Punjab

Ludhiana

CC/19/131

Ashraf Masih - Complainant(s)

Versus

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

Amandeep Bhanot Adv.

09 Nov 2023

ORDER

    DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:131 dated 06.03.2019.                                                         Date of decision: 09.11.2023.

 

Ashraf Masih son of Inayat Masih, resident of House No.35, Issa Nagri, Play Ground, Ludhiana, since deceased and now represented through is LR/sister Dr. Usha Singh                                                                                                                                                                                            ..…Complainant

                                                Versus

1. Max Bupa Health Insurance Company Ltd., Regd. Office: Max House, 1, Dr. Jha Marg, Okhla, New Delhi-110020, through its General Manager.
2. Max Bupa Health Insurance Company Ltd., Plot No.88, 2^nd Floor, Kunal Tower, Mall Road, Opposite Axis Bank Ltd., Ludhiana through its Manager.

…..Opposite parties 

Complaint Under section 12 and 14 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Amandeep Bhanot, Advocate who                                                        represented through legal heir namely Dr. Usha                                           Singh.

For OPs                          :         Sh. V.S. Mand, Advocate.

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that the complainant (hereinafter called DLA) availed mediclaim policy No.30600862201600 of the OPs for sum assured of Rs.12,50,000/- having validity for two years i.e. from 15.11.2016 to 14.11.2018 by paying premium of Rs.28,250/-. During the subsistence of the policy, the complainant suffered from paralysis attack and he remained admitted in C.M.C. & Hospital, Ludhiana from 28.09.2018 to 12.10.2018 regarding which he lodged claim with the OPs for availing cashless hospitalization benefits but the OPs denied the authorization of claim as someone had got incorporated/written/mentioned that the complainant is suffering from hypertension. It is further stated that the complainant earlier remained admitted in Ludhiana Mediways Hospital from 22.09.2017 to 26.09.2017 and incurred a sum of Rs.1,18,000/-. However, he suffered with a stroke and was brought to causality in C.M.C. & Hospital by some unknown person who did not know about medical history of the complainant but on asking of doctor on duty, wrote the information which was not accurate history. The complainant was not suffering from disease of hypertension before his hospitalization. Even the requisite medical tests of the complainant were conducted by doctor of the OPs and the complainant was not found to be suffering from any disease. As such, the repudiation of the claim of the complainant by the OPs was totally illegal, arbitrary and against the rules, regulations and guidelines and without any authorization due to which he suffered mental pain, agony etc. The complainant even contacted the OPs to pay the claim amount but to no effect. In the end, the complainant has prayed for issuing directions to the OPs to make the payment of Rs.3,48,000/- along with compensation of Rs.3,00,000/- and litigation expenses of Rs21,000/-.

2.                Upon notice, the opposite parties filed joint written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability of the complaint, the complaint being an abuse of process of law and suppression of material facts by the complainant. The opposite parties stated that the policy bearing No.30600862201600 was issued by them on the basis of the information provided by the Proposer to the Company. The policy was Policy issued on 15.11.2016 and was valid till 14.11.2018. Since the information provided by the Proposer was established to be incorrect by the the OPs so the OPs were well within its rights to repudiate the said claim of the complainant. OPs have acted within the four corners of the statutory provisions, no case of deficiency in services can be said to have arisen. The OPs further stated that the repudiation of the claim under the subject policy was on the grounds of misstatement of information, suppression of material information and furnishing of false information in the Proposal Form. The Proposer, at the time submitting the proposal from did not disclose the correct information about his health and habits, as per the submitted documents/investigation done by the company, it was found that the insured had history of hypertension since 8 to 10 years and was under treatment for the same. This medical problem much prior to the issuance of the policy but in the proposal form the complainant has given wrong information in order to mislead the OP Company. Hence as per the policy terms and conditions the claim was repudiated. These facts were also not disclosed at the time of taking the policy and the same came to the knowledge of the company only after the investigation was done. The Ops further stated that the complainant submitted the claim under the policy stating that the insured was treated for Acute Ischmic Stroke and was admitted for treatment at Christian Medical College and Hospital from 28.09.2018 to 12.10.2018. As such the OPs have rightly repudiated the claim preferred by the complainant. Insurance contracts are contracts based on "Utmost Good Faith". As per the contract, the insurer is bound to honour the claim under the policy, provided that the Insured at the time of applying for the policy, had disclosed all relevant information with regard to his health, habits etc. which are the basis on which the insurer decides to cover the said person and at what rates. Since the Insured did not perform his duty to disclose all material information, the contract of insurance between the Company and the Insured is a void contact. Insurance claim payouts are made from the pool of funds of many consumers of the services of an insurance company. Hence, to honour an illegitimate claim, would mean doing injustice to other genuine Policyholders. According to the OPs the treatment done post 14.11.2018 is outside coverage period and cannot be paid by them.

                    On merits, the opposite parties reiterated the crux of preliminary objections. The opposite parties have denied any deficiency in service on their part and in the end, prayed for dismissal of the complaint.

3.                In support of his claim, the complainant tendered his affidavit Ex. C1 in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C2 is the copy of proposal form, Ex. C3 is the copy of insurance policy as well as policy terms and conditions, Ex. C4 is the copy of premium receipt, Ex. C5 to Ex. C7 are the copies of bills/receipts of Mediways Hospital, Ex. C8 is the copy of repudiation letter dated 11.12.2018, Ex. C9 is the copy of denial of authorization, Ex. C10 is the copy of letter written to Medical Superintendent, CMC Hospital for correction of history, Ex. C11 is the copy of certificate issued by CMC Hospital, Ex. C12 is the copy of ID card of Ashraf Masih, Ex. C13 is the copy of welcome letter, Ex. C14 is the copy of bill of CMC Hospital and closed the evidence.

                   In additional evidence, the complainant tendered affidavit Ex. CB of Sh. Liakat Masih and closed the additional evidence.

4.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Ms. Chandrika Bhattacharya, Senior Manager of the opposite parties along with documents Ex. OP1/1 is copy of authority letter, Ex. OP1/2 is the copy of book on Principles of Internal Medicine, Ex. OP1/3 is the copy of proposal form, Ex. OP1/4 is the copy of welcome letter and policy documents, Ex. OP1/5 is the copy of cashless claim form, Ex. OP1/6 is the copy of denial of authorization dated 05.10.2018, Ex. OP1/7 is the copy of claim form, Ex. OP1/8 is the copy of investigation report, Ex. OP1/9 is the copy of repudiation letter dated 25.05.2019, Ex. OP1/10 is the copy of letter dated 09.10.2018 written to the complainant and closed the evidence.

5.                During the pendency of the complaint, the complainant Ashraf Masih expired and Dr. Usha Singh filed application for impleading her as legal heir of Ashraf Masih  which was allowed vide order dated 11.05.2023.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavits and documents produced on record by both the parties.

7.                Admittedly, vide Ex. C2 = Ex. OP1/4, the DLA Ashraf Masih purchased  Policy of Health Companion Heath Insurance Plan from the opposite parties for himself for two years w.e.f. 15.11.2016 to 14.11.2018. Firstly, the complainant remained admitted at Ludhiana Mediways Hospital from 22.09.2017 to 26.09.2017 where he incurred Rs.1,18,000/- on his treatment vide bills/receipts Ex. C5 to Ex. C7. However, the complainant/DLA during his life time did not submit any claim regarding his said hospitalization with the OPs.   Secondly, the DLA was admitted at C.M.C. & Hospital, Ludhiana on 28.09.2018 due to paralysis attack and remained admitted up to 12.10.2018 regarding which pre-authorization form (cashless) Ex. OP1/5 was submitted with the OPs. However, the OPs rejected his cashless authorization request vide letter dated 05.10.2018 Ex. C9 = OP1/6 by invoking clause 10.21 of the terms and conditions of the policy, the operative part of which reads as under:-

“As per policy T&C 10.21, the details submitted along with the preauthorization suggest that patient has adverse medical condition due to which it is not possible to ascertain the liability at this juncture (due to gross non-disclosure of material facts-Hypertension since 6 years)-Hence cashless cannot be extended to this case.”

                   The DLA further submitted claim form Ex. OP1/7 with the Ops for reimbursement of Rs.1,50,107/- spent    on his treatment from 28.09.2018 to 12.10.2018 with C.M.C. & Hospital, Ludhiana. However, the said claim was also declined by the OPs vide repudiation letter dated 11.12.2018 Ex. C8, the operative part of same reads as under:-

                   “Disallowance reason

As per available records patient is known case of hypertension last 10 years and that was not disclosed as there is non-disclosure of material facts hence rejected as policy terms and conditions.

Treatment done on 28 September, 2018 falls outside member coverage period from 15 November 2016 to 14 November 2017.”

8.                Now the question arise whether the rejection the claim on the ground mentioned therein is valid or not? The rejection of the claim of the complainant was effected by the opposite parties by invoking the reason that the complainant had not disclosed about the pre-existing disease of hypertension for last 10 years. In the proposal form Ex. C2 = OP1/3 under the column of medical history, the DLA the answered all the questions in negative. The claim of the complainant is sought to be rejected on the ground that he was a patient of hypertension since 10 years. It is a matter of common knowledge that as a normal practice the form is filled by the insurance agent. In addition to this, despite being of age of about 51 years at the time of issuance of the policy, the complainant was not got medically examined and moreover, the insurance company may have additional questions for the insured or may ask him to undergo medical tests to complete full medical assessment. No evidence has been lead by the opposite parties as to whether any additional questions were put to the complainant or not nor any evidence has been adduced that the complainant was subjected to some medical tests at the time of issuance of the policy in the Month of November 2016.

9.                In the present case, the complainant remained admitted in CMC & Hospital, Ludhiana from 28.09.2018 to 12.10.2018 with the diagnosis of acute Ischemic stroke (status post IV thrombolysis), DM-2, Hypertension, obstructive sleep apnea, which finds mention in the certificate Ex. C11 issued by Dr. Vineeth Jaison, MBBS, MD, Assistant Professor of Neurology, CMC & Hospital, Ludhiana. Therefore, any treatment taken by the complainant prior to taking the policy about which no questions were asked in the proposal form, it cannot be said that the opposite parties are justified in rejecting the claim on the ground of suppressing his  pre-existing disease of hypertension for 10 years. Further, the opposite parties have not produced any evidence of medical record with regard to diagnosis and treatment of the said pre-existing disease of the complainant. Even the report or the affidavit of the investigator was not brought on record to substantiate its claim. It is well settled that on account of non-disclosure of such general diseases, the genuine claim cannot be rejected. In this regard, reference can be made to Religare Health Insurance Company Ltd. Vs Subhash Chander Aggarwal in 2017(3) CLT 140 whereby it has been held by Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh that hypertension is a common disease and can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack. Further reference can be made to Tarlok Chand Khanna Vs United India Insurance Co. Ltd. 2012(1) C.P.J. 84 whereby it has been held by Hon’ble National Consumer Disputes Redressal Commission, New Delhi  that the onus to prove that the insured was suffering from pre-existing disease was on the insurer and if the insurer has not produced the expert opinion, the reasons for repudiation of the claim were held to be unjustified. A reference can be further made to Lakhwinder Singh and another Vs United India Insurance Company etc.  decided in Appeal No.29 of 2009 whereby it has been held by Hon’ble State Consumer Disputes Redressal Commission, U.T, Chandigarh that the maladies like diabetes, hypertension being normal wear and tear of the life cannot be treated as pre-existing diseases.

10.              Further in a case titled as Manmohan Nanda Vs United India Assurance Co. Ltd. and others 2022(I) CPJ 20 (SC) wherein the Hon’ble Supreme Court of India has observed as under:-

“(6)   The appellant’s argument that there is no hard and fast rule that every person with DM-II will necessarily have a cardiac disease merely because it is a risk factor holds water. A person who does not suffer from DM-II can also suffer from a cardiac ailment. He had disclosed his DM-II status for which he was under treatment. The ECG report and other tests also indicated normal parameters. Further, statins were a preventive prescription to prevent development of cardiac issues as DM-II is a risk factor, not because he had a cardiac ailment or hyperlipidaemia. Further, the examining physician was informed of the same before the policy was taken. Accordingly, there was no suppression of any material fact by the appellant to the insurer.

(7)     It was for the insurer to gauge related complications based on the information provided. The insurance company did not think that the medical and health condition of the appellant was such which did not warrant issuance of a medical policy. The insurance company therefore did not decline the proposal of the assured as a prudent insurer.”   

Therefore, in our considered view, the rejection of the claim on the basis of   non-disclosure of pre-existing diseases could not have  been made a ground to   reject the claim and this ground cannot be sustained  in the eyes of law.  The insurance companies are required to be more liberal in their approach without being too technical.

11.              Moreover, the DLA incurred Rs.1,18,000/- on his treatment availed from Ludhiana Mediways Hospital from 22.09.2017 to 26.09.2017 regarding he tendered bills/receipts Ex. C5 to Ex. C7. The complainant/DLA during his life time did not raise any claim with the OPs but in the complaint the DLA has claimed a sum of Rs.1,18,000/- on account of his hospitalization with Ludhiana Mediways Hospital. In the given set of above said facts and circumstances, it would be just and appropriate if the repudiation letter Ex. C8 issued by the opposite parties is set aside and the opposite parties are directed to settle and reimburse claim lodged by the DLA in respect of his treatment at C.M.C. & Hospital, Ludhiana from 28.09.2018 to 12.10.2018 and further the legal heir of DLA is directed to lodge the claim with the OPs regarding hospitalization of DLA Ashraf Masih with Ludhiana Mediways Hospital from 22.09.2017 to 26.09.2017 within 15 days from the date of receipt of copy of order and the OPs shall consider and reimburse the said claim within 30 days from the date of receipt of claim from the legal heir of the DLA. The OPs are further burdened with composite costs of Rs.10,000/-.

12.              As a result of above discussion, the complaint is partly allowed with an order that the repudiation letter Ex. C8 issued by the opposite parties is set aside and the opposite parties are directed to settle and reimburse claim lodged by the DLA in respect of his treatment at C.M.C. & Hospital, Ludhiana from 28.09.2018 to 12.10.2018 as per terms and conditions of the policy within period of 30 days from the date of receipt of copy of the order failing which the opposite parties shall pay interest @8% per annum on the settled amount to the complainant from the date of order till its actual payment. Further the legal heir of DLA is directed to lodge the claim with the OPs regarding hospitalization of DLA Ashraf Masih with Ludhiana Mediways Hospital from 22.09.2017 to 26.09.2017 within 15 days from the date of receipt of copy of order and the OPs shall consider and reimburse the said claim within 30 days from the date of receipt of claim from the legal heir of the DLA. The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Payment of costs shall be made within a period of 30 days from the date of the receipt of the copy of this order. All the amounts shall be paid to Dr. Usha Singh, legal heir of the DLA Ashraf Masih. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.     

 

13.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                     (Sanjeev Batra)

Member                         Member                                       President         

 

Announced in Open Commission.

Dated:09.11.2023.

Gobind Ram.