The Division Bench of District Consumer Disputes Redressal Commission, East Delhi (Delhi) Chairman Sukhvir Singh Malhotra, Ravi Kumar (Member) and Ms. Rashmi Bansal (Member) directed Niva Bupa Health Insurance Company Limited to produce all important documents like hospital bills and receipts.
held responsible for deficiency in service for not paying the full sum insured after claiming. The District Commission said that refusing to pay the sum assured as per the terms and conditions and canceling the policy at a later stage amounts to deficiency in service on the part of the insurance company.
Mahesh Chand Jain (“Complainant”) had a bank account with Bank of Baroda (“Bank”). The Bank offered the complainant a group mediclaim policy from Niva Bupa Health Insurance Company Limited (“Insurance Company”) with a coverage amount of Rs 5,00,000. The complainant availed an insurance policy for himself and his wife, which was in force for 1 year starting from 27 March 2020. During this period, the complainant was admitted to Max Smart Super Specialty Hospital (“Hospital”) after he tested positive for COVID-19 on June 20, 2020. When he was discharged, the hospital raised a bill of Rs 2,76,507 and the complainant claimed the said amount from the insurance company. However, the insurance company refused cashless payment of the treatment, hence, the complainant paid Rs 2,71,507 to the hospital after a discount of Rs 5000. After making the payment, the complainant submitted the claim papers to the insurance company, which after reviewing the paperwork, sanctioned only Rs 94,280, saying the claim was not valid and the bills were inflated. Subsequently, the complainant contacted the insurance company several times, but did not receive any response. The complainant then filed a consumer complaint with the District Consumer Disputes Redressal Commission, East Delhi, Delhi (“District Commission”).
The bank refuted the complainant’s contentions saying that they were only proposers of the insurance policy and the premium was paid by the complainant directly to the insurance company.
The insurance company said that they acted as per the GI Council COVID-19 guidelines and approved the claim as per the prescribed rates. He also mentioned that he came to know from the past medical records of the complainant’s wife that she was suffering from rheumatoid arthritis and post hysterectomy about 8-10 years ago and these facts were not disclosed at the time of inception of the policy and hence he A notice to cancel the policy was also issued to the complainant.
The hospital argued that there were misrepresentations by the parties in the complaint and clarified that they had no role in settling the claim, providing medical treatment as per the protocol and charging as per the prescribed rates.
Commission’s Comments:
Referring to the insurance company’s contention that they had acted as per the GI Council COVID-19 guidelines, the District Commission said that it failed to clarify how these guidelines applied to the complainant’s case and how these guidelines were implemented. How the complainant was informed. Further, the insurance company’s investigation into the past illness of the complainant’s wife and the subsequent notice of cancellation of the policy raised questions. The District Commission noted that the insurance company did not consider this aspect while issuing the policy and only examined it upon receiving the claim, potentially depriving the complainant and his family of the policy benefits.
Therefore, the District Commission held that the insurance company did not produce sufficient evidence to approve only a partial amount of the complainant’s claim. The District Commission noted that the insurance company was bound to abide by the terms and conditions of the insurance policy issued by it, and denial of benefits under the policy amounted to deficiency in service. The District Commission rejected the complaint against the bank and the hospital and said that the complaint against them was baseless.
As a result, the District Commission directed the insurance company to pay Rs 1,77,227 to the complainant along with interest at the rate of 7% per annum. Besides this, the insurance company was also directed to pay Rs 15,000 to the complainant for the mental agony caused to him and the legal expenses incurred by him.
