Chandigarh

DF-II

CC/580/2014

Achla Goswami - Complainant(s)

Versus

Max Bupa Health Ins. Company Ltd. - Opp.Party(s)

Sh. Rajeev Sharma,Adv Adv.

23 Apr 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	580 of 2014
Date  of  Institution	:	11.11.2014
Date   of   Decision	:	23.04.2015

 

 

 

 

 

Achla Goswamy w/o Sh.Praveen Goswamy, R/o H.No.1285, Sector 42-B, Chandigarh.

 

             …..Complainant

 

Versus

 

1]  Customer Service Unit, Max Bupa Health Insurance Company Limited, through Authorised Officer SCO No.36-38, Sector 8-C, First Floor, Chandigarh.

 

2]  Customer Service Unit, Max Bupa Health Insurance Company Limited, B-1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi 110044, through authorised officer.

 

….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         SH.JASWINDER SINGH SIDHU       MEMBER

         MRS.PRITI MALHOTRA             MEMBER

 

Argued By:  Sh.Rajiv Sharma, Counsel for the complainant.

Sh.G.S.Sandhu, Counsel for the OPs.

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          As per the case of the complainant, she availed medical insurance policy from Opposite Party No.1 since 2012 renewed upto 2014 having maximum limit of Rs.1.00 lacs plus Rs.15.00 lacs as a floater.  It is averred that the complainant took treatment from Fortis Hospital on 3.3.2014 on account of stomach pain and relieved on 4.3.2014.  Bills of Rs.44,540/- was raised by the hospital which was payable by the Max Bupa, but it refused (Ann.C-1).  Then the complainant filed medical claim with the OPs which was rejected by order dated 9.5.2014 on the ground that the health condition was not disclosed at the time of renewal (Ann.C-2). The complainant also approached Insurance Ombudsman, but it too rejected the claim on the ground that the condition was not disclosed at the time of taking medical insurance.   It is pleaded that the medical claim was regarding stomach pain, but the alleged non-disclosure is regarding condition of blood pressure and it is not permanent disease and was not on continuous medication.  It is also pleaded that the complainant is taking the medicine only on SOS basis and not in regular fashion and that there is no disease and at the time of renewal, no medical was done and no question was asked to the complainant.  Hence, this complaint has been filed alleging the repudiation/rejection of claim as deficiency in service on the part of the Opposite Parties.  

 

2]       The Opposite Parties have filed joint reply and admitted the treatment taken by the complainant during policy period, receipt of claim for reimbursement of Rs.44,540/- from the complainant and its rejection. 

         It is submitted that the earlier policy of the complainant was lapsed on 11.7.2013 after the premium was not paid and thereafter, fresh proposal form was filled on 6.2.2014 and a fresh policy commencing from 6.2.2014 till 5.2.2015 was issued.  It is also submitted that the OPs have appreciated the matter and found that the insured was suffering from hypertension since 8-10 months which was not disclosed at the time of taking the policy, hence as per the policy terms & conditions under Clause No.5 g 3 ii, this fall under non-disclosure and the claim was repudiated. It is further submitted that the complainant has herself admitted that she is taking medicines for high blood pressure since 8-10 months.  Moreover, case medical documents submitted along with the claim clearly states that the complainant is a k/c/o (known case of) hypertension and is on regular medication.  Rest of the allegations have been denied with a prayer to dismiss the complaint.

 

3]       Parties led evidence in support of their contentions.

 

4]       We have heard the ld.Counsel for the parties and have also perused the record.

 

5]       The facts which are proved on record are that the complainant had earlier taken Health Insurance policy from the OPs, which got expired on 11.7.2013.  After that she afresh applied for the Health Insurance policy, which was accordingly issued to her for the period from 6.2.2014 to 5.2.2015 for maximum limit of cashless facility of Rs.1.00 lakh plus Rs.15.00 lakhs as a floater.  Undisputedly, the complainant got admitted for the treatment of CA OF OVERY and incurred an amount of Rs.44,540/- on her treatment.  The lodging of the claim with the OPs for reimbursement under the policy is also undisputed.  It is only due to the repudiation of the claim lodged by the complainant that she filed the present complaint challenging that repudiation to be wrong and arbitrary.

 

6]       From the submissions on record as well as from the argument, it comes out that the Opposite Parties repudiated the claim of the complainant on account of suppression of facts. 

 

7]       It is submitted by the ld.Counsel for the OPs that the complainant suppressed the material facts of her ailment, which she suffered for more than 8/10 months earlier to the issuance of fresh policy, which is against the doctrine of good faith on which the contract of insurance is based. The ld.Counsel for the OPs further submitted that the complainant was suffering from hypertension for more than 8-10 months, which she failed to disclose in the proposal form.  It is further submitted that the repudiation of the claim is justified as per Clause No.5 (g)(3)(ii) of the terms & conditions of the Insurance Policy vide which the complainant was supposed to disclose the true facts about her health status.

 

8]       The perusal of the documents on file particularly the Discharge Summary of the Hospital concerned reveals that the complainant was admitted with the Original Complaint of Abdomen pain associated with vomiting and loose stool x 2 days (Ann.R-3 at Page No.26) & in Column ‘Past History’ it is mentioned ‘not significant’.  The perusal of the Column of ‘Past Medical/Surgical History’ of ‘Triage History & Physical Sheet’ (Page No.28) only shows that the complainant is known case of hypertension and is on regular medicines, but there is no particular time mentioned over there since how long she is on medication and when she was diagnosed for the same.  It is only the investigation report of the OPs which claims that as per the statement of the complainant, she is suffering from hypertension since 8 to 10 months, but that report is not supported by the affidavit of the author of the report, so cannot rely on the same. 

9]       Further, it is admitted in Para No.16 of the Written Statement by the Opposite Parties that the complainant was earlier insured with them from 12.7.2012 to 11.7.2013 and thereafter, she applied for fresh policy on 6.2.2014 with higher sum assured i.e. Rs.17 lacs. There is no document on record to show that before the issuance of the fresh policy for such big sum assured, the complainant ever undergone any medical test.  No doubt the contract of insurance is based on the principle of good faith, but both the parties are bound to abide by certain obligations on their part, which in the present case, the OPs failed to act upon. 

 

10]      In our opinion, the complainant was supposed to undergo certain medical tests, as per the requirements of the Policy, which the Opposite Party’s never opted for.  So, at this juncture, they cannot shun their liability in case, the claim is lodged with them for reimbursement of the medical treatment.  It was the duty of the Opposite Parties to verify the health status of the proposed, especially when it was a policy after a gap of 6/7 months and that too for a higher sum insured. Above all, there is no cogent prove placed on record by the OPs to show that the complainant had suppressed the fact of alleged pre-existing disease. So, the ground taken by the Opposite Parties to repudiate the claim of the complainant is not sustainable and thus, we find them deficient in service. 

 

11]      We are also supported by the case law cited by the complainant, while arriving to the final conclusion, which is a under:-

a)  R.P.No.2615 & 2616 of 2011 – Life Insurance Corporation of India Vs. Priya Sharma & Ors, decided on 02.11.2012 by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi;

b)  W.P.(C) 656/2007 – Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., Decided on 17.09.2007 by Hon’ble Delhi High Court at New Delhi;

c)  Appeal No.2033 of 2008 – Prem Sachdeva Vs. Oriental Insurance Company, decided on 04.11.2009 by Hon’ble State Consumer Disputes Redressal Commission, UT, Chandigarh.  

 

12]      In view of the foregoing conclusion, we allow the present complaint against Opposite Parties and direct them jointly & severally as below:-

 

[a] To pay the claim amount of Rs.44,540/- to the complainant;

 

[b] To pay Rs.15,000/- on account of deficiency in service and causing mental agony and harassment to the Complainant; 

[c] To pay Rs.5,000/- as cost of litigation;

 

         The above said order shall be complied with within 45 days of its receipt by the Opposite Parties; thereafter, they shall be jointly & severally liable for the payment of an interest @18% per annum, on amount as mentioned in sub-para (a) & (b) of above Para No.12, from the date of institution of this complaint till it is paid, apart from paying the cost of litigation of Rs.5,000/-. 

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

23^rd April, 2015                                                              Sd/-

                                                        

 (RAJAN DEWAN)

PRESIDENT

 

 

 

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER

 

 

 

Sd/-

(PRITI MALHOTRA)

MEMBER

 

                                                                                                             

 

 

DISTRICT FORUM – II

CONSUMER COMPLAINT NO.580 OF 2014

PRESENT:   None   Dated the 23rd day of April, 2015

O R D E R                        Vide our detailed order of even date, recorded separately, the complaint has been allowed against Opposite Parties.                    After compliance, file be consigned to record room.

 

 

( Priti Malhotra )	(Rajan Dewan)	(Jaswinder Singh Sidhu)
Member	President	Member