East Delhi District Commission Holds Niva Bupa Health Insurance Co. Liable For For Deficiency In Service

Brief Facts:

Mahesh Chand Jain (“Complainant”) had a bank account with the Bank of Baroda (“Bank”). The bank proposed a Group Mediclaim Policy, from Niva Bupa Health Insurance Co. Ltd. (“Insurance Company”) with a coverage amount of Rs. 5,00,000/-, to the Complainant. The Complainant availed the insurance policy for himself and his wife, which was applicable for 1 year starting from 27th March 2020. During this period, the Complainant, diagnosed with COVID-19 on June 20, 2020, was admitted to Max Smart Super Speciality Hospital (“Hospital”). When he was discharged, the Hospital made a bill of Rs. 2,76,507/- and the Complainant claimed the said amount from the Insurance Company. However, the Insurance Company denied the cashless payment of the treatment, therefore, the Complainant made a payment of Rs.2,71,507/- to the Hospital after a discount of Rs. 5000/-. After making the payment, the Complainant submitted claim papers to the Insurance Company, which after reviewing the paperwork, sanctioned Rs. 94,280/- only, saying that the claim was not valid and bills were exaggerated. Thereafter, the Complainant approached the Insurance Company several times but didn't receive a response. The Complainant then filed a consumer complaint in the District Consumer Disputes Redressal Commission, East Delhi, Delhi (“District Commission”).

The bank denied the Complainant's contentions, stating that they were only proposers of the insurance policy and that the premium was directly paid by the Complainant to the Insurance Company.

The insurance company stated that they acted according to GI Council COVID-19 guidelines and approved the claim in line with the prescribed rates. They also mentioned that they came to know from previous medical records of the Complainant's wife that she was suffering from Rheumatoid Arthritis and Post Hysterectomy about 8-10 years back and these facts were not revealed at the time of inception of the policy and therefore they issued a notice of cancellation of the policy to the Complainant also.

The Hospital contended that the complaint had a misjoinder of parties and clarified that they had no role in settling the claim, providing medical treatment as per protocols, and charging as per prescribed rates.

Observations by the Commission:

While referring to the Insurance Company's submission that they had acted according to GI Council COVID-19 Guidelines, the District Commission held that it failed to clarify how these guidelines applied to the Complainant's case and how these guidelines were communicated to the Complainant. Furthermore, the Insurance Company's investigation into the Complainant's wife's previous illness and the subsequent notice for policy cancellation raised concerns. The District Commission noted that the Insurance Company did not consider this aspect at the time of policy issuance and only examined it upon receiving the claim, potentially depriving the Complainant and his family of policy benefits.

Therefore, the District Commission held that the Insurance Company didn't present enough evidence to justify sanctioning only a partial amount of the Complainant's claim. The District Commission noted that the Insurance Company was obligated to adhere to the terms and conditions of the insurance policy it issued, and denying benefits under the policy constituted a deficiency in service. The District Commission rejected the complaint against the Bank and the Hospital noting that the complaint was unsubstantiated against them.

Consequently, 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. Further, the Insurance Company was also directed to pay Rs. 15,000/- to the Complainant for mental agony and legal expenses incurred by him.

Case Title: Mahesh Chand Jain Vs Bank of Baroda And Others

Case No.: Complaint Case No. CC/8/2021

Advocate for the Complainant: N.A.

Advocate for the Respondent: N.A.