Punjab

Ludhiana

CC/14/316

Harish Bagga - Complainant(s)

Versus

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

16 Mar 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                 Complaint No: 316 of 17.04.2014

                                                                                                                    Date of Decision: 27.02.2015

                                                                                                                   

Harish Bagga s/o Sh.Babu Ram Bagga resident of House No.2148, St.No.27, Janta Nagar, Ludhiana.

……Complainant

Versus 

1. M/s Max Bupa Health Insurance Company Limited, Kunal Towers, Mall Road, Ludhiana.

2. M/s Max Bupa Health Insurance Company Limited, Mathura Road, New Delhi-110044, through its Director, Strategy and Development.

…..Opposite parties 

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:     Sh.R.L.Ahuja, President

                    Sh.Sat Paul Garg, Member

                   Smt.Babita, Member

 

Present:       Sh.Vishal Tewari, Advocate for complainant.

                   Sh.G.S.Kalyan, Advocate for OPs.  

 

                   

                        ORDER

 

(SAT PAUL GARG, MEMBER)

 

1.               Present complaint under Section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Harish Bagga s/o Sh.Babu Ram Bagga resident of House No.2148, St.No.27, Janta Nagar, Ludhiana (herein-after in short to be referred as ‘complainant’) against M/s Max Bupa Health Insurance Company Limited, Kunal Towers, Mall Road, Ludhiana and others (herein-after in short to be referred as ‘OPs’)- directing them to reimbursement of the amount as per the policy terms, to pay an interest @ 12% p.a. to be charged on the delay of reimbursement and to pay an amount of Rs.50,000/- as compensation for harassment and mental agony suffered by the complainant, to pay other allied expenses borne by the complainant and to payRs.10,000/- as litigation expenses to the complainant alongwith any other relief.

2.                Brief facts of the complaint are that the complainant had subscribed for Heartbeat Silver 02 lacs two adults plan with policy no.30166503201300 commencing on 8.1.13 alongwith his wife Mrs.Veena Bagga as insured after completing all the formalities. The abovesaid policy was got renewed by the complainant vide policy no.30166503201401 with date of commencement from 8.1.14 upto 7.1.15 for a sum assured of Rs.2.00 lacs and an amount of Rs.12,107/- was paid by the complainant on account of insurance premium. Since the age of the complainant at the time of renewal of the policy was 50 years and that of the other insured was 51 years necessary medical examinations were conducted. The complainant was admitted to Satguru Partap Singh Apollo Hospital, Sherpur Chowk, G.T.Road, Ludhiana on 16.1.14 after the development pain in his chest. For this, PTCA + Stenting of LAD was done and a single Sirolimus Eluting Stent was deployed and the complainant was discharged on 20.01.14. The complainant had requested for pre-authorization vide requests no.37805, but the same was denied by the OP2, vide SMS on cell phone date 17.1.14. Subsequent to his discharge from the hospital the complainant approached the OP1 for reimbursement of his medical expenses, but the complainant received an e-mail dated 24.2.14 alongwith denial letter dated 24.2.14, through which the OP2 disallowed the claim of the complainant with reason “Patient is suffering from diabetes since five years which was prior to policy inception, but the same was not disclosed at the time of taking policy so claim is not payable as per the policy terms and conditions (non discloser of material facts exclusion no.5g3ii. Since the complainant has complied with all the necessary requirements, even then the legal and valid claim of the complainant has been rejected with false allegations. Claiming the above act as deficiency in service on the part of the Ops, the complainant has filed this complaint.

3.                On notice of the complaint, Ops appeared through their counsel and filed written statement taking preliminary objections that the present complaint is not maintainable and the same is without any cause of action; the insurance is a contract between the parties in good faith; the company has explained entire features of the said health insurance plan to the complainant and the complainant out of his own free will and volition agreed to terms and conditions of the policy; Ops believed the information to be true and the Ops issued and supplied complete booklet alongwith policy no.30166503201300 for the period 8.1.13 to 7.1.14 to the complainants/insured. Thereafter the policy was renewed vide policy no.30166503201401 for the period 8.1.14 to 7.1.15. During the said policy, the Ops received claim from complainant, vide pre-authorization form dated 16.1.14 request for hospitalization at S.P.S Apollo Hospital, the Ops immediately responded to Satguru Pratap Singh Apollo Hospital, Sherpur Chow, Ludhiana, vide Acknowledgement of receipt dated 16.1.14 alongwith additional information request sought for supply of additional information from the complainant. However on 17.1.14 the Ops, vide Denial of authorization dated 17.1.14 declined to issue pre-authorization for hospitalization due to reasons detailed below:-

            “Non-Disclosure- The documents and details submitted alongwith the pre-authorization request suggests that there is non disclosure of the material facts (diabetes since 5 years). At the time of proposal of the policy. Hence this pre-authorization request cannot be approved. Request hospital to settle all the bills directly with the customer.”

 

                   In view of the above, the Ops disallowed the claim of the complainant, vide denial of authorization letter dated 17.1.14 on the ground of non-disclosure of material information such as diabetes since 5 years and hypertension at the time of proposal and the policy become void. The Ops repudiated the claim of the complainant under the provision of the terms and conditions of the policy. On merits, denying the contents of all other paras Ops prayed for the dismissal of the complaint.

4.                Ld. Counsel for complainant has adduced the evidence affidavit of complainant Harish Bagga Ex.CA, wherein the same facts have been reiterated as narrated in the complaint and also attached documents Ex.C1 to Ex.C20. On the other hand, Ld. Counsel for Ops has adduced the evidence by way of duly sworn affidavit of Sh.Vikram Jain, Senior Manager Max Bupa Health Insurance Co. Ltd., B-1/1-2, Mohan Co-operative Industrial Area, Mathura Road, New Delhi Ex.RA, wherein, the same facts have been reiterates as narrated in the written statement and also attached documents Annexure-A to Annexure-F.

5.                Case was fixed for arguments. Ld. Counsel for complainant argued that the complainant had subscribed for Heartbeat Silver 02 lacs two adults plan with policy no.30166503201300 commencing on 8.1.13 alongwith his wife Mrs.Veena Bagga as insured after completing all the formalities. The abovesaid policy was got renewed by the complainant vide policy no.30166503201401 with date of commencement from 8.1.14 upto 7.1.15 for a sum assured of Rs.2.00 lacs and an amount of Rs.12,107/- was paid by the complainant on account of insurance premium. Since the age of the complainant at the time of renewal of the policy was 50 years and that of the other insured was 51 years necessary medical examinations were conducted. The complainant was admitted to Satguru Partap Singh Apollo Hospital, Sherpur Chowk, G.T.Road, Ludhiana on 16.1.14 after the development pain in his chest. PTCA + Stenting of LAD was done and a single Sirolimus Eluting Stent was deployed and the complainant was discharged on 20.01.14. The complainant had requested for pre-authorization vide requests no.37805, but the same was denied by the OP2.

6.                Refuting the allegations leveled by the Ld. Counsel for Ops filed written arguments averring that the complainant sent through hospital pre-authorization request and as per pre-authorization request send by the hospital, the complainant is suffering from heart disease from last five years. Annexure A is a proposal Form obtained at the time of policy as per medical history column, the complainant is not suffering from any disease. So, the OP has declined the claim of the complainant, vide annexure –F on the ground of non discloser of material facts at the time of proposal of the policy. In this manner, the complainant had not disclosed the pre-existing health condition at the time of policy. The claim was rightly declined as per the terms and conditions of the policy. After going through the pre-authorization request and proposal form, it is clear that the complainant has concealed the pre-existing health condition at the time of policy. In this case, policy alongwith terms and conditions is admitted and relied upon the judgement passed in case titled as Deokar Exports Pvt. Ltd. Vs New India Assurance Company Ltd.-2009 (2) CLT 15 (SC), LIC of India Vs Premlata Aggarwal- 2012 (2) CLT 182.

7.                We have gone through the pleadings of the complainant as well as defence taken by the OP2 and have gone through the written arguments submitted on behalf of Ops alongwith judgement and have also perused the entire record placed on file and the complaint is found to be maintainable.

8.                It is evident that the complainant availed policy Heartbeat Silver 02 lacs to adults commencing on 8.1.13 alongwith his wife Mrs.Veena Bagga and the said policy was got renewed by the complainant, vide policy no.30166503201401 with the date of commencement from 8.1.14 to 7.1.15 for a sum assured of Rs.2.00 lac. The complainant underwent treatment PTCA + Stenting of LAD. Further argued that complainant got his sugar level tested from the National Clinical Laboratory, Ludhiana and sugar level was found to be within limit. Moreover, the treatment taken by the complainant does not fall under the exclusion clause no.5g3ii. Since the complainant has complied with all the necessary requirements, even then the legal and valid claim of the complainant has been rejected with false allegations, because the pre-existing disease was alleged to be diabetes and the present disease for which he has treated has no nexus with the pre-existing disease, for the sake of arguments it is presumed to be a pre-existing one. Though he had already clarified his stands by the report of the National Laboratory, as such, citations cited by the Ops are not relevant to the present case. The OPs have not been able to prove the grounds of the denial of the claim. Simply averring that “the insurance is a contract between the parties in good faith, the company has explained entire features of the said health insurance plan to the complainant and the complainant out of his own free will and volition agreed to terms and conditions of the policy and OPs believed the information to be true and the Ops issued and supplied complete booklet alongwith policy no.30166503201300 for the period 8.1.13 to 7.1.14 to the complainants/insured does not carry any weightage in the defence of OPs.

9.                Sequel to the above discussion, the present complaint is allowed and the repudiation letter of the Ops is hereby quashed and further Ops are directed to settle and pay the claim of the complainant, as per terms and conditions of the policy. Further Ops are directed to pay Rs.2000/-(Two thousand only) as compensation and litigation expenses compositely assessed to the complainant. Order be complied within 30 days of receipt of the copy of the order, which be made available to the parties, free of costs. File be consigned to record room.

 

                   (Babita)                          (S.P.Garg)                      (R.L.Ahuja)

                   Member                           Member                         President

Announced in Open Forum.

Dated:27.02.2015 

Hardeep Singh