Chandigarh

StateCommission

A/71/2021

Niva Bupa Health Insurance Company Ltd. - Complainant(s)

Versus

Abhishek Gupta - Opp.Party(s)

Karandeep Singh Cheema, Gauranv Bhardwaj & Chetan Gupta Adv.

24 Feb 2022

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

UNION TERRITORY, CHANDIGARH

 

Appeal No.	71 of 2021
Date of Institution	06.09.2021
Date of Decision	24.02.2022

1. NIVA BUPA Health Insurance Company Limited (Formerly known as Max Bupa Health Insurance Company Limited) through its Authorized Officer, Registered Office at C-98 Lajpat Nagar, Part 1, New Delhi-110024.
2. NIVA BUPA Health Insurance Company Limited (Formerly known as Max Bupa Health Insurance Company Limited), through its Authorized Officer, Branch Office SCO No.55, 56 & 57, Sector 8-C, Madhya Marg, Chandigarh 160009 .

    …..Appellant/Opposite Party

Versus

Abhishek Gupta, R/o H.No.1488/1, Sector 43-B, Chandigarh.                                                                                    …..Respondent/Complainant               

BEFORE:  MRS. PADMA PANDEY, PRESIDING MEMBER

                MR. RAJESH K. ARYA, MEMBER

               

Argued by:  Sh. Gaurav Bhardwaj, Advocate for the Appellant.

 Ms. Pratula Sethi, Advocate for the Respondent.

                       

PER PADMA PANDEY, PRESIDING MEMBER

              This appeal is directed against an order dated 01.07.2021, rendered by District Consumer Disputes Redressal Forum-II (now District Commission-II), U.T., Chandigarh (in the short ‘the District Commission’ only), vide which, it allowed the Consumer Complaint, with the following directions: -

“a)  To reimburse the medical claim of Rs.1,20,845/- to the complainant, as claimed vide claim form Ann.R-5;

 

b)  To revive the earlier policy of the complainant bearing Policy No.30888932201900 (Ann.C-1) from the date of cancellation for further period, without any gap, and in case the same has expired after full term, to issue a fresh policy in continuation thereof, demand premium thereof, from the complainant to be deposited within 30 days from the date of receipt of such communication;

c)  To pay a compository amount of Rs.20,000/- to the complainant towards compensation for the harassment suffered by him as well as litigation expenses.

      This order shall be complied with by the OPs within a period of 30 days from the date of its receipt, failing which they shall be liable to pay additional cost of Rs.10,000/- apart from the above relief.”

2. The facts, in brief, are that the complainant obtained health insurance from Opposite Parties vide Policy No.30888932201900 (Annexure C-1) making payment of two years premium for Health Companion Variant-2 Policy effective from 06.02.2019 to 05.02.2021 covering the complainant, his wife and son. It was stated that the complainant was not taking any treatment from any doctor. It was further stated that the complainant suffered from skin itching for which he visited Dr. Swami Dass Mehta, Skin Specialist, who diagnosed it to be scabies and gave treatment from 28.03.2019 till 18.05.2019 (Annexure C-2).  It was further stated that the complainant was having fever despite taking medicine as prescribed by doctor, ultimately visited Mohan Dai Oswal Hospital, Ludhiana on 15.06.2019 where he remained admitted from 15.06.2019 to 19.06.2019 and then was discharged referring him to higher institution for further treatment and management vide Annexure C-5 and then the complainant visited Fortis Hospital, Mohali on various dates in the month of June to August, 2019 (Annexure C-6).  It was further stated that the complainant submitted reimbursement of various bills qua medical treatment expenditure of Rs.1,20,845/- with Opposite Parties alongwith all requisite documents, but the same was rejected by the Opposite Parties vide letter dated 04.11.2019 on the ground that symptom of the present ailment fall prior to the policy date being that of ‘Skin Rashes” and amounts to non-disclosure of material fact (Annexure C-10). It was further stated that the Opposite Parties also cancelled the policy of the complainant for the same reason as that of papillary skin rashes since Sept., 2018 (Annexure C-11). It was further stated that the aforesaid act of the Opposite Party, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant, was not redressed, left with no alternative, a complaint, was filed.
3. The Opposite Parties filed reply and admitted the factual matrix of the case. It was stated that as per the documents/investigation done by the company, it was found that the insured had history of disease before taking the policy; he had Papillary Lesions and Severe & intense itching and was treated for the same, three months prior to the issuance of the policy, and the same was not disclosed at the time of taking the policy with Max Bupa, and therefore, the claim will not be payable under the policy.  It was further stated that the complainant had history of medical problems before the date of submitting the proposal form, which was not disclosed at the time of taking the policy, therefore, the answering Opposite Parties rightly repudiated the claim.  It was further stated that the complainant being specifically asked about the material information, had not disclosed his adverse health conditions in the proposal form, therefore, the claim of the complainant as well as the policy, in question, is rejected & cancelled. It was further stated that there is no deficiency in service on their part, and the Opposite Parties had prayed for dismissal of the complaint.
4. In the rejoinder, filed by the complainant, he reiterated all the averments, contained in the complaint.
5. The parties led evidence, in support of their case.
6. After hearing the Counsel for the Parties, and, on going through the evidence, and record of the case, the District Commission, allowed the complaint against Opposite Parties, as stated above.
7. Feeling aggrieved, the instant appeal, has been filed by the Opposite Parties.
8. We have heard the Counsel for the Parties, and have gone through the evidence, and record of the case, carefully.
9. After giving our thoughtful consideration, to the contentions, advanced by the Parties, and the evidence, on record, we are of the considered opinion, that the appeal is liable to be dismissed, for the reasons to be recorded hereinafter.
10. From the records of the learned District Commission, we find that the main reason for the appellant to repudiate the claim was that the respondent did not disclose about the health status against the health columns as mentioned in the proposal form and therefore, held guilty by the insurance company for
    non-disclosure of material information as per the policy conditions and hence the repudiation. But on a perusal of the record, it is observed that the itching problem faced by the respondent is a very common, could occur due to change of season, with dust and pollution allergy and having such itching is not serious problem that non-disclosure of the same is to be considered as concealment of material information. It is also observed that at the time of the issuance of the policy, the respondent was not under the medication of itching. However, after the issuance of the policy, he was diagnosed with the problem of itching. Thus, we find that the respondent did not conceal any information about his health, which warranted repudiation of his claim. This Commission therefore inclined to fall in line with the decision of the District Commission and accordingly, the appeal stand dismissed.
11. For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, with no order as to costs. The order of the District Commission is upheld.
12. Consequently, Miscellaneous Application No.659 of 2021 for staying the operation of the impugned order dated 01.07.2021 also stands dismissed, having been rendered infructuous.
13. Certified copies of this order, be sent to the parties, free of charge.
14. The file be consigned to Record Room, after completion.

 

Pronounced.

24.02.2022

      

 

                                                                        Sd/-                     

[PADMA PANDEY]

PRESIDING MEMBER

 

                                                                           Sd/-                                         

[RAJESH K. ARYA]

 MEMBER

GP