DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL) ISBT KASHMERE GATE, DELHI – 110006
CC No. 436/2016
No. DF/Central Date: 29 /01 /2018
Sh. Neeraj Grover
S/o Late Sh. H.L. Grover,
R/o 30/53, First Floor,
West Punjabi Bagh, New Delhi - 110026
…… COMPLAINANT
VERSUS
Max Bupa Health Insurance Co. Ltd.,
Having its Registered Office at ;
Max House, 1 Dr. Jha Marg,
Okhla, New Delhi
Also At :
3rd Floor, Samyak Towers,
Pusa Road, Karol Bagh,
Near Karol Bagh Metro Station,
New Delhi - 110005
…..OPPOSITE PARTY
Ms. Rekha Rani, President
Sh. Vikram Kumar Dabas, Member
Mrs. Manju Bala Sharma, Member
ORDER January 2018
Sh. Vikram Kumar Dabas, Member
1. Instant complaint was filed on 19.12.2016 wherein the complainant had alleged that he had purchased a health insurance policy for OP for the period 28/05/2016 to 27/05/2017. It covered the complainant, his wife Smt. Monika Grover & his children Dhruv Grover and Raunak Grover. The wife of the complainant Smt.Monika Grover was admitted to Sir Ganga Ram Hospital on
07/06/2016 due to pain in right flanks. She was diagnosed to be a case of ‘’Right Suprarenal Mass - ? Pheochromocytoma’’. She was operated upon on 11/06/2016 and was discharged on 15/06/2016. A sum of Rs. 415749/- was spent on her treatment. The complainant had lodged a claim for reimbursement with the OP which was repudiated on the ground that it was not payable as per clause 4 (b) of the policy and OP also cancelled the policy.
The complainant has alleged deficiency in service on the part of the OP and has prayed that the OP be directed to pay the amount of Rs. 4,15,749/- along with compensation and has further prayed that the policy of insurance be ordered to be restored.
The OP has contested the complaint and has claimed that the complaint is false and frivolous. It has admitted that it had issued a policy of Insurance in favour of the complainant of which the insured wife was a beneficiary. It has however claimed that the claim lodged by the complainant was not payable as per policy terms and conditions 4 (b). It has further claimed that the insured was also guilty of suppression of material facts as regards the state of her health. It was also stated that insured did not disclose that she was suffering from pre existing disease and as a result of this the consent to enter in to the contract stood vitiated. It was stated that since there was absence of good faith on the part of the complainant, the claim was repudiated and the policy of insurance had been cancelled. It was prayed that the complaint be dismissed.
The complainant had filed a rejoinder and has also filed his affidavit dated 24/04/2017 in support of his complaint. On behalf of the OP an affidavit has been filed by Miss. Shetal Patwa (Manager Legal) in support the case of the OP.
We have heard arguments advance at the bar and have perused the record.
The learned counsel of the OP has drawn our attention to the fact that the policy of insurance was purchased on 28/05/2016 and the patient was admitted in the hospital on 07/06/2016 i.e barely after a period of 9 days. Our attention has been drawn to clause 4 (b) of the Policy Terms and Conditions which reads as under :
‘’ 90 days waiting period : we will not cover any treatment taken during the first 90 days since the date of commencement of the Policy, unless the treatment needed is a result of an Accident or Emergency. This waiting period does not apply to any subsequent and continuous renewals of your Policy.’’
Our attention has then be drawn to ex RW 1/5 which is a copy of the investigation report along with noting of ICP (Indoor case papers) self declaration of the Insured and discharge slip. Relevant portion of the self declaration of the Insured is reproduced as under:
‘’ I am Monika Grover wife of Neeraj Grover resident of 30/53 West Punjabi Bagh. My age is 38 yrs. My height is 5.3 feet. My weight is 68 Kgs. On 2nd of June 16 ‘’I feel pain on my right side of my stomach. I consulted doctor Sudhir Chadha 9810233670 he advised for ultrasound whole abdomen.
After seeing the report of ultrasound doctor referred for C.T. Scan which was done on National MRI Punjabi Bagh. Report came on 5 June. Right adreral mass. After seeing the report doctor advised for the surgery of adenal gland. But on 7th June 16 got severe pain on right side and admitted to Sir Ganga Ram Hospital in emergency. I had gone for surgery on 11 of June 16 and discharged on 15th June 2016.’’
A perusal of this document shows that the patient was diagnosed to be suffering from Right Suprarenal Mass - Pheochromocytoma on 05/06/2016 and after seeing the report the Doctor advised her surgery of Adrenal Gland which indicates that the surgery was planned. As per annexure R -5 (colly) indoor case papers the progress note dated 08/06/2016 of Dr. Ashiana Mehta indicates that patient was suffering from headache, sweating & palpitation from the last 5 to 6 months prior to admission in the hospital which was not disclosed at the time of filling up of proposal form. The learned counsel of the OP has contended that the claim was rightly repudiated under clause 4 (b) and on account of non disclosure of pre-existing disease.
We have considered the contention raised before us with which we had to agree. The Indoor case papers placed on record make it amply clear that the case of the complainant’s wife was covered under clause 4 (b) of the policy of insurance as per which the expenses incurred on the treatment during the first 90 days from the date of commencement of the policy was not payable.
We hold that the case of the wife of the complainant was not covered in emergency as defined in clause (b) of the policy terms and conditions which reads as under :
‘’Emergency means a severe illness or injury which results in symptoms which occur suddenly and unexpectantly, and required immediate care by a
Medical Practitioner to prevent death or serious long term impairment of the Insured Persons’s health’’
We also noted that the complainant was guilty of non disclosure of material facts. The complainant has not disclosed that his wife was suffering from headache, palpitation and sweating for a period of 5 /6 months before the purchase of the policy. There was therefore absence of good faith on the part of the complainant. The OP was therefore justified in repudiating the claim lodged by the complainant and in cancelling the policy of the Insurance. We hold that there is no merits in this case. The same is hereby dismissed. There is no order as to costs.
Copy of this order be sent to the parties as per law. File be consigned to record room.
Announced on this day of ___________, 2018
