Punjab

Ludhiana

CC/14/782

Gurpreet Singh - Complainant(s)

Versus

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

Ashu Lekhi

17 Jun 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                    Complaint No: 782 of 17.11.2014

                                                                   Date of Decision: 17.06.2015

                    

Gurpreet Singh aged 23 years s/o S.Surinder Singh, resident of House no.2396, Amarpura, Ludhiana.

.…Complainant

Versus 

1. Max Bupa Health Insurance Company Ltd., B-1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi, through its Director/M.D.

2. Max Bupa Health Insurance Company Ltd., Kunal Tower, Mall Road, Ludhiana, through its Manager.

…..Opposite parties

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:    Sh.R.L.Ahuja, President

                    Sh.Sat Paul Garg, Member

 

Present:     Complainant Sh.Gurpreet Singh in person.

                   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.Gurpreet Singh s/o S.Surinder Singh, resident of House no.2396, Amarpura, Ludhiana (herein-after in short to be referred as ‘complainant’) against Max Bupa Health Insurance Company Ltd., B-1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi, through its Director/M.D. and others (herein-after in short to be referred as ‘OPs’)- directing them to make the payment of the claim amount of Rs.24,086/- to the complainant besides compensation to the tune of Rs.50,000/- alongwith any other additional or alternative relief to which the complainant may be found entitled.

2.                Brief facts of the complaint are that complainant Medical Insurance Policy no.30147949201301 from the OPs effective from 15.11.13 to 14.11.14 and it was a cashless policy. During the subsistence of the insurance policy, the complainant suffered from Peripheral Vascular Disease and he had to be admitted in CMC and Hospital, Ludhiana, where he remained admitted from 6.7.14 to 12.7.14 and a sum of more than Rs.25,000/- were incurred on his treatment. After undergoing the treatment, the complainant lodged the claim with the Ops, but the claim of the complainant was repudiated in a wrong and illegal manner. The complainant made numbers of visits to the OPs to get his claim amount, but each and every time he was left un-redressed. The complainant got served a registered legal notice dated 25.8.14 upon the OPs, through his counsel. However despite service of the legal notice, the OPs failed to do the needful in this regard. 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 his counsel and filed written statement taking preliminary objections that the present complaint is not maintainable and the same is without any cause of action and is liable to be dismissed; 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. After understanding the same, the complainant/insured filled the proposal from which was assumed to be true and correct information and decided to take the policy. Further submitted that during the policy period, the OPs received a pre-authorization request for cashless facility on 18.4.14 for the complainant’s treatment for varicose veins of lower extremities. However, the pre-authorization request was denied as the said disease falls under the medical conditions that would be subjected to special waiting period of 24 months as per clause 4 (C) (14) of the policy terms and conditions. The OPs again received a pre-authorization request for availing cashless facility on 7.7.14 for treatment of viral pneumonia. On going through the medical papers submitted alongwith the pre-authorization request, it was found that the complainant was a known case of peripheral vascular disease and had taken treatment in 2012 for recurring ulcerative in both legs, urticaria, swelling over face and tightening of skin and discolouration. However, the same was not disclosed by the complainant despite having been specifically asked to disclose his medical history at the time he filled the policy proposal form. Clause 5 relating to Medical History in the policy proposal form specifically asks whether the complainant consulted any doctor/health care professional within the last 2 years, whether the is taking any medicines, whether he has experienced any health problems or medical conditions which the complainant has not seen a doctor for in the last 3 months, whether he takes any tablets, drugs or medicines on a regular basis. However, the complainant answered in negative to all these questions and hides his true medical history. If OPs had known at the time of receipt of proposal that the complainant is suffering from the above said disease/health condition. The OPs might have evaluated the risks differently and that the OPs have been deprived of proper & fair underwriting and risk assessment evaluation. On merits, denying the contents of all other paras of the complaint, Ops prayed for the dismissal of the complaint.

4.                Complainant has adduced the evidence by way of his duly sworn affidavit Ex.CA, wherein, the same facts have been reiterated as narrated in the complaint and also attached documents Ex.C1 to Ex.C27. 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 Cooperative, Industrial Area, Mathura Road, New Delhi Ex.RA, wherein, the same facts have been reiterated as narrated in the written statement and also attached documents Ex.R1 to Ex.R5.

5.                Written arguments by the complainant filed, wherein reiterating the facts narrated in the complaint submitted that the OPs have taken totally false objections in the written statement filed by them. The present claim is being made on account of treatment of Chest disease. Dr.Sushil Gupta, MBBS, DNB, MNAMS, PGDHHM, formerly attached to Sir Ganga Ram Hospital, New Delhi and Ex. Consultant DMCH, Ludhiana, has issued one certificate to the complainant, in which he had certified that the complainant is suffering from Interstitial Lung Disease and as per chemical judgement, it is not due to incompetent saphenofenioral junction as described in u/s Doppler of Limbs done at CMC Hospital. In order to prove his case, the complainant himself stepped into the witness box and exhibited many documents on record. From his testimony as well as documents produced on the file, the complainant has fully proved his case and the complainant has been successful in bringing home the deficiency in services and unfair trade practice committed by the OPs.

6.                Refuting the allegations leveled by the complainant, Ld counsel for OPs filed written arguments, whereby it is averred that after going through the file, it is clear that the complainant has concealed the material facts from the OPs and even did not disclose same to the Forum. Infact the complainant has taken treatment of some other disease, but mentioned some other disease in the complaint. The complainant has also filed the same affidavit. After going through the record it is clear that as per Ex.R-1 the complainant has also sent pre-authorization request for pre-existing disease and the same was denied vide letter dated 18.4.13. The said fact has not been mentioned by the complainant. Thereafter the complainant again sent pre-authorization request vide Ex.R5 to the Ops company for the treatment and the same was again denied vide letter dated 9.7.14. The working of the letter is as under:-

“Cashless cannot be provided in this case due to gross non-disclosure of material facts at the time of policy inception (History of Urticaria since 2001, received steroids 5 years back and recurrent ulceration of legs with varicose veins since January, 2012 and known case of peripheral Vascular Disease as per constitution paper of January, 2012). Although present ailment is not related, but liability cannot be ascertained for present claim due to gross non-disclosure of material facts, which required further verification. Hence cashless cannot be provided in this case.”

                   The complainant has concealed the Ex.RY, Ex.RX treatment from the Ops at the time of taking policy.  Ld. counsel for Ops also relied upon the judgments passed in cases titled as Deokar Exports Pvt. Ltd. Vs New India Assurance Company Ltd.- 2009 (2) CLT 15 passed by Supreme Court of India, Life Insurance Corporation of India Vs Smt.Neelan Sharma- Revision Petition no.967 of 2008 passed by Hon’ble National Commission, New Delhi, Life Insurance Corporation of India Vs Santosh Devi- 2014 (4) CLT 89 passed by Hon’ble National Commission, New Delhi, Manager, SBI Life Insurance Company Limited and others Vs Santosh Nagnath Kedari- 2014 (4) CLT 404 passed by Maharashtra State Commission, Mumbai.

7.                We have gone through the pleadings of the complainant and written arguments submitted on behalf of both the parties as well as defence taken by the OPs and also perused the entire record placed on file.

8.                It is evident that complainant availed Medical Insurance Policy no.30147949201301 for the period 15.11.13 to 14.11.14 and during the subsistence of the insurance policy the complainant remained admitted in CMC and Hospital, Ludhiana for the period 6.7.14 to 12.7.14 and was treated for ‘Peripheral Vascular Disease’. It is also evident that complainant submitted pre-authorization form (cashless) on 22.4.14 for the treatment of varicose veins of lower extremities. However, the pre-authorization request was denied as the said disease falls under the medical conditions that would be subjected to special waiting period of 24 months as per clause 4 (C) (14) of the policy terms and conditions. The OPs again received a pre-authorization request for availing cashless facility on 7.7.14 for treatment of viral pneumonia. On going through the medical papers submitted alongwith the pre-authorization request, it was found that the complainant was a known case of peripheral vascular disease and had taken treatment in 2012 for recurring ulcerative in both legs, urticaria, swelling over face and tightening of skin and discolouration. However, the same was not disclosed by the complainant despite having been specifically asked to disclose his medical history at the time he filled the policy proposal form. In the written arguments in para no.4, the complainant has averred that OPs have taken false objections in the written statement filed by them. The present claim is being made on account of treatment of Chest disease. Dr.Sushil Gupta, MBBS, DNB, MNAMS, PGDHHM, formerly attached to Sir Ganga Ram Hospital, New Delhi and Ex. Consultant DMCH, Ludhiana, has issued one certificate to the complainant, in which he had certified that the complainant was suffering from Interstitial Lung Disease and as per chemical judgement, it is not due to incompetent saphenofenioral junction as described in u/s Doppler of Limbs done at CMC Hospital. In view of the averments and the certificate issued by Dr.Sushil Gupta, the patient was suffering from ‘Interstitial Lung Disease and it is not due to incompetent saphenofenioral junction.

9.                In view of the above discussion, the complaint is partly allowed and OPs are directed to re-examine the claim of the complainant afresh in the light of the above mentioned certificate of Dr.Sushil Gupta and to settle and pay the claim of the complainant. Further OPs are directed to pay Rs.2500/-(Two thousand five hundred 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.

 

                             (Sat Paul Garg)                                 (R.L.Ahuja)

                                  Member                                          President

Announced in Open Forum.

Dated:17.06.2015 

Hardeep Singh