Punjab

Ludhiana

CC/19/484

Surinder Pal Singh - Complainant(s)

Versus

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

Alok Mohindra Adv.

22 Sep 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:484 dated 15.10.2019.                                                         Date of decision: 22.09.2023.

 

1. Surinder Pal Singh son of Sh. Naurang Singh, resident of House No.B-5/447, Hazoori Road, Near Madhopuri Chowk, Madhopuri, Ludhiana since deceased through his legal heirs:-

1. Jasjit Kaur (widow) of Sh. Naurang Singh, resident of Prem Colony, Village Meharban, Tehsil and Distt. Ludhiana.       
2. Arshdeep Kaur (Daughter) of Sh. Naurang Singh, resident of Prem Colony, Village Meharban, Tehsil and Distt. Ludhiana.
3. Ramandeep Kaur (Daughter) now wife of Sh. Ranpreet Singh, resident No.14-A/17, Block A, WEA Karol Bagh, Central Delhi.
4. Dilpreet Singh (son) of Sh. Naurang Singh, resident of Prem Colony, Village Meharban, Tehsil and Distt. Ludhiana.                                                                                     ..…Complainant

                                                Versus

Max Bupa Health Insurance Co. Ltd. Having its corporate office at Block B1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi-110044 through its Managing Director/Chairman/CEO.                                                                                                                                       …..Opposite party 

Complaint Under section 12 of the Consumer Protection Act, 1986.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Dinesh Kumar, Advocate.

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

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant took Family First Silver 1L=10L health insurance policy No.30579272201802 for a sum insured of Rs.12,20,000/- having validity from 12.09.2018 to 11.09.2019 on premium of Rs.48,389/- by covering himself and his wife Jasjit Kaur. Prior to this policy, the complainant had taken health insurance policy No.30579272201701 from the opposite party from 12.09.2017 to 11.09.2018 with coverage of Rs.12,00,000/- for himself and his wife. During the subsistence of the policy from 12.09.2018 to 11.09.2019, wife of the complainant Smt. Jasjit Kaur suffered from pain and swelling in umbilical region and after consulting at Chawla Nursing Home & Multispecialty Hospital, Ludhiana, she was admitted in the said hospital on 08.10.2018 and was discharged on 15.10.2018. The complainant spent Rs.81,910/- including Rs.63,800/0 on her hospitalization and medicines vide bill dated 15.10.2018 for Rs.16,600/-, Rs.110/- on 08.10.2018 and Rs.1400/- incurred on 06.10.2018. The complainant lodged a claim with the opposite party for reimbrusem4nt of the amount along with all the requisite documents with the opposite party but till date the same amount had not been paid. However, the opposite parties refused to pay the claim on the ground that the wife of the complainant is a known case of umbilical swelling which is a preexisting disease and the claim was rejected under clause 7.1 being not payable. The rejection was conveyed to the complainant vide letter/email dated 28.12.2018. The complainant further stated that he got the health insurance policy from the opposite parties for the first time in the year 12.09.2016 and has been regularly renewing the same without any break. Neither the complainant nor his wife was suffering from any disease and they filled the proposal form correctly. Even the opposite parties got the medical checkup of the complainant and his wife and thereafter, they issued the policy after satisfying them about the health of the complainant and his wife. The wife of the complainant suffered from swelling in the umbilical region about four months prior to her admission in the hospital and she was admitted in Chawla Nursing Home & Multispecialty Hospital, Ludhiana on 08.10.2018 and she was diagnosed of Umbilical Hernia for which she was operated upon by way of laparoscopic surgery and was discharged on 15.10.2018. The complainant submitted all the hospital and medicine bills to the opposite parties amounting to Rs.81,910/- and also pre and post hospitalization expenses. The opposite parties sent a letter/email dated 28.12.2018 stating that the wife of the complainant is a known case of umbilical swelling which is a pre-existing disease and rejected the claim under Clause 7.1. The complainant further stated that in the medical history of his wife, it was wrongly recorded that she is suffering from Umbilical swelling for the last 4 years for which he and his wife immediately met the doctors in Chawla Nursing Home & Multispecialty Hospital, Ludhiana and told them that at the time of her admission, the prior medical history was recorded by Junior staff of the hospital where she clearly told that she is suffering from Umbilical swelling for the last about 4 months and further asked them to made necessary correction in the record. According to the complainant his wife was not suffering from any pre-existing disease prior to issuance of policy as alleged by the opposite parties rather the said problem occurred only 4 months ago and the junior staff of the hospital wrongly mentioned the word “year” instead of the word “month” at the time of recording the history. As such, Chawla Nursing Home issued certificate dated 11.11.2018 menti9ning that the patient was admitted with past history of Umbilical swelling for the past 4 months but the resident wrote 4 years by mistake. The said medical certificate was sent to the opposite parties by the complainant along with letter dated 11.12.2018. However, the opposite parties never visited the concerned hospital to check the veracity of the said certificate. In the end, the complainant has prayed for issuing direction to the opposite parties to pay the amount of Rs.81,910/- along with interest @12% per annum and also to pay compensation of Rs.1,00,000/- on account of harassment, mental pain, agony suffered by the complainant.

2.                Upon notice, the opposite parties appeared and filed written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability of the complaint; lack of jurisdiction; suppression of material facts; lack of cause of action etc. The opposite parties stated that they issued Family First Silver Policy No.30579272201600 on the basis of information provided by the proposer in the proposal form. The plan opted for by the complainant was Family First Siler 1 Lac + 10 Lacs and sum insured under the police was Rs.1Lac individual and Rs.10 Lac floater. The complainant and his wife Jasjit Kaur were insured under the policy which was renewed from time to time. According to the opposite parties, the complainant preferred a claim for treatment of hernia, but as per the documents submitted with the claim, it was seen that the complainant was suffering from swelling in umbilical region since 4 years and as such, the claim was rejected since pre-existing conditions had a waiting period of 48 months.

                   Under the column of facts of the case, the opposite parties stated that they received an application form requesting for issuance of health policy for the complainant and his wife Jasjit Kaur and as such, on 12.09.2016, they issued Family First Siler Policy No.30579272201600 on the basis of information provided by the proposer in the proposal form which had been renewed thereafter. According to the opposite parties under the policy no benefit is payable for the claim intimated to them. As per the documents submitted by the complainant and hospital records, it was found that the insured person i.e. Jasjit Kaur was a known case of Umbilical Swelling since 4 years at the time of taking treatment on 08.10.2018. The history had been dully recorded in the discharge card of Chawla Nursing Home where she was treated upon. Therefore, the same came in the category of pre-existing condition and non-disclosure and as such, the claim was not payable as per clause 7.1 of the Policy terms and conditions. Further as per clause 7.1 of the policy no benefits shall be paid for any pre-existing disease unless such pre-existing disease is mentioned in the proposal form. The policy was commended on 12.09.2016 and as such, the period of 48 months has not elapsed as per the insurance plan. The opposite parties further stated that from the patient medical record/discharge card of Chawla Nursing Home, it has been specifically mentioned that the insured was a known case of Umbilical Swelling for the past 4 years. According to the opposite parties they being insurance company pay the claim amount from the common pool of the policyholders and payment of one wrongful claim adversely affects thousands of other rightful policyholders and as such, the repudiation of the claim of the complainant is just, proper, legal, valid and made on the grounds of non-disclosure of material facts.

                   On merits, the opposite parties reiterated the facts mentioned in the preliminary objections. The opposite parties have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.         

3.                During the proceedings of the complaint, the complainant Surinder Pal Singh expired on 21.05.2021 and an application for impleading his legal heirs as party was moved. The said application was allowed vide order dated 03.01.2023.

4.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of welcome letter dated 07.09.2017, Ex. C2 is the copy of insurance policy w.e.f. 12.09.2017 to 11.09.2018, Ex. C3 is the copy of premium receipt, Ex. C4 is the copy of Annexure-I List of Insurance ombudsman, Ex. C5 is the copy of terms and conditions of the policy and closed the evidence.

5.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Sh. Bhuwan Bhasler, Manager of the opposite parties along with documents Ex. OP1/1 is the copy of letter of authorization, Ex. OP1/2 is the copy of proposal form, Ex. OP1/3 is the copy of welcome letter and policy documents, Ex. OP1/4 is the copy of discharge card and medical record of Chawla Nursing Home, Ex. OP1/5 is the copy of repudiation letter dated 13.11.2019 and closed the evidence.

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 affidavit and documents produced on record by both the parties.

7.                There is not much of the dispute so far as the facts of the case are concerned. The complainant (now deceased) obtained Family First Silver 1L=10L health insurance policy Ex. C2 w.e.f. 12.09.2017 to 11.09.2018 for himself and his wife Jasjit Kaur, having a coverage of Rs.12,00,000/- on premium of Rs.45,015/-. The said policy was further renewed from 12.09.2018 to 11.09.2019 having sum insured of Rs.12,20,000/-. Further it is not disputed that Smt. Jasjit Kaur was hospitalized with Chawla Nursing Home & Multispecialty Hospital, Ludhiana from 08.10.2018 to 15.10.2018. Thereafter, the patient was discharged in satisfactory condition as is evident from the discharge summary Ex. OP1/4 However, the bills in respect of hospitalization of Smt. Jasjit Kaur has not been paid by the opposite parties. Instead the opposite parties issued letter Ex. OP1/5 whereby the claim was rejected on the ground that the patient was a known case of umbilical swelling last 4 years as treatment for pre-existing ailment falls under 48 month, waiting period.

8.                Now the question arise whether the rejection of the claim on the ground mentioned therein is valid or not? The opposite parties have rejected the claim of the complainant by invoking clause 7.1 of the policy terms and conditions on the ground of the insured having suffered from umbilical swelling since 4 years. Clause 7.1 of the terms and conditions of the policy is reproduced as under:-

          “7. Pre-existing Diseases:

All Pre-existing diseases shall not be covered until 24 months of continuous coverage have elapsed since the inception of the First Policy with us for insured persons to whom the Gold and Platinum Plans are applicable and until 48 months of continuous coverage have elapsed since the inception of the First Policy with us for insured persons to whom the Silver Plan is applicable.

No benefits shall be paid for any pre-existing disease unless such pre-existing disease is stated in the proposal and specifically accepted by us and endorsed thereon.”

It has been vehemently argued by the counsel for the opposite parties that in the proposal form, copy of which Ex. OP1/2 has been placed on the file, the complainant provided the wrong information with regard to the medical history. Here it would be relevant to reproduce the Column No.6 of the proposal form Ex. OP1/2, which deals with the medical history of the insured. In the column of medical history, following four questions were required to be filled by the insured:-

1)      Within the last 2 years, have you consulted a doctor or a healthcare professional?

2)      Within the last 7 years, have you been to a hospital for an operation and/or an investigation (e.g. scan, X-ray, biopsy or blood tests)?

3)      Do you take tablets, medicines or drugs on a regular basis?

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

The complainant answered all the aforesaid questions in negative. The claim of the complainant is sought to be repudiated on the ground that she was a suffering from umbilical swelling since 4 years. The first question in Column No.6 relates to a period of only 2 years immediately preceding the policy. While question No.2 relates to hospitalization within 7 years immediately preceding the policy. The proposal form Ex. OP1/2 filled on 01.09.2016. 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 58 years at the time of issuance of the policy, the complainant was not got medically examined though in the proposal form there is a note at the end of column No.6 that in addition to the above four questions, 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 year 2016 or subsequently when the policy was renewed from time to time.

9.                In the present case, the insured Smt. Jasjit Kaur was admitted in the Chawla Nursing Home & Multispecialty Hospital, Ludhiana on 08.10.2018 with chief complaints of swelling in umbilical region for 4 years as per discharge card/summary Ex. OP1/4.  As per discharge card, the treatment given to the patient was Laparoscopic intraperitoneal onlay mashpalsty done on 08.10.2018 and the patient recovered well. She is being discharged in satisfactory condition. However, the opposite parties rejected the claim by stating that Jasjit Kaur was a patient of umbilical hernia for the last 4 years.

                   There is no nexus between the diagnosed disease and the alleged pre-existing disease. 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 or canceling the policy on the ground of suppressing her taking treatment for umbilical hernia for the last 4 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 father 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:-

“(i) There is a duty or obligation of disclosure by the insured regarding any material fact at the time of making the proposal. What constitutes a material fact would depend upon the nature of the insurance policy to be taken, the risk to be covered, as well as the queries that are raised in the proposal form.

(ii) What may be a material fact in a case would also depend upon the health and medical condition of the proposer.

(iii) If specific queries are made in a proposal form then it is expected that specific answers are given by the insured who is bound by the duty to disclose all material facts.

(iv) If any query or column in a proposal form is left blank then the insurance company must ask the insured to fill it up. If in spite of any column being left blank, the insurance company accepts the premium and issues a policy, it cannot at a later stage, when a claim is made under the policy, say that there was a suppression or non­disclosure of a material fact, and seek to repudiate the claim.

(v) The insurance company has the right to seek details regarding medical condition, if any, of the proposer by getting the proposer examined by one of its empanelled doctors. If, on the consideration of the medical report, the insurance company is satisfied about the medical condition of the proposer and that there is no risk of pre­existing illness, and on such satisfaction it has issued the policy, it cannot thereafter, contend that there was a possible pre­existing illness or sickness which has led to the claim being made by the insured and for that reason repudiate the claim.

(vi) The insurer must be able to assess the likely risks that may arise from the status of health and existing disease, if any, disclosed by the insured in the proposal form before issuing the insurance policy. Once the policy has been issued after assessing the medical condition of the insured, the insurer cannot repudiate the claim by citing an existing medical condition which was disclosed by the insured in the proposal form, which condition has led to a particular risk in respect of which the claim has been made by the insured.

(vii) In other words, a prudent insurer has to gauge the possible risk that the policy would have to cover and accordingly decide to either accept the proposal form and issue a policy or decline to do so. Such an exercise is dependant on the queries made in the proposal form and the answer to the said queries given by the proposer.               

Therefore, in our considered view, the repudiation of the claim on the basis of non-disclosure of pre-existing diseases such as umbilical swelling could not have been made a ground to reject the claim.  The insurance companies are required to be more liberal in their approach without being too technical. In this case, the complainant (now deceased) had raised a claim of Rs.81,910/- for the treatment of his wife Jasjit Kaur. In the given set of above said facts and circumstances, it would be just and appropriate if the opposite parties are directed to settle and reimburse claim lodged by LA Jasjit Kaur in respect of her treatment/pre as well as post-hospitalization with Chawla Nursing Home & Multispecialty Hospital, Ludhiana from 08.10.2018 to 15.10.2018 along with composite costs of Rs.10,000/-. 

11.              As a result of above discussion, the complaint is partly allowed with direction to the opposite parties to settle and reimburse the claim lodged by LA Jasjit Kaur in respect of her treatment/pre as well as post-hospitalization with Chawla Nursing Home & Multispecialty Hospital, Ludhiana from 08.10.2018 to 15.10.2018 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 legal heirs the complainant from the date of order till its actual payment. The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the legal heirs of 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. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.  

12.              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:22.09.2023.

Gobind Ram.