Punjab

Ludhiana

CC/15/4

Satpaul Bansal - Complainant(s)

Versus

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

Sanjeev K Laddi

07 Oct 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

Consumer Complaint No. 04 of 02.01.2015

Date of Decision          :   07.10.2015

 

Satpaul Bansal aged about 55 years, son of Shri Sohan Lal, resident of Ram Bagh, Aggar Nagar Enclave, Ludhiana.

….. Complainant

 

Versus

 

1.Max Bupa Health Insurance Company Limited, B-1/I-2, Mohal Cooperative Industrial Estate, Mathura Road, New Delhi-110044, through its Managing Director.

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

..…Opposite parties

 

 

 (COMPLAINT U/S 12 OF THE CONSUMER PROTECTION ACT, 1986)

 

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

SH.SAT PAUL GARG, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant                      :       Sh.Sanjeev K.Laddi, Advocate

For OPs                         :       Sh.G.S.Kalyan, Advocate

 

PER G.K DHIR, PRESIDENT

 

1.                          Sh.Satpaul Bansal filed complaint under Section 12 of the Consumer Protection Act, 1986(hereinafter referred to as the ‘Act’) against the OPs, by alleging that he and his family members earlier were insured with National Insurance Co.Ltd., having its registered office at Kolkata for period of 4 years commencing  from 26.10.2008 and ending on 25.10.2012. Representative of OP1 approached complainant for requesting him to get himself and his family members insured from OP1 because of its good reputation. So complainant ported his insurance company from National Insurance Company Limited to OP1. An application with OP1 was submitted and an amount of Rs.67,831/- was paid to OP1 on 26.9.2012 vide cheque No.458579 drawn on State Bank of India, Focal Point, Ludhiana. At the time of portability of the policy, the complainant was apprised that his policy will be considered to be continued from 2008 uptill date. Insurance Policy number of complainant is 30138864201402 and the validity of the same is uptill 9.10.2015. On 9.4.2014, wife of the complainant namely Mrs.Kanika Bansal was got admitted in Global Health Pvt. Ltd. (Medanta, the Medicity, New Delhi) for treatment of Achalasia Cardia. She remained admitted there upto 13.4.2014. An amount of Rs.57,522/- was incurred as expenses on this treatment. Though, Ops are liable to reimburse the medical expenses incurred on treatment of Mrs.Kanika Bansal, but they are procrastinating the matter. Even emails sent by the complainant to Ops did not entail any results. Complainant has suffered mental pain, agony, harassment and distress and as such, compensation of Rs.40,000/- under this head sought alongwith reimbursement of medical expenses of Rs.57,522/- with interest @18% thereon.

2.                On appearance, OPs filed written statement by claiming that the complainant has not approached this Forum with clean hands and he has mis-represented and concealed material facts. Besides, it is claimed that allegations levelled in the complaint are false, frivolous and vexatious. It is also pleaded

interalia as if complainant has no cause of action and there is no deficiency in service on the part of Ops. Complainant approached Ops for health cover. Terms and conditions of the policy were duly explained to complainant and after understanding the terms and conditions, he filled the proposal form dated 1.1.2012 for obtaining policy No.301388864201200 for the duration of 10.10.2012 to 09.10.2013 for an amount of Rs.30,00,000/-. Thereafter, said policy was renewed vide policy No.30138864201301 for the duration of 10.10.2013 to 09.10.2014 and further vide policy No.30138864201301 for the duration 10.10.2014 to 09.10.2015. Complainant was bound to disclose true information regarding detail of clause 6 of the proposal form. Complainant was asked as to whether insured has consulted a doctor or a health care professional within the last 2 years and as to whether he had been to a hospital for an operation and/or an investigation within the last 7 years or he had been taking tablets, medicines or drugs on a regular basis or as to whether he experienced any health problem or medical conditions within the last 3 months and he replied in negative to all these questions. Believing the information provided by the complainant as correct, policy in question was issued. Wife of complainant got hospitalized for Achalasia Cardia on 9.4.2014 and submitted pre-authorization request for availing cashless facility on the same day with Ops. The hospital was asked to provide additional information regarding the case. After going through the consultation papers, it was found that wife of complainant first consulted doctor at Medanta Hospital on 24.9.2012. It was revealed from perusal of IPD papers that wife of complainant had been suffering from Achalasia Cardia for the last 5 years. So, wife of complainant was suffering from pre-existing disease, for which,she had been diagnosed prior to the inception of the policy. However, facts in that respect were concealed while filling the proposal form. Thereafter, complainant filed claim for reimbursement of medical expenses incurred during hospitalization, but the claim was repudiated because of non disclosure of pre-existing disease by the complainant at the time of filing the proposal form. In view of non disclosure qua pre-existing medical conditions, claim was duly repudiated as per terms and conditions of the insurance policy. Each and every other averment of the complaint denied.

3.                Complainant to prove his case tendered his affidavit Ex.CA alongwith documents EX.C1 to Ex.C6 and thereafter, closed the evidence.

4.                On the other hand, counsel for the OP tendered in evidence affidavit Ex.RA of Sh.Anand R.Choudhary, Head Legal of Max Bupa Health Insurance Company Limited of OP1 and even tendered documents Ex.R1 to Ex.R6 and thereafter, closed the evidence.

5.                          Written arguments were submitted by counsel for the parties. Oral arguments even addressed and were heard. Records gone through minutely. 

6.                From perusal of documents Ex.C1 to Ex.C6 and Ex.R1 and pleadings of the parties, it is made out that undisputed facts are that earlier complainant got medi-claim health insurance policy for self and his wife and daughter from National Insurance Company Limited from 20.10.2008 to 25.10.2012, but thereafter, he obtained medi-claim health insurance policy from OP1 uptill date. Wife of complainant Mrs.Kanika Bansal was insured through out during the policy period of 20.10.2008 to 9.10.2015 under the policies, cover notes of which are Ex.C1 to Ex.C6. So certainly submission advanced by the counsel for complainant has force that complainant and his wife got medi-claim health insurance policies for the last 8 years. Portability of the policy to concern of OP1 even took place and submission of counsel for complainant in that respect has force.

7.                It is contended by counsel for the complainant that there was no occasion with complainant for getting himself and his family members insured from new insurance company because he was fully conversant with the fact that no chronic disease was covered under the new insurance policy after the lapse of 48 months. It is contended that agent of Ops allured the complainant that his policy will be continued one and as such, there is no suppression of facts, particularly when the wife of the complainant was not suffering from any disease at the time of initial purchase of the policy on 26.10.2008 through Ex.C4. Even if complainant may have purchased the policy by way of portability from OP1, despite that terms and conditions of the contract of insurance strictly to govern the case of the parties because as per law laid down in case of Deokar Exports Pvt. Ltd. vs. New India Assurance Co.Ltd.-I(2009)CPJ-6(S.C.), rights and obligations under policy of insurance are strictly governed by the contract of insurance and no exception or relaxation can be made on the ground of equity. So terms and conditions of insurance policy in question contained in Ex.R1 to govern the case of the parties.

8.                As per law laid down in case of Manager, SBI Life Insurance Company Limited and others vs. Santosh Nagnath Kedari-2014(4)CLT-404(Maharashtra State Consumer Disputes Redressal Commission, Mumbai), merely because the insured was subjected to medical check-up before the issue of policy, he was not absolved from responsibility of truthfully disclosing the correct facts about his health. It is so because contract of insurance is based upon utmost good faith, due to which, insured is under obligation to inform about everything concerning his health. So, in case of deliberate suppression of material facts qua Achalasia Cardia disease by the complainant or his proposer proved by the insurer, then repudiation of claim will be justified. It is so because as per law laid down in case of Satwant Kaur Sandhu vs. New India Assurance Company Limited-2009(4)RCR(Civil)-692(S.C.), in case, an insured while taking medi-claim insurance policy suppressed the fact of ailment, then he/she or his/her heirs not entitled to claim compensation in the event of death or injury. So, in case material information regarding pre-existing disease found to be suppressed while filling the proposal form, then repudiation of claim will be justified. In a contract of insurance any fact which would  influence the mind of a prudent insurer in deciding whether to accept or not to accept the risk is a “material fact”. So, if the proposer has knowledge of such fact, then he is obliged to disclose it particularly while answering the questions in the proposal form. Any inaccurate answer in the proposal form will entitle the insurer to repudiate his liability because there is a clear presumption that any information sought for in the proposal form is material for the purpose of entering into a Contract of Insurance. Same is the proposition of law laid down in cases Life Insurance Corporation of India vs. Santosh Devi-2014(4)CLT-89(N.C.); Life Insurance Corporation of India vs. Smt.Neelam Sharma-Revision Petition No.967 of 2008 decided on 30.09.2014 by Hon’ble National Consumer Disputes Redressal Commission, New Delhi.

9.                The proposal form Ex.R2 was filled up by the complainant on 1.1.2012 for purchasing the policy in question from OP1 for self, his wife Mrs.Kanika Bansal and daughter namely Bhawna Bansal. At that time, it was disclosed that complainant, his wife or daughter have not consulted a doctor or health care professional within the last 2 years and nor they have been to a hospital for an operation and/or an investigation (E.C.G., Scan, X-ray, Biopsy or blood tests) within the last 7 years. Even through proposal form Ex.R2, it was disclosed that complainant, his wife or daughter have never taken any tablets, medicines or drugs on a regular basis and nor they have experienced any health problem or medical conditions within the last 3 months. However, on submission of claim form Ex.R5 for treatment of wife of complainant for period w.e.f.9.4.2014 to 13.4.2014 and pre-authorization request, investigation was got conducted and investigation report format Ex.R3 was obtained for denying the pre-authorization request through Ex.R4. Investigation Report Format Ex.R3 alongwith denial of pre-authorization request Ex.R4 establishes that Mrs.Kanika Bansal was diagnosed as a case of Achalasia Cardia and she got treatment from Global Health Pvt. Ltd. (Medanta, the Medicity, New Delhi) earlier. Perusal of Ex.R3 further reveals that when investigator contacted complainant and his wife, then wife of the complainant refused to give any statement to the investigator. It was thereafter that investigator visited Global Health Pvt. Ltd. (Medanta, the Medicity, New Delhi) and verified the indoor case papers. As per the collected papers from that hospital, the investigator found that wife of complainant remained indoor patient with complaint of medical management. Copy of Radiology report obtained from Global Health Pvt. Ltd. (Medanta, the Medicity, New Delhi) has been produced on record alongwith Ex.R3 to prove that Mrs.Kanika Bansal was admitted on 24.9.2012 in Global Health Pvt. Ltd. (Medanta, the Medicity, New Delhi). After doing necessary tests, impression was gathered through radiology report that features/symptoms are suggestive of Achalasia Cardia. Smooth tapering of the distal thoracic oesophagus upto the gastro-oesophageal junction was described to be found as per this radiology report. So, this material produced on record establishes that wife of the complainant was having history suggestive of Achalasia Cardia on 24.9.2012. Radiological examination of her was conducted in Global Health Pvt. Ltd. (Medanta, the Medicity, New Delhi). Similar radiology report from Global Health Pvt. Ltd. (Medanta, the Medicity, New Delhi) obtained qua insured Mrs.Kanika Bansal qua her date of admission as 5.3.2014. Encounter Form of   Global Health Pvt. Ltd. (Medanta, the Medicity, New Delhi) shows the visit of Mrs.Kanika Bansal to that hospital on 24.9.2012 also and refers same to the disease of Achalasia Cardia on it. So, disease of Achalasia Cardia is a heart disease which was faced by the insured from 24.9.2012 i.e. prior to the filing of the proposal form Ex.R2 on 1.10.2012. As terms of contract to govern the case of the parties and as such, keeping in view the terms of Clause 4(a) of Contract Agreement, repudiation of claim is quite proper. That Clause 4(a) of terms and conditions of the policy got by the complainant with Ops reads as under:-

“We shall not liable under this policy for any claim in connection with or in respect of the following:-

a.Pre-Existing Conditions

Benefits will be available for pre-existing conditions until 48 months of continuous coverage have elapsed since the inception of the first policy with us.” s

10.              From the perusal of this clause, it is obvious that in case insured was having pre-existing conditions, then he is not entitled to medi-claim benefits for 48 months of continuous coverage of the policy with Ops. In this case before us, the policy with Ops was started for the first time w.e.f.26.10.2012 onwards by filing proposal form Ex.R2 on 1.10.2012. So, policy with Ops commenced w.e.f.26.10.2012. Period of 48 months from such commencement was to elapse on 25.10.2016. As per clause 4(a) of the terms and conditions of the policy for pre-existing conditions, benefit of insurance not available until 48 months of continuous coverage elapsed since the inception of the first policy with Ops and as such virtually the benefit for treatment for period from 9.4.2014 to 13.4.2014 claimed within two years of the inception of the first policy with Ops. As pre-existing condition qua Achalasia Cardia became known to the complainant on 25.9.2012 is a fact born from perusal of record of Global Health Pvt. Ltd. (Medanta, the Medicity, New Delhi) and Radiology report referred above, so, repudiation of claim certainly is as per clause 4(a) of the terms and conditions of the insurance policy. In view of that there is no deficiency in service on the part of the Ops.

11.              Therefore, as a sequel of the above discussion, we find that complainant suppressed the material facts of sufferance of insured with heart disease at the time of filing of the proposal form and as such, repudiation of claim is fully justified. So, present complaint merits dismissal and same is hereby dismissed with no order as to costs. Copy of this order be made available to the parties free of costs as per rules.

12.                        File be indexed and consigned to record room.

 

                   (Sat Paul Garg)                            (G.K.Dhir)

                       Member                                      President

Announced in Open Forum

Dated:07.10.2015

Gurpreet Sharma.