STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

                                    U.T., CHANDIGARH 

Paramjit Mittu, aged 50 years, resident of House NO.312, Village Haripur, Sector 4, Panchkula.

                                                                                             …Appellant

                                         V e r s u s

1]   Manager, Max Bupa Health Insurance Co. Ltd., SCO 55-56-57,                     Sector 8-C, Chandigarh.

2]   Manager Claims, Max Bupa Health Insurance Co. Ltd., B-1/1-                        2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi                 110044                                                                                                                                                                                    ...Respondents

Appeal under Section 15 of the Consumer Protection Act, 1986 against   order dated 03.02.2017 passed by  District   Consumer Disputes Redressal Forum-II, U.T. Chandigarh in Consumer Complaint No. 397/2016.

Argued by:    Ms. Ritu S.Sharma, Advocate for the appellant

 BEFORE:  JUSTICE JASBIR SINGH (RETD.), PRESIDENT                                              MR.DEV RAJ, MEMBER

                     MRS. PADMA PANDEY, MEMBER

PER JUSTICE JASBIR SINGH (RETD.), PRESIDENT

                    Appellant/Complainant has filed this appeal against order dated 03.02.2017, passed by the District Consumer Disputes Redressal Forum-II, U.T., Chandigarh (in short the Forum only), vide which his complaint bearing  No.397/2016 was allowed. By filing this appeal, a prayer has been made to enhance the amount awarded vide order, referred to above. 

2.            As per facts on record, the complainant had purchased one health insurance Policy for the sum insured of Rs.9,00,000/-, valid between 7.6.2014 to 6.6.2015, against payment of premium of Rs.20,964/-.  On expiry of the above said Policy, it was further  renewed upto 6.6.2016 for insurance cover of Rs.9,20,000/- by paying premium of Rs.22,238/-. During survival of the above said Policy, the complainant fell ill and remained admitted in Alchemist Hospital between 23.12.2014 to 24.12.2014.  He was treated for Hemoptysis. The hospital charged bill for an amount of Rs.43,305/-. The complainant raised a claim for reimbursement of the amount paid. However, his claim was rejected on the ground that he had past history of hypertension since 1999 and he was alcoholic also.  Under above circumstances, a consumer complaint was filed in the Forum. 

3.            Upon notice, reply was filed. It was said that claim of the complainant was rejected because of violation of terms and conditions of the Policy. Past history qua hypertension was not disclosed when Policy was obtained. On receipt of claim for reimbursement, investigation was got conducted  and it was confirmed that the insured was suffering from the above said disease prior to the purchase of the insurance Policy. He also suffered gunshot injury at an early point of time.  He has failed to disclose the material facts at the time of obtaining the insurance cover, and as such, his claim was rejected. 

4. Both the parties led evidence.
The Forum, on analysis of pleadings, documents on record, and arguments address, allowed the complaint ordering the OPs/respondents to make payment of  an amount of Rs.43,305/- to the complainant within the stipulated period and further an amount of Rs.10,000/- towards litigation expenses. When granting the above said relief, the Forum observed as under ;

“ In the pre-authorization form (Annexure-C) Hypertension in column Past History of any illness has been marked without any duration of time nor any document has been placed on record by OPs to substantiate this fact of Hypertension as disease since long.  This could have been the immediate result of the sufferings arising out of disease/problem of Hemoptysis for which the complainant got admitted in Hospital on 23.12.2014.

The complainant is reported to be merely occasionally alcoholic (Ann.P)

The gunshot injury, if any, suffered by the complainant has no nexus with the present disease of Hemoptysis. 

The grounds of repudiation of claim of Rs.43,305/- on account of treatment by complainant for Hemoptysis, by the OPs are untenable, frivolous and without merits.

      The complainant had valid Medical Health Insurance Policy for the period w.e.f. 7.6.2014 to 6.6.2015.  The OPs have themselves renewed the Health Insurance Policy for further period of 7.6.2015 to 6.6.2016 on receiving the premium of Rs.22,238/- from the complainant after his hospitalization and treatment in Alchemist Hospital w.e.f. 23.12.2014 to 24.12.2014.  Had there been any doubt or question about eligibility of complainant, the OPs should not have renewed the policy.” 

5.             It was rightly held that hypertension has no nexus to the disease suffered by the complainant and further gunshot injury 10 years prior to the purchase of the Policy has nothing to do with the claim raised. The complainant was holding a valid insurance cover and his claim was wrongly rejected.  However, contention of Counsel for the appellant that the amount awarded is on the lower side, is not tenable.  We have gone through the documents on record and found that the Forum has rightly ordered reimbursement of billed amount and also litigation costs.  We find no case made out to interfere in the order, under challenge.

 6.         For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed,   at the preliminary stage, with no order as to costs. The order of the District  Forum is upheld.

7.             Certified copies of this order, be sent to the parties, free of charge.

8.           The file be consigned to Record Room, after completion.

Pronounced.

25.04.2017