BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 473 of 2014

Date of Institution: 27.08.2014

Date of Decision: 24.02.2016

Ms.Komal Sharma daughter of Sh.Satya Paul, resident of House No. 785, Gali No.2, Nai Sadak, Katra Karam Singh, Amritsar.  

Complainant

Versus

1.       Smt.Ruhi Bhrany, carrying on business as an authorized agent of Max Bupa Health Insurance Company Limited, at 367, Green Field, Amritsar, Punjab.

2.       Max Bupa Health Insurance Company Limited, 2^nd Floor, Kunal Towers, Plot No. 88, Mall Road, Ludhiana, Punjab through its Manager/ Principal Officer.    

Opposite Parties

Complaint under section 11 and 12 of the Consumer Protection Act, 1986 as amended upto date.

Present: For the Complainant: Sh. S.K.Sharma, Advocate.

              For Opposite Party No.1: Sh.Rajat Anand, Advocate.

              For Opposite Party No.2: Sh.R.P.Singh, Advocate.

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Ms.Komal Sharma under the provisions of the Consumer Protection Act alleging therein that  she obtained medical policy bearing No. 30172837201300 from Opposite Parties  i.e. Max Bupa Health Insurance  under the Health  Companion Silver 02.0 lacs 1 Adult Plan starting w.e.f. 23.1.2013 to 22.1.2014, for a sum of Rs.2 lacs. Complainant alleges that on 16.7.2013 she became unconscious with sudden starry look while studying in her room and subsequently got admitted to Uppal Neuro Hospital and Super Specialty Center at 4, Rani Ka Bagh, Amritsar and the Opposite Parties  were informed accordingly by the father of the complainant. The hospital authorities had done MRI and other treatment and according to their discharge report. The complainant was discharged from the hospital on 19.7.2013. After few days the representative of the Opposite Parties  approached the complainant and asked for original policy documents and hospital bills. Accordingly, the complainant had submitted all the original hospital bills to Opposite Party which amounts to Rs.15,590/- alongwith photo copy of the policy in question.  But the Opposite Parties  repudiated the claim of the complainant on 21.8.2013 on the ground that as per the investigation report the patient has been suffering from seizure for 15 years and she was also suffering with depression and all this was not disclosed at the time of inception of policy, thus denied for being pre-existing, non-disclosure and further psychosomatic disorder are not payable.  It is worthwhile to mention over here that the complainant had a brilliant academic record and at present she is studying in the Final year of Chartered Accountant, so the contention of the Opposite Party that the complainant has been suffering from seizures for 15 yeas is wrong and unbelievable.   Alleging the same to be deficiency in service, complaint was filed seeking directions to Opposite Parties  to make the payment of claim amount of Rs.15,590/- alongwith interest @ 24% per annum from 16.7.2013 till its payment. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Party No.1 appeared and filed written version in which it was submitted that  the complaint against the answering Opposite Party is liable to be dismissed at the threshold as there was no contract/ agreement between the complainant. Opposite Party No.1 being the authorized agent of Opposite Party No.2 merely offered/ explained/ introduced the policy to the complainant and no terms and conditions or commitments regarding the policy were ever settled between the complainant and Opposite Party No.1. All the averments in the complaint are denied for want of knowledge and being not related to Opposite Party No.1 in any manner.  While denying and controverting other allegations, dismissal of complaint was prayed.
3. Opposite Party No.2 appeared and filed written version in which it was submitted that company had explained entire features of the said health insurance plan to the complainant and the complainant out of her own free will and volition agreed to terms and conditions of the policy. However, the complainant did not disclose her pre-existing disease of GTC seizures which she had been suffering for the last 15 years as per her own statement. As per the documents, the complainant Komal Sharma was suffering from diseases (specifically shown in the case history of Uppal Neuro Hospital and Super Specialty Center at 4, Rani Ka Bagh, Amritsar  and the statement given by the complainant) for the last 15 years, but this fact has not been mentioned in the proposal form, duly filled in and signed by the complainant at the time of getting the policy issued from the Opposite Party, therefore, the complainant intentionally concealed the material facts from the Opposite Parties. While denying and controverting other allegations, dismissal of complaint was prayed.
4. Complainant tendered into evidence her affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C19 and closed the evidence on behalf of the complainant.
5. Opposite Party No.1 tendered into evidence her affidavits Ex.OP1/1 and Ex.OP1/A. Similarly, Opposite Party No.2 tendered into evidence affidavit of Sheena Kaur Ex.OP2/1 alongwith documents Ex.OP2/2 to Ex.OP2/8 and affidavit of Sh.Anand R.Chaudhary Ex.OP2/9 and closed the  evidence on behalf of the Opposite Parties.
6. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
7. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant  obtained medical policy bearing No. 30172837201300 (copy of certificate of insurance is Ex.C2 and copy of policy alongwith terms and condition Ex.OP2/6)  from Opposite Parties for the period from 23.1.2013 to 22.1.2014, for a sum assured of Rs.2 lacs. On 16.7.2013 the complainant became ill and was admitted in Uppal Neuro Hospital and Super Specialty Center at 4, Rani Ka Bagh, Amritsar. Opposite Parties  were also informed accordingly. The complainant was discharged from the aforesaid hospital on 19.7.2013 as per discharge card Ex.C5. The complainant spent Rs.15,590/- on her medical treatment as per detail of bills Ex.C10, and copies of bills. Ex.C11 to Ex.C17. After discharge from the hospital, the claim was lodged with Opposite Parties, but the Opposite Parties repudiated the claim of the complainant vide letter dated 20.9.2013 Ex.C19 on the ground of concealment of facts by the complainant/ father of the complainant (proposer) at the time of taking the policy. Ld.counsel for the complainant has submitted that she/ or her father had not concealed any material fact while obtaining the policy in question. Opposite Party has wrongly repudiated the claim of the complainant under the aforesaid policy and all this amounts to deficiency of service on the part of the Opposite Parties.       
8. Whereas the case of the Opposite Parties is that the complainant has concealed the material facts while obtaining the policy in question. She is not entitled to any claim. The complainant Komal Sharma was suffering from disease GTC seizures specifically shown in the case history of Uppal Neuro Hospital and Super Specialty Center at 4, Rani Ka Bagh, Amritsar  and statement given by the complainant, for the last 15 years, but has not mentioned in the proposal form Ex.OP2/7 duly filled in and signed by the father of the complainant Satya Paul, proposer, for getting the policy issued from the Opposite Party. Therefore, the complainant/ her father intentionally concealed the material facts from the Opposite Parties  while taking the insurance policy. Opposite Party appointed Investigator Ms.Sheena Kaur who thoroughly investigated the matter and submitted the investigation report Ex.OP2/2 dated 19.8.2013 and she got recorded the statement of Komal Sharma complainant as well as father of the complainant in which the complainant as well as her father has admitted that the complainant was suffering from depression and stress disorder for the last 15 years. Apart from this investigator collected the medical record of complainant from Uppal Neuro Hospital and Super Specialty Center at 4, Rani Ka Bagh, Amritsar  Ex.OP2/5 in which it has been written that the complainant had been suffering from seizures for the last about 15 years and as per the exclusion clause No. 4 of the terms and conditions of the policy Ex.OP2/6, the insurance company is not liable under this policy for any claim in connection with pre existing conditions until 48 months  of continuous coverage have elapsed since the inception of the first policy as well as for treatment of any mental illness or sickness of disease including a psychiatric condition, disorganization of personality or mind, or emotions or behaviour, even if caused or aggravated by or related to an accident or illness or general debility or exhaustion (Clause 4.e.xviii). Ld.counsel for Opposite Party submitted that Opposite Party has rightly repudiated the claim of the complainant vide letter dated 20.9.2013 Ex.C19. As such, there is no deficiency of service on the part of the Opposite Parties  qua the complainant.          
9. From the entire above discussion, we have come to the conclusion that father of complainant namely Satya Paul got medical insurance policy in the name of his daughter i.e. complainant Komal Sharma vide policy bearing No. 30172837201300 (copy of certificate of insurance is Ex.C2 and copy of policy alongwith terms and condition is Ex.OP2/6)  from Opposite Party No.2 for the period from 23.1.2013 to 22.1.2014 with sum assured  Rs.2 lacs. Komal Sharma, complainant became ill and she was admitted in Uppal Neuro Hospital and Super Specialty Center at 4, Rani Ka Bagh, Amritsar on 16.7.2013 and discharged on 19.7.2013. The complainant spent Rs.15,590/- on her medical treatment, as per detail of bills Ex.C10, and copies of bills. Ex.C11 to Ex.C17. Claim was lodged with Opposite Party No.2 and Opposite Party No.2 appointed investigator Ms.Sheena Kaur, Proprietor of Prompt Investigators, New Delhi who thoroughly investigated the case of the complainant and submitted her report Ex.OP2/2 dated 19.8.2013. She collected the entire medical record of the complainant from Uppal Neuro Hospital and Super Specialty Center at 4, Rani Ka  Bagh, Amritsar  Ex.OP2/5 and she also  recorded joint statement of the  complainant  and  her father Satya Paul Ex.OP2/4, in which the complainant as well as her father have admitted that the complainant was suffering from disease GTC Seizures for the last 15 years. While  filling  in the  proposal form Ex.Op2/7 for taking  the  policy in question father of the complainant as well as complainant  had      not mentioned this disease of the complainant, rather they have concealed this fact while taking the medical policy in question from the Opposite Parties.  As per the exclusion clause No. 4 of the terms and conditions of the policy Ex.OP2/6, the insurance company is not liable under this policy for any claim in connection with pre existing conditions until 48 months  of continuous coverage have elapsed since the inception of the first policy as well as for treatment of any mental illness or sickness of disease including a psychiatric condition, disorganization of personality or mind, or emotions or behaviour, even if caused or aggravated by or related to an accident or illness or general debility or exhaustion (Clause 4.e.xviii). It has been held by Hon'ble National Commission in case Life Insurance Corporation of India Vs. Mansa Devi 2003(1) Judicial Reports Consumer 501 that where the insured has suppressed the material facts of existence of any pre-existing disease and had undergone treatment for that, the suppression of such a material fact renders the contract of insurance illegal, invalid, void abinitio and unenforceable. Hon'ble National Commission further held that the contract of insurance is of utmost good faith i.e. Ubremma Fidei and the life assured is bound to disclose honestly, truthfully and correctly all the answers in the proposal form concerning the state of his health. The same view has been taken by the Hon'ble National Commission in case Sr. Divisional Manger, LIC of India Vs. Smt. Satwant Kaur Sandhu Legal Digest April 2011 page 85 as well as in case Panchal Ramabhai Motibhai Vs. LIC of India Legal Digest April 2011 page 83. So the concealment of this material fact by the complainant while obtaining the present policy from the opposite party renders this contract of insurance illegal and void. Hon'ble Supreme Court of India in case Satwant Kaur Sandhu Vs. New India Assurance Company Ltd IV (2009) CPJ 8 (SC) has held that in case of mediclaim policy where the policy holder suffering from chronic diabetes and renal failure not disclosed while obtaining the medi claim insurance policy, this suppression of material fact has been fully proved by the opposite party. Apart from this Hon'ble Supreme Court of India observed in case Satwant Kaur Sandhu Vs. New India Assurance Company Limited (supra) that :-

“A medi claim policy is a non-life insurance policy meant to assure the policy-holder in respect of certain expenses pertaining to injury, accidents or hospitalizations. Nonetheless, it is a contract of insurance falling in the category of contract ubremma fidei, meaning a contract of utmost good faith on the part of the assured. Thus, it needs little emphasis that when an information on a specific aspect is asked for in the proposal form, an assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. It is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not. Of course, the obligation to disclose extends only to facts which are known to the applicant and not to what he ought to have known. The obligation to disclose necessarily depends upon the knowledge one possesses. His opinion of the materiality of that knowledge is of no moment.”

10. From the above discussion, we are of the opinion that as the complainant/ her father have concealed the material facts while taking the medical insurance policy in question for the complainant, the Opposite Parties were  therefore, justified in repudiating the claim of the complainant vide letter dated 20.9.2013 Ex.C19.       
11. Resultantly, we hold that the complaint is without merit and the same is hereby dismissed with no order as to costs. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 24.02.2016.                                                            (Bhupinder Singh)                                                                                                                                                                                                     President

hrg                                                 (Kulwant Kaur Bajwa)    (Anoop Sharma)

                                                           Member                         Member