ORDER:
Alleging deficiency in service on the part of opposite party, complainant has filed this complaint with the averments that the complainant got issued a Health Plus policy from OP with Group Master policy no. 50179000202100 on 20.06.2021 for a sum insured of Rs.1,00,000/- and complainant paid Rs.995/- as premium for the same to the OP. During the policy period, the complainant was diagnosed with stone lower ureter "R" side intramural part and remained under treatment in the Bhardwaj Hospital, Bhiwani w.e.f 17.3.2023 to 20.03.2023 and operated (Endoscopic Removal) on 18.3.2023 and total treatment expenses were incurred for Rs.39,151/-. The complainant had submitted his claim online with OP company on 27.3.02023 and attached all the documents and OP issued claim ID 2000032702. It is averred that OP had demanded documents on 26.04.2023 and complainant again sent all the required documents. The OP had sent an email message on 1.5.2023 stating that "We acknowledge the receipt of additional documents for claim No.2000032702, documents have been shared with our medical team for further evaluation. The
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outcome will be shared within 7 working days". The surveyor of the company has also visited the house and the complainant has also supplied all the documents and also replied all the queries. It is further averred that OP company through email messaged on 2.5.2023 has approved the claim to the tune of Rs.28,109/- and assured that you will receive the payment within next two working days. It is averred that OP Company again on 28.6.2023 had sent a email message demanding some documents and the same were supplied. It is further averred that the OP repudiated the claim of the complainant vide letter dated 18.7.2023 on the ground that "claim review and remains rejected as documents still not received", hence the claim is not payable. . The complainant further averred that due to the act and conduct of the OP, he had to suffer mental agony, humiliation and harassment. Hence, it amounts to deficiency in service on the part of OP and as such he had to file the present complaint.
2. The opposite party has contested the complaint and filed written statement pleading therein that the complaint pertains to hospitalization claim of Neeraj S/o Sh. Bijender Kumar, who was insured under Health Plus Policy having policy vide no. 50179000202100, for the period from 5.5.2022 to 4.5.2023. However, it is submitted that the afore-said insurance policy was issued to the complainant by the OP subject to the terms and conditions of the insurance policy, which was never disputed by the insured. Therefore, it is submitted that in case if any liability would arise against the OP, then it would be subject to the terms and conditions of the insurance policy. Further, the reimbursement claim was filed by the complainant. Thereafter, the opposite party sought the requisite documents which was required:
Ultrasound report•
Indoor case papers including admission notes, mediclaim chart and vitals chart of the patient• Copy of the Hospital registration certificate with registration number with the local authorities/certificate from the hospital for the number of beds and other facilities available in the hospital.
• All the relevant records including consultation papers, investigation reports for treatment taken for current ailment prior to hospitalization.
• As per records submitted, patient is a known case of ureteric stone, please submit treating doctor certificate mentioning duration of the ureteric stone, all the treatment records including first consultation paper. Certificate is required to be signed and stamped by treating doctor.
• Copy of pre anesthetic check-up records and Operation theatre (OT) Notes for current surgery.• It is pertinent to mention here that reminders for the requirements of mandatory documents were sent on 23.3.2023, 19.4.2023 and 26.4.2023. The complainant has failed to provide the mandatory documents due to which the claim was repudiated by stating that as mandatory documents not received even after repeated reminders so claim cannot be processed. Rest of the averments made by complainant has been denied by the opposite party and requested that the complainant is not entitled for any relief and prayed for dismissal of the complaint.
3. In his evidence, the counsel for the complainant has filed affidavit Ex.CW1/A and documents Ex. C-1 to Ex.C-50 and closed the evidence on 24.4.2024.
4. On the other hand, the learned counsel for the opposite party has filed affidavit Ex.RW1/A along-with documents Annexure R1 to Annexure R5 and closed the evidence on 5.7.2024.
5. Arguments advanced by learned counsel for both the parties were heard and documents available on file were perused.
6. While having due regard to the contentions of learned counsel for both the parties, it is observed that it is not in dispute that the complainant viz. Shri Neeraj Kumar was having a Health Plus Policy, No. 50179000202100 which was valid from 5.5.2022 to 4.5.2023 for the insured value of Rs.one lakh. Learned counsel for complainant has argued that the complainant was admitted in Bhardwaj Hospital, Bhiwani on17.3.2023 with complaint of diagnose with stone lower ureter "R" side intramural part and operation for
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removal of the stone was carried out. After required operation, the complainant was discharged on 20.3.2023. An expenses for Rs.39,151/- were incurred as per treatment details and bills submitted vide Ex.C5 to Ex. C42. The complainant claimed reimbursement of said expenses from the OP under policy. The said claim was acknowledged by OP with claim ID no.2000032702 vide email dated 27.3.2023 (Ex.C43). Subsequently OP asked for additional documents vide email dated 26.04.2023 which were sent by the complainant. The additional documents were acknowledged by the OP vide email dated 01.5.2023 (Ex.C46). Thereafter, the OP vide its email dated 02.05.2023 (Ex.C47) conveyed to the complainant that Rs.28,109/- has been approved for his claim ID no.2000032702. However, the said approved amount of Rs.28,109/- was not released to the complainant. Subsequently, the claim was denied by the insurance company/OP on 18.7.2023 vide email dated 18.7.2023 (Ex.C50) giving reason: documents not received.
7. From perusal of above facts and documents placed on record, it is observed that any insurance company while issuing any insurance policy to any customer lures the client with benefits of the policy and smooth service in respect of settling the claim but lateron on filing claim, normally rejects the claim on false and frivolous grounds and sometimes asks for irrelevant documents repeatedly only to harass a customer. Any person who purchase the policy for his benefit, generally does not get the benefits of the same as per his entitlement in terms of the policy. In the instant case, as per document Ex.C47, insurance company approved the claim for Rs.28,109/-. However, the same was not released and subsequently additional documents were asked despite the acknowledgement of necessary documents which were made available to the OP by the complainant.
8. In the light of above-mentioned facts, circumstances, documents placed on record and arguments advanced by the counsel of both the parties, we find that complainant has been harassed by the OP as the claim was approved only for Rs.28,109/- against claim of Rs.39,151/- borne by the complainant and also the approved claim for Rs. 28,109/- was not released. It has no iota of ambiguity that OP would have approved claim for Rs.28,109/- on 02.05.2023 in the absence of requisite documents. Definitely the same was approved after receiving requisite documents. However with a malafide intention of denial of the claim, the additional documents were asked from the complainant again and finally the claim was repudiated on the ground of non submission of documents. This tantamounts to deficiency in service and unfair trade practice on the part of OP which caused also harassment of the complainant. Hence, the present complaint is allowed alongwith strict warning to OP-Insurance Company to avoid such type of mischievous activities in future otherwise we will be forced to direct Insurance Regulatory Development Authority of India to take strict action against this Niva Bupa Health Insurance Company. However, this time we are not taking any stringent action and pass following directions against insurance company.
The opposite party is directed to make payment of Rs.39,151/- (Thirty nine thousand one hundred fifty one only) incurred by the complainant on operation/treatment/medicines along-with interest @ 12% per annum from 20.03.2023 when the complainant made payment for the expenses till final payment to the complainant.
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To pay Rs. 25,000/- (Rs. Twenty Five Thousand only) for torture, mental agony and harassment.ii. To pay Rs. 25,000/- (Rs. Twenty Five Thousand only) for punitive damage as exemplary cost.iii. To pay Rs.10,000/- (Rs. Ten thousand only) as litigation expenses.iv.
The OP is directed to comply the order within 45 days from the date of receipt of this order, failing which OP shall pay interest of 15% p.a. from defaulted period.
9. If the order of this Commission is not complied with, then the complainant shall be entitled to file execution petition under section 71 of Consumer Protection Act, 2019 and in that eventuality, the opposite party may also be liable for prosecution under Section 72 of the said Act which provides punishment of imprisonment for a term which shall not less than one month, but which may extend to three years or with fine, which shall not be less than twenty-five thousand rupees, but which may extend to Rs. one lac or with both. Copies of this order be sent to the parties free of costs as per rules and this order be promptly uploaded on the website of this Commission. File be consigned to the record room after due compliance
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