Order No.  7  dt.  18/06/2018

        The case of the complainant in brief is that the complainant is a businessman and he obtained a policy from o.p. insurance company. Name of the policy was Health Guard (Floater) Policy which has been agreed and ported by the o.p. from previous policy of Max Bupa Insurance Co. Ltd. The complainant has medical insurance since 27.09.2002 i.e. more than 15 years. The complainant switched over to different insurance companies and lastly the same was ported to o.p. and the policy was valid from 12.10.2017 to 11.10.2018. During the substance of the said policy the complainant while went to Hyderabad for a routine checkup it was found that there was mass on right kidney and the complainant was treated by Dr. S.V. Kandasami and subsequently he was referred to Asian Institute of Nephrology and Urology, Hydrabad. The patient was hospitalized in the said hospital for the period from 05.12.2017 to 11.12.2017. The complainant paid the medical bill to the tune of Rs.3,10,000/- (Rupees Three Lakh and Ten Thousand) only, after recovery the complainant claimed the said amount from o.p. but the claim of the complainant was repudiated with the observation that as per Doctor’s Certificate the complainant was suffering from Renal upper pole  tumour since 23.11.2017 which was prior to inception of the policy and the same was not disclosed in the proposal form, for which claim of the complainant was not accepted.           

            On the basis of the said fact the complainant filed this case praying for direction upon the o.p. for payment of the Bill of Rs.3,31,444/- (Rupees Three Lakh Thirty One Thousand Four Hundred and Forty Four) only and also prayed for compensation of Rs.50,000/- (Rupees Fifty Thousand) only  for harassment and mental agony along with litigation cost.

            The o.p. did not contest the case, as such, the case has proceeded ex-parte against o.p. insurance company. The complainant in order to substantiate his claim filed an affidavit of evidence whereby he stated that during the subsistence of the said policy the complainant became ill and he was treated in the hospital and after recovery from his said illness he submitted the bill to the o.p. but the o.p. insurance company repudiated the claim stating inter alia that the complainant suppressed the material of fact at the time of inception of the policy. The complainant in order to show the subsistence of the policy files and documents and during the period of the said policy the complainant fell ill. The complainant has also alleged that the policy was ported from Max Bupa health insurance policy and the o.p. accepted the terms of the policy as the complainant used to enjoy during the continuation of the policy under Max Bupa Health Insurance Policy. The complainant has also filed the documents showing that he was admitted to the hospital for his treatment and incurred the expenses to the tune of Rs.3,31,444/- (Rupees Three Lakh Thirty One Thousand Four Hundred and Forty Four) only the evidence filed by the complainant has remained unchallenged and it appears from the materials on record that at the time of undergoing treatment by the complainant the policy was valid and the complainant immediately after his recovery he submitted the claim to the insurance company. The insurance company in order to evade the payment of the bill to the complainant repudiated the claim of the complainant without having any cogent reason whatsoever. It appears from the record that the policy was valid and the same was ported to the o.p. insurance company from Max Bupa.

            In view of the facts stated above, we hold that there is no contrary evidence against the claim of the complainant having regard to the said fact we hold that the complainant will be entitled to get the medical expenses incurred by him as well as the compensation and litigation cost.

                        Hence, it is ordered,

            that the case no. 75 of 2018 is allowed ex-parte with cost against o.p. and the o.p. is directed to reimburse the amount of Rs.3,31,444/- (Rupees Three Lakh Thirty One Thousand Four Hundred and Forty Four) only and pay compensation Rs.10,000/- (Rupees ten Thousand) only for harassment and mental agony along with litigation cost of Rs.5,000/- (Rupees Five Thousand) only within 30 days from the date of communication of this order, i.d. an interest @ 8% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.