Punjab

Ludhiana

CC/14/817

Sangeeta Rani - Complainant(s)

Versus

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

Rajnish Garg

30 Jun 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

 

                                                                    C.C.No: 817 of 28.11.2014

                                                                    Date of Decision: 30.06.2015

 

Sangeeta Rani aged about 48 years w/o Ramesh Kumar resident of House No.45, Green Park, Civil Lines, Ludhiana.

……Complainant

Versus 

 

1.Max Bupa Health Insurance Company Limited, B-1/I-2, Mohan Co-operative Industrial Estate, New Delhi-110044.

2.Max Bupa Health Insurance Company Limited, Mall Road, Ludhiana.

 

…..Opposite parties

 

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

 

Quorum:   Sh.R.L.Ahuja, President

                   Sh.Sat Paul Garg, Member.

                   

Present:     Sh.Sachin Arora, proxy counsel 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 Mrs.Sangeeta Rani w/o Ramesh Kumar (hereinafter in short to be described as ‘complainant’) against Max Bupa Health Insurance Company Limited and others (herein-after in short to be referred as ‘OPs’)- directing them to pay of Rs.99,900/- alongwith interest, damages and cost of litigation to the complainant.

2.                Brief facts of the complaint are that complainant got insured herself with the Ops vide policy No.30227813201401 effective w.e.f.20.6.2014 to 19.6.2015 and prior to it complainant was having her policy with the Ops effective from 20.6.2013 to 19.6.2014. Unfortunately, the complainant fell ill and was got admitted in Gynae unit of DMC and Hospital, Ludhiana on 18.8.2014 and she was discharged on 23.8.2014 and she was diagnosed as sufferer of Fibroid Uterous/Leiomyoma of uterous (Rasoli in uterous) and she was treated for the said disease and spent Rs.99,900/- for the treatment of said disease. The complainant filed claim with the OPs. But the Ops repudiated the claim of the complainant vide repudiation letter dated 18.10.2014 taking false ground that the complainant was suffering from mellitus diabetes and hypertension since 3-4 years which was not disclosed at the time of the policy inception. The reason and cause of repudiation by the Ops is claimed to be illegal, arbitrary, without basis and not sustainable by the complainant. The complainant approached the Ops many times with the request to re-consider their claim but with no result and ultimately, notice was given but they did not pay any heed. Hence, this complaint.

3.                On notice of the complaint, OPs appeared through their counsel and filed their written statement taking preliminary objections that the complainant has not come before this Forum with clean hands; complainant has mis-represented and concealed the material facts from this Forum; The complainant being guilty of “suppressio very” and suggestio falsi” have no right of maintaining the present complaint against the OPs; no cause of action has ever accrued in favour of the complainant. Further submitted that the complainant had approached the answering Ops for health cover and after understanding the terms and conditions, the complainant/insured filled in the proposal form and obtained from the Ops policy No.30227813201401 for the duration between 20.6.2013 to 19.6.2014 for an amount of Rs.25 lakh. The policy was renewed for the period 20.6.2014 to 19.6.2015. OPs had explained entire features/terms and conditions of the said health insurance plan to the complainant and the complainant out of her own free will and volition agreed to terms and conditions of the policy. Before issuing the policy, the complainant was asked to fill in the policy proposal form, in which, the complainant was supposed to disclose all the pre-existing medical conditions. Clause 6 of the policy proposal form relating to the Medical History asks specifically as follows:-

a.         Within the last 2 years, have you consulted a doctor or a health care professional?

b.         Within the last 7 years, have you been to a hospital for an operation and/or an investigation (eg. Scan, x-ray, biopsy or blood tests)?

c.         Do you take tables, medicines or drugs on a regular basis?

d.         Within the last 3 months have you experienced any health problem or medical conditions which you/proposed insured have/has not seen a doctor for?

                   However, the complainant did not disclose any medical history and answered in negative to all the above questions. Further submitted that the complainant was got hospitalized for Fibroid Uterus on 18.8.2014 and pre-authorization request for availing cashless facility was sent to the answering Ops on the same day. The said pre-authorization request was partly approved for Rs.50,000/-. However, on receipt of additional documents from the hospital, it was found that the complainant has been suffering from Diabetes Mellitus since 3 years and Hypertension since 3-4 years. Therefore, the previously approves pre-authorization request was cancelled due to non-disclosure of material facts vide letter dated 23.8.2014. In view of the clause 6 of the policy proposal form, it becomes abundantly clear that the complainant was duty bound to disclose her pre-existing medical condition at the time of procuring the insurance policy. Despite such clear and direct questions put to the complainant in the policy proposal form, the complainant deliberately gave false information and withheld material facts from the OPs. However, the pre-existing disease recorded in the Discharge Summary and non-disclosure of those diseases by the complainant at the time of policy inception, the claim was repudiated on 18.10.2014 as per policy terms and conditions. Clause 5 of General Selection Section III of the policy proposal form clearly cautions the proposer to make full and frank disclosures of all material facts. Moreover, as per clause 4(a) of the policy terms and conditions, no claim shall be paid for any pre-existing disease until 48 months have elapsed since policy inception. The insurance is a contract between the parties in good faith. On merits submitted that diabetes and hypertension are not “Major Disease” and just because they are very common does not mean that they are not diseases or are not serious in nature. Further the contents of all other paras of the complaint have been denied.

4.                Ld. counsel for complainant has adduced the evidence by way of duly sworn affidavit of complainant Sangeeta Rani Ex.CA, wherein, the same facts have been reiterated as narrated in the complaint and also attached documents Ex.C1 to Ex.C43. On the other hand, Ld. counsel for OPs has adduced the evidence by way of duly sworn affidavit of Sh.Sumeet Bajaj, Chief Manager-Legal, Max Bupta Health Insurance Co. Ltd. B-1/1-2, Mohan Co-operative, Industrial Area, Mathura Road, New Delhi Ex.RA, wherein again the same facts have been reiterated as narrated in the written statement and also attached documents Ex.R1 to Ex.R8.

5.                Case was fixed for arguments. Proxy counsel for complainant argued that complainant was treated for Gynae Unit of DMC and Hospital, Ludhiana on 18.8.14 for the disease Fibroid Uterus/Leiomyoma of Uterus (Rasoli in Uterus) and complainant spent an amount of Rs.99,900/-. The complainant filed claim with the OPs for the payment of Rs.99,900/-. But the Ops repudiated the claim of the complainant vide repudiation letter dated 18.10.2014 on the ground that the complainant was suffering from mellitus diabetes and hypertension since 3-4 years which was not disclosed at the time of the policy inception. The reason and cause of repudiation by the Ops is claimed to be illegal, arbitrary, without basis and not sustainable by the complainant. Ld. counsel for complainant has relied upon the judgement passed in case titled as New India Assurance Co. Ltd. Vs Harbans Singh-IV (2007) CPJ 182 (NC) passed by Hon’ble National Commission, New Delhi.

6.                Refuting the allegations leveled by the complainant, Ld counsel for OPs argued that complainant has concealed material facts specially regarding the pre-existing disease. OPs had explained entire features/terms and conditions of the said health insurance plan to the complainant and the complainant out of her own free will and volition agreed to terms and conditions of the policy. Before issuing the policy, the complainant was asked to fill the policy proposal form, in which, the complainant was supposed to disclose all the pre-existing medical conditions. Clause 6 of the policy proposal form relating to the Medical History asks specifically as mentioned in para 3 supra. However, the complainant did not disclose any medical history and answered in negative to all the above questions. The complainant was treated for the disease Fibroid Uterus on 18.8.2014 and pre-authorization request for availing cashless facility was sent to the answering Ops on the same day. The said pre-authorization request was partly approved for Rs.50,000/-. However, on receipt of additional documents from the hospital, it was found that the complainant had been suffering from Diabetes Mellitus since 3 years and Hypertension since 3-4 years. Therefore, the previously approved pre-authorization request was cancelled due to non-disclosure of material facts vide letter dated 23.8.2014. In view of the clause 6 of the policy proposal form, it becomes abundantly clear that the complainant was duty bound to disclose her pre-existing medical condition at the time of procuring the insurance policy. Ld. counsel for OPs also relied upon the judgements passed in cases titled as 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 as well as defence taken by the OPs and also perused the entire record placed on file as well the citations so quoted.

8.                It is evident that complainant was insured with the OPs and policy was issued for the period 20.6.14 to 19.6.15. During the subsistence of coverage of abovesaid period complainant was got admitted in Gynae Unit of DMC and Hospital and remained admitted there for the period 18.8.14 to 23.8.14, where she was treated for Fibroid Uterus/Leiomyoma of Uterus (Rasoli in Uterus). It is further observed that there is no connection of the pre-existing disease i.e. Hypertension and Diabetes Mellitus with the present disease of Fibroid Uterus/Leiomyoma of Uterus (Rasoli in Uterus) for which the complainant was treated and lodged the claim and the claim of the complainant was repudiated only on the ground that complainant was suffering from Hypertension and Diabetes Mellitus. The OPs failed to justify how these pre-existing disease are having nexus with Fibroid Uterus/Leiomyoma of Uterus (Rasoli in Uterus) or the disease treated was the result of those pre-existing diseases.

9.                In view of the discussion, we hereby allow this complaint and direct the OPs to settle and pay the claim of the complainant as per the terms and conditions of the policy. Further, OPs are directed to pay Rs.5000/-(Five thousand only) as compensation and as litigation costs compositely assessed to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of this order, which be available to the parties free of costs. File be completed and consigned to record room.

 

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

                         Member                                                   President  

Announced in Open Forum

Dated:30.06.2015

Hardeep Singh