OP, the complainant paid the above said treatment charges of Rs.1,53,052/- to the Paras Hospital, Panchkula from his own pocket at the time of discharge of his wife, since the hospital without receiving the charges was not discharging his wife. Thereafter the complainant submitted the claim and submitted all the original bills issued by the hospital along with certificates issued by the hospital authorities with the OP for the release of the health claim against aforesaid health policy and the OP registered the claim as cashless claim No.393327 dated 09.09.2021 but till date it failed to release the legal and valid claim of the complainant. The complainant also got the OP served with a legal notice dated 17.09.2021 but to no avail. Hence, the present complaint.
3.           Upon notice, OP appeared and filed written version and  raised preliminary objections to the effect that  the instant complaint is false, malicious, incorrect and malafide and is nothing but an abuse of the process of law;    the complainant has concealed true and material facts and has approached this Commission with unclean hands;  the present complaint is devoid of any cause of action; the present complaint is liable to dismissed in view of the settled proposition of law that -the Contracts of Insurance are contracts of Uberrima fides utmost good faith - and every material facts must be disclosed correctly, otherwise there is a good ground for recession of the contract; the present complain is not maintainable etc. On merits, it has been stated that the complainant has not filed the claim for reimbursement and approached this Commission after the denial of cashless treatment. The details of the Policy were also explained to the complainant. The Policy terms and conditions comprised Free Look Period whereby Policy holder if is dissatisfied with the terms and conditions of the policy, then he/she had the option of cancelling the Policy within 15 days ("free-look period") of receipt of the Policy. The OP company received a preauthorization request for cashless facility from Paras Hospitals, Panchkula for the patient Mamta Rani who was admitted on 09.09.2021 with the complaint of abdomen pain for last 60 days and estimated days of admission was 4 days with estimate of Rs.1,78,950/- and was diagnosed Malignant neoplasm of uterus, part unspecified.. The malignant neoplasm is another term for a cancerous tumor. The term "neoplasm" refers to an abnormal growth of tissue. The term "malignant" means the tumor is cancerous and is likely to spread (metastasize) beyond its point of origin. Denial of cashless cannot be considered as denial of treatment.
4.           After receipt of pre-authorization request, the company examined the documents submitted with pre-authorization form and medical documents submitted with preauthorization form and thereafter denied the cashless request stating that cashless cannot be provided due to information about the chronicity of the illness and possibility of pre-existing conditions can be ruled out and needed further verification under clause 5.1. Thereafter the OP received a legal notice sent by the complainant through his counsel and as such the OP duly replied the same and asked the complainant to lodge/file claim for reimbursement of medical expenses but the complainant filed the present complaint instead of filing the claim. Rest of the averments of the complainant were denied by OP and prayed for dismissal of the present complaint.
5.           Complainant tendered his affidavit, as Annexure CW1/A alongwith documents as Annexure C-1 and C-110 and closed the evidence on behalf of the complainant. Learned counsel for the OP tendered affidavit of Ms.Manisha Rani, Senior Executive-Legal and Authorized Representative of OP-Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Company Limited) as Annexure RW1/A alongwith documents Annexure RW1 to RW7 and closed the evidence on behalf of the OP.
6.           We have heard the learned counsel for the parties and have also carefully gone through the case file.
7.           The learned counsel for the complainant submitted that by neither granting preauthorization approval for cashless treatment of wife of the complainant and thereafter not making payment of the amount spent by the complainant in respect of the treatment taken by her wife, despite the fact that she was covered under the insurance policy in question, the OP is deficient in providing service, negligent and adopted unfair trade practice. 
8.           On the contrary, learned counsel for the OP submitted that since in the first instance the OP was to verify the correctness of the claim, as such, cashless preauthorization was not approved by it, yet, later on, vide letter dated 04.10.2021, Annexure R-7 the complainant, through his Advocate, was asked to file reimbursement claim alongwith necessary documents, to analyze and adjudicate the same on merits, but instead of doing that he filed this consumer complaint.  
9.           Since neither the issuance of the policy in question by the OP in favour of the complainant and his family members, nor treatment taken by her wife for Uterine Sarcoma during subsistence of the policy in question, for which an amount of Rs.1,53,052/- stood paid by the complainant from his pocket as the OP denied the cashless treatment, are not in dispute, as such, the only question which falls for consideration is, as to what relief, the complainant is entitled to, in the present case?. It may be stated here that the OP has fairly admitted that  in the first instance, the complainant was not accorded approval for cashless treatment, aforesaid, yet, a justification has been given by the OP in its written version and also by its Counsel during the course of arguments that it was on account of the reason that verification was required to be done in the matter, as the patient Mamta Rani, who was admitted on 09.09.2021 with the complaint of abdomen pain for last 60 days and estimated days of admission was 4 days with estimate of Rs.1,78,950/-, was diagnosed Malignant neoplasm of uterus, part unspecified. At the same time, it is also coming out from the record that in reply to the legal notice dated 17.09.2021 having been sent by the complainant to the OP, it in return, sent letter dated 04.10.2021, Annexure R-7/C-3 to the complainant, through his Advocate, asking him to file reimbursement claim alongwith necessary documents, to analyze and adjudicate the same on merits. Though, the complainant has placed on record number of documents, running into 167 pages, yet, there is nothing on record to prove that the claim was ever filed by him with the OP or that if the claim stood filed by him the same was repudiated by the OP, meaning thereby that the claim has neither been filed nor rejected by the OP. In our considered opinion, once the OP has specifically asked the complainant vide letter dated 04.10.2021, Annexure R-7 to file claim alongwith necessary documents for reimbursement thereof, as such, it was required of the complainant to do so, yet, instead of doing that, he has filed this consumer complaint. Thus, under these circumstances, we are of the considered view that this complaint being premature is not maintainable at this stage, before this Commission.
10.           However, in the interest of justice, we dispose of this complaint with the direction to the complainant to lodge the claim along with necessary documents with the OP within 30 days from the date of receipt of certified copy of this order. At the same time, we also direct the OP to consider the claim of the complainant within a period of 45 days from the date of lodging of the claim by him, alongwith necessary documents. However, the complainant is left with the liberty to file a fresh complaint, if any cause of action arose to him, qua the claim in question, after lodging the same with the OP.  Certified copies of the order be sent to the parties concerned as per rules.  File be annexed and consigned to the record room. 

                  

Announced:- 09.06.2023.

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President