DISTRICT CONSUMER DISPUTES REDRESSAL, FORUM
TEHSIL COMPLEX, MANSA
CC No.209 of 2014
Date of Institution: 04.11.2014.
Date of Decision: 05.03.2015.
Amritpal Singh S/o Kuldeep Singh resident of Street No.1, Link Road, near Bus Stand Mansa, Tehsil and District Mansa.
......Complainant.
Versus
Max Bupa Health Insurance Co. Ltd. Corporate Office 2nd Floor, Salcon Resvilas, D-1, District Center, Saket, New Delhi- 110017 through its MD.
......Opposite Party.
Complaint under Section 12 of the
Consumer Protection Act, 1986.
Present:
For complainant : Sh. Satish Singla, Advocate. For OP : Sh. Rishu Singla, Advocate.
Quorum:
Sh. Surinder Mohan, President.
Sh. Shiv Pal Bansal, Member.
Smt. Neena Rani Gupta, Member.
ORDER
Surinder Mohan, President.
Brief facts are that complainant purchased cashless insurance policy from OP for the period 19.10.2013 to 18.10.2014. Complainant suddenly fell ill and was got admitted in Max Hospital Mohali. At the time of delivery of the policy, a list of paneled hospitals was also given by the OP to complainant. Due to cashless policy, complainant delivered all the relevant documents of his policy to Max Hospital Mohali. After receiving the documents, the Doctors of Max Hospital started treatment of complainant. The Doctors of Max Hospital Mohali also confirmed from the officials of Insurance Company at their toll free number. The officials of Insurance Company assured the Doctors that they will pay all the expenses incurred on the treatment of complainant. After confirmation the Doctors started treatment of the complainant. At the time of discharge, complainant was shocked and bothered when he came to know that expenses of his treatment were not paid by the insurance company. Officials of Max Hospital told the complainant that they will only discharge after he will pay all the expenses incurred on his treatment. Complainant paid Rs. 25000/- as expenses incurred on his treatment. After receiving the payment Max Hospital discharged the complainant from the Hospital. The claim was not paid by OP without mentioning any reason just to harass the complainant. In this way, OP is clearly deficient in rendering service to the complainant. Complainant was harassed mentally and physically and is also entitled to claim compensation on account of harassment from OP. A prayer has been made to direct the OP to pay Rs. 25000/- with interest as expenses incurred on the treatment of complainant and to pay Rs. 20000/- as compensation on account of harassment and Rs. 10,000/- for legal expenses.
2. In reply several legal objections have been taken by OP. The complainant has failed to make out a case of “deficiency of service”. The claim was not payable as per exclusions clause 4(a) of the terms and conditions of the policy, which is reproduced as under:-
a) Pre-Existing diseases.
Benefits will not be available for pre-existing diseases until 48 months of continuous coverage have elapsed since the inception of the first policy with us.
The complainant was suffering from hypertension since one year and he was diagnosed with “Essential (Primary) hypertension”. Therefore, the claim is not payable. At the time of processing the policy, the complainant concealed the fact that he was suffering from hypertension and thus has suppressed material and relevant facts at the time of taking the policy. The complainant was specifically asked to disclose medical history vide 4 questions as detailed in the Information Summary Sheet. The complainant answered in negative to all the questions and did not disclose that he is suffering from hypertension. When an information on a specific aspect is asked for at the time when insured proposes to buy a policy, an insured is under solemn obligation to make a true and full disclosure of the information on the subject which is within knowledge. The complaint has been filed with malafide and dishonest intention. Complainant has not only concealed material facts but also twisted and distorted the same to suit his own convenience and to mislead the Forum . The complainant has acted in bad faith with respect to subject of this complaint and has approached the Forum with unclean hands. The insurance between the complainant and OP is governed by its policy terms and conditions and as per law laid down by Hon'ble Apex Court in case titled “Vikram Greentech (i) Ltd and another Vs New India Assurance Co. Ltd 2009(4) CLT 313” and further in case titled “Deokar Exports Pvt. Ltd. Vs New India Assurance Co. Ltd 2009 (2) CLT 15” it is held that;
“In a contract of insurance, rights and obligations are strictly governed by the policy of Insurance. No exception or relaxation can be made on the ground of equity”.
None disclosure amounts to fraud and nobody can take the benefit of its owns wrongs. The complainant has unnecessarily dragged the answering respondent into uncalled for litigation under the garb of CPA.
3. It is admitted that the policy was issued on the basis of information supplied by complainant. It is pleaded as a matter of record that complainant was admitted in MAX Hospital Mohali for treatment. It is denied that after receiving the documents, the Doctors of Max Hospital started the treatment. As per procedure for the cashless facility, pre-authorization request is submitted by the hospital to the insurance company. The hospital has to submit the pre-authorization form containing the diagnoses/treatment and details of the expenses alongwith health card and identity proof of the patient. Accordingly on 17.6.2014 at about 01.01.29 PM respondent received the pre-authorization request for cashless treatment of complainant for an amount of Rs. 15,200/-. After receipt of pre-authorization request, it was ascertained from pre-authorization form that complainant was suffering from hypertension since one year and diagnosed with “Essential (primary) hypertension” and “dyspnea on exertion”. Thereafter, the respondent declined the pre-authorization request for cashless treatment as per clause 4 (a) of the policy as the complainant was suffering from hypertension since before the policy inception and complainant had not disclosed the same at the time of policy issuance despite being specifically asked. Intimation of denial of cashless facility was immediately given to the hospital as pre-existing diseases are not covered for 48 months from the date of policy inception. It is denied that respondent ever assured the doctors of the hospital for payment of cashless treatment. Complainant has concocted a false story regarding assurance of payment of medical expenses by the respondent. The respondent vide denial of authorization dated 17.6.2014 specifically mentioned the reasons for denial of cashless treatment. The said fact is very well in the knowledge of complainant. There is no deficiency in service on the part of respondent. Other paras of the complaint have been denied and OP prayed for dismissal of complaint.
4. In order to prove the case, complainant tendered documents Ex. C-1 Affidavit of Sh. Amritpal Singh complainant; Ex. C-2 Copy of insurance certificate (19.10.2013 to 18.10.2014); Ex. C-3 Copy of premium receipt dated 21.10.2013 for Rs. 15410/-; Ex. C-4 Copy of information summary dated; Ex. C-5 Copy of invoice dated 28.6.2014 for Rs. 2625.69ps; Ex. C-6 to C-8 Copies of invoices dated 18.10.2014, 28.6.2014 and 17.6.2014; Ex. C-9 Copy of deposit/Advance Receipt dated 18.6.2014 for Rs. 1630/-; Ex. C-10 Copy of interim Inpatient Bill dated 17.6.2014 for RS. 19,130/-; Ex. C-11 Copy of Deposit/Advance Receipt dated 17.6.2014 for Rs. 17500/-.
5. In order to rebut this evidence, OP tendered documents Ex. OP-1 Copy of terms and conditions of Policy; Ex. OP-2 Copy of Insurance Ombudsmen; ex. OP-3 Copy of Annexure III; Ex. OP-4 Copy of Blank Claim Form; Ex. OP-5 Copy of Summary Sheet; Ex. OP-6 Copy of Pre-authorization form dated 17.6.2014; Ex. OP-7 Copy of voter card; Ex. OP-8 Affidavit of Vikram Jain, Authorized Signatory, Max Bupa Health Insurance Company.
6. We have heard learned counsel for the parties and have gone through the file very carefully.
7. There is no dispute that complainant purchased insurance policy for the period 19.10.2013 to 18.10.2014. Complainant suddenly fell ill and was admitted in Max Hospital, Mohali, which is paneled hospital. He was admitted on 17.6.2014. Complainant purchased medicines worth Rs. 1200/-vide bill Exhibit C-8. Complainant also spent Rs. 2625.69ps on various medicines vide bills exhibit C-5 & C-7 on 28.6.2014. He also purchased medicine worth Rs. 1567.80ps on 18.10.2014 vide invoice Exhibit C-6. In this manner total bill for the purchase of medicines was Rs. 5393.49 ps during the period 17.6.2014 to 18.10.2014.
8. A pre-authorization form Exhibit OP-6 was submitted by hospital wherein sum total expected cost of hospitalization was mentioned as Rs. 15200/- and proposed line of treatment was surgical management. It is also mentioned in pre-authorization form that complainant had hypertension for the last one year. The pre-authorization was denied vide fax information dated 17.6.2014 on the ground that in accordance with Clause 4 (a) benefit will not be available for Pre-existing conditions until 48 months of continuous coverage have elapsed since inception of the first policy and that this cashless request can not be approved. Meaning thereby that cashless request was denied on the ground that complainant has hypertension for the last one year and this benefit will not be available for pre-existing condition until 48 months of continuous coverage has elapsed.
There is no direct evidence on the file that complainant had hypertension for the last one year.
9. Learned counsel for OP has referred to Exhibit C-4 Information Summary Sheet wherein the complainant had answered all medical questions in negative. Question arises whether complainant was actually suffering from hypertension and if so, whether complainant had knowledge about it. To prove this fact, there is absolutely no evidence on the file on behalf of OP. Even OPD card dated 17.6.2014 submitted by OP in the evidence does not show any blood pressure to complainant.
Hon'ble Union Territory Consumer Disputes Redressal Commission, Chandigarh in case with the title Life Insurance Corporation of India and Anr Versus Sarabjit Kaur reported in III(2008)CPJ 120 was of the view that;
“ Diabetes, hypertension are not serious diseases. These are part of ordinary strain, stress of life and repudiation of claim on this ground is totally unjustified.”
In para No.15 of the judgment Hon'ble Commission has held that;
“Even otherwise diabetes which is under control and hypertension are not serious diseases and are part of ordinary strain and stress of life. Otherwise also insurance company must have examined the insured before giving policy and such diseases could have been easily detected. There is no evidence that assured had knowledge of these diseases and had not voluntarily disclosed the same.”
In 2014(2) CLT 561 with the title “New India Assurance Co. Ltd Versus Kuldeep Kumar Nayyar Hon'ble National Consumer Disputes Redressal Commission, New Delhi was of the view that;
“ There is no link between pre-existing disease and the existing ailment-Insured is entitled to get reimbursement of expenses incurred on treatment inspite of suppression of pre-existing diseases.”
10. Rebutting to facts of the present case as observed earlier there is no direct evidence on the file that complainant had hypertension for the last one year. The hypertension for one year is mentioned only in pre-authorization form but presuming that complainant was suffering from hypertension for the last one year, even then there is no evidence to hold that there is any nexus between hypertension and dyspnea on exertion, which is mentioned on Exhibit OP-6.
11. We are, therefore, of the opinion that OP has wrongly denied authorization for cashless treatment. In this case complainant has placed on the file Exhibit C-10 summary of Interim Inpatient bill for Rs. 19,130/-. Exhibit C-6 and C-7 are bills for medicines for Rs. 1567.80ps and Rs. 2625.69ps whereas bill Exhibit C-8 is for Rs. 1200/- for cardiology. The complainant is also entitled to these bills. To sum up, the complainant is entitled to Rs. 19,130/- + 1567.80ps/- + 2625.69ps/- and + Rs. 1200/- total Rs. 24523.49 ps/- rounded of Rs. 24500/-.
12. Therefore, the complaint is accepted and OP is directed to disburse Rs. 24500/- to complainant within one month from the date of receipt of this order, failing which OP will pay interest @ 9% p.a from the date of order till final realization.
13. Let certified copies of order be communicated to the parties free of cost by registered post and file be consigned to the record room.
Announced:
05.03.2015.
Neena Rani Gupta, Shiv Pal Bansal Surinder Mohan,
Member Member President.
Krishan
