Punjab

Ludhiana

CC/15/61

Vaneet Jain - Complainant(s)

Versus

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

Sumit Jain

14 Feb 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

 

Consumer Complaint No. 61 of 29.01.2015

Date of Decision            :   14.02.2017

 

Vaneet Jain aged 37 years s/o Sh.Bhupinder Jain, resident of House No.514, Sec-39, Chandigarh Road, Ludhiana previously resident of House No.F-23, Jain Niwas, Officer Colony, Mangawal, Ludhiana.

….. Complainant

Versus

 

1.Max Bupa Health Insurance Company Limited, P No.88, 2^nd Floor, Kunal Tower, Mall Road, Ludhiana through its Person Incharge/Branch Manager.

2.Max Bupa Health Insurance Company Limited, Balraj Khanna Marg, East Patel Nagar, Patel Nagar, New Delhi, Delhi 110008, through its Person Incharge/Managing Director/Chief Managing Director.

 

…Opposite parties

 

                              (Complaint U/s 12 of the Consumer Protection Act, 1986)

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

SH. PARAM JIT SINGH BEWLI, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant               :           Sh.Sumit Jain, Advocate

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

 

PER G.K DHIR, PRESIDENT

 

1.                           Complainant an ex-employee of Max Bupa Health Insurance Company Limited took health insurance policy No.30033766201302 with validity period from 30.4.2011 to 29.4.2012 for assured sum of Rs.3 lac. Employment of the complainant with OPs was in April 2011. The policy was availed because it was offered by OP2 to all its employees. After elapse of period of the policy, the complainant kept the policy continued for the next years with validity period from 30.4.2012 to 29.3.2013 and 30.4.2013 to 29.3.2014 for sum assured of Rs.3 lac for self, spouse and daughter. Complainant had been depositing all the premiums regularly with Ops from 2011. Complainant disclosed all the material facts qua disease of the family members at the time of purchase of the policy.      Complainant earlier was having experience of working in medi claim and  health insurance in Bajaj Allianz & Max Bupa Health Insurance. Complainant was well aware that if any disease remained undisclosed, then insurance company may reject the claim immediately.  Complainant deposited the proposal form with OP1 for disclosing that a miscarriage has happened once previously to his wife, due     to which, she is taking a pill on regular basis for her skin problem. Moreover, the complainant disclosed that parents of his wife were patient of heart and Cancer disease. On 12.12.2013, the wife of complainant Smt.Vadana Jain was hospitalized in CMC Hospital, Ludhiana for the third time in last two years for the same Gastro problem and she was diagnosed as a case of ‘Gastroenteritis & Anemia Secondary Blood Loss’. She was discharged from the hospital on 17.12.2013. Cashless facility against this hospitalization was provided under the policy scheme. Few days after discharge of wife of the complainant, she felt not feeling well and she was diagnosed for HB on 02.01.2014. This HB was low at 5.2 on 2.1.2014, but at 5.9 on 05.01.2014. Complainant decided to take another opinion and for that purpose, he approached Dr.Subhash Sachdeva. Complainant was made known as if his wife has some Gynecological problem for the last 1 year. Dr.Subhash Sachdeva diagnosed as if the problem can be Menorrhagia and as such, he advised the complainant to get opinion of Dr.Ajit Sood of DMC & Hospital, Ludhiana for Gastroenteritis first. Complainant got her wife admitted on 13.01.2014 on advise of Dr.Ajit Sood for further check up. After admission, Dr.Tejinder Singh assistant to Dr.Ajit Sood came in the room for getting first information from the wife of complainant and he wrote as if wife of complainant suffered from Menorrhagia for the last 5 years. In fact, he was to write that miscarriage done five years ago. It is claimed that said information recorded due to misunderstanding because there was actually no problem of Menorrhagia earlier. Complainant consulted doctors at PGI Chandigarh vide Cr. No.201204675269 dated 8.12.2012 for the first time. Word Menorrhagia was never reported in any of the report or consultation prepared by PGI doctors. After diagnosis, Dr.Sood advised to the wife of complainant to have one more advance test for knowing about the exact root cause of the problem,       to which she facing for the last 2-3 years. Dr.Sood consulted with Gynecologist Dr.Ashima, who advised for Hormonal therapy due to possibility of Adenomyosis. Finally the wife of the complainant was discharged from hospital on 16.1.2014. Complainant spent Rs.73,161/- on the treatment of his wife. Intimation of this treatment was submitted with Ops and thereafter, relevant documents consisting of bills etc was submitted. Ops vide letter dated 14.1.2014 repudiated the genuine claim under cashless facility with the following words:-

“On going through all the documents submitted by the insured/patient/hospital, it is evident that the insured is admitted for weakness and anemia due to Menorrhagia. As per the documents the patient is suffering from Menorrhagia since five years. As the disease/ailment falls beyond the coverage date/period, it is considered to be pre-existing and hence the request for cashless facility is denied. Hence, the request for cashless is repudiated as per the clause 4a of the policy which states benefit will not be available for pre-existing conditions until 48 months of continues coverage have elapsed since inception of the first policy with us.”

Due to refusal of providing cashless facility, complainant had to pay the said amount. After rejection of the cashless facility, the complainant talked to Dr.Tejinder and Dr.Ajit Sood by showing of the reports again. Dr.Tejinder gave clarification letter for mentioning that the patient 35 years old female admitted vide CR No.5808 in DMC on 13.1.2014 has recent onset anemia for the last one month and is unrelated to the previous disease. When wife of the complainant earlier was admitted in hospital for two times for Gynecological related problem, then Ops provided cashless facility because no problem of Menorrhagia was detected. Even after clarification of Dr.Ajay Sood through Dr.Tejinder, Ops refused to    reimburse the hospital expenses. Problem of Menorrhagia was not existing            at the time of availing the health policy. Despite repeated requests, the claim amount not paid and as such, by pleading deficiency in service on the part of Ops, prayer made for directing Ops to reimburse the spent amount of Rs.73,161/- along with interest @12% per annum from the date of treatment till payment. Rs.75000/- on account of mental pain, harassment and agony, but Rs.10,000/- on account of litigation expenses more claimed.

2.                           In written reply submitted by OP1 and OP2 jointly, it is pleaded interalia as if complaint is not maintainable because the complainant has no cause of action; contract of insurance is a contract of utmost good faith, due to which material facts must have been disclosed at the time of filling of the proposal form and that the terms and conditions of the policy were duly explained to the complainant. Through that proposal form, complainant was required to disclose about all the pre-existing disease along with other things. Complainant was asked specific questions regarding medical history and the replies were specified in the proposal form. Insurance policy regularized by the terms and conditions of the policy. Complainant was an employee of Ops and he availed the insurance policy in question after fully understanding the terms and conditions of the policy. Ops believed the information supplied by the complainant to be true. Booklet consisting of Welcome Letter, insurance certificate, premium receipt, proposal form, blank claim form and terms and conditions of the policy were supplied to the complainant. Admittedly, the policies in question issued with validity period from 30.4.2011 to 29.4.2012; 30.4.2012 to 29.4.2013 and 30.4.2013 to 29.4.2014 as well for period from 30.4.2014 to 29.4.2015. Ops received pre-authorization request for cashless facility of the complainant from DMC & Hospital, Ludhiana and thereafter, on request of Ops, additional information/record was supplied by the said hospital. After going through admission notice provided by the hospital, it was found that the complainant had been suffering from Menorrhagia for the last 5 years prior to the inception of the policy. However, when proposal form was checked, then it was found as if this fact was not disclosed therein and that is why, the pre-authorization request was denied vide letter dated 14.1.2014 by keeping in view of clause 4a of the terms and conditions of the policy. Even after receipt of complete claim documents along with discharge summary, it was found that  patient was diagnosed with Dimorphic Anemia. Officials of Ops after scrutinizing the claim documents and after applying their mind repudiated the claim by invoking clause 5g read with 3(ii). Repudiation of claim defended as legal and valid because as per medical literature available on Wikipedia, Menorrhagia or hematomunia is an abnormally heavy and prolonged menstrual period at regular intervals. Menorrhagia can be caused by abnormal blood clotting, disruption of normal hormonal regulation of periods, or disorders of the endometrial lining of the uterus. Depending upon the cause, it may be associated with abnormally painful periods (dysmenorrheal). Fibroids can cause Menorrhagia. Due to clause 5 relating to medical history in the proposal form, it was specifically asked as to whether complainant consulted any doctor/health care professional within the last two years or as to whether he is taking any medicines or had experience of any health problem     or medical conditions or taking any tablets, drugs or medicines on regular basis, to which, answers were given in negative. Despite caution of providing full and frank disclosures contained in section III of the policy proposal form, the complainant deliberately played fraud with Ops by not disclosing the correct medical history at the time of submission of the proposal form. Besides, claim of the complainant alleged to be exorbitant. Ops are not liable to pay the claimed amount. In the proposal form mention regarding the miscarriage of wife of the complainant not made and nor mention regarding health condition of her parents made. Now a story is concocted in this respect. Earlier, Ops did not found about Menorrhagia sufferance at the time of previous pre-authorization request received in 2011       and that is why said request was allowed in good faith. No statement given by any doctor for claiming that history of miscarriage or history of Menorrhagia mentioned by mistake. Each and every other averment of the complaint denied.

3.                 Counsel for complainant tendered in evidence affidavit Ex.CA of complainant along with documents Ex.C1 to Ex.C33 and thereafter, closed the evidence.

4.                 On the other hand, counsel for OPs tendered in evidence affidavit Ex.RA of Sh.Sumeet Bajaj, Chief Manager of OPs along with documents Ex.R1 to Ex.R10 and thereafter, closed the evidence.

5.                           Written arguments submitted by the OPs, but not by the complainant. Oral arguments addressed by counsel for both the parties heard. Records gone through minutely. 

6.                 It is vehemently contended by counsel for complainant Sh.Sumit Jain, Advocate that discharge summary Ex.C4 refers to Gastroenteritis and Anemia Secondary to blood loss as final diagnosis with respect to the admission of Smt.Vandana Jain, wife of complainant in CMC & Hospital, Ludhiana during period from 12.12.2013 to 17.12.2013 and as such, she was not suffering from Menorrhagia. In view of this final diagnosis report Ex.C4, earlier two claims were allowed and as such, it is contended that now denial of cashless facility or of claim for reimbursement is unjustified. In Ex.C33, the discharge summary of Smt.Vandana Jain for treatment period from 13.1.2014 to 16.1.2014 in DMC & Hospital, Ludhiana, mention of Dimorphic Anemia again made and as such, it is contended that virtually the claim in this case put forth regarding the same treatment, for which, the earlier claim was allowed. So, in view of this, it is contended that record is created regarding  the earlier sufferance of Menorrhagia by the wife of the complainant. However, submission of counsel for the complainant has no force because after going through hospital course record annexed with discharge summary of Smt.Vandana Jain for treatment period from 13.1.2014 to 16.1.2014 of DMC & Hospital, Ludhiana, it is made out as if consultative Dr.Ajit Sood along with other doctors recorded therein as if Smt.Vandana Jain earlier was having history of Menorrhagia and that is why possibility of Adenomyosis was kept. This finding in hospital course recorded on the discharge summary in question on the basis of admission notes of doctor concerned of DMC & Hospital, Ludhiana. Those admission notes are annexed with Ex.R6. History of present illness is mentioned in these admission notes. It is specifically mentioned in these admission notes as if the patient has history of excessive Menorrhagia for the last 5 years. The doctor who recorded these admission notes bound to record these on the basis of information provided to him by the patient or her relatives and not otherwise. These admission notes obtained from the DMC & Hospital, Ludhiana along with record of prescribed medicines and of undergone hospital course cannot be held manipulated at all. Rather,                                      the complainant himself has taken the plea in the complaint that doctor due to mistake has mentioned this fact of previous history of Menorrhagia for the last five years. Certificate of doctor qua this inadvertent mistake has not been produced and nor the said doctor examined through affidavit or otherwise and as such, complainant virtually has failed to prove that this history of Menorrhagia  for the last five years erroneously recorded in the admission notes. When such is the position, then case of Ops stand fully proved that actually patient has history of Menorrhagia for the last five years and that is why the same was disclosed to the doctor, who recorded the admission notes annexed with Ex.R6. Admission record is recorded on the paper head of the hospital and it cannot be manipulated and as such, photo stat copy of admission record and discharge record liable to be accepted as correct. In holding this view, we are fortified by law laid down in case of ICICI Prudential Life Insurance Co.Ltd. and others vs. Yashika Alias Meera & others-2015(4)CLT-518(N.C.). Being so, Ops able to prove as if patient Smt.Vandana Jain was having history of Menorrhagia for the last five years prior to her admission in DMC & Hospital, Ludhiana during period from 13.1.2014 to 16.1.2014 because this admission record annexed with Ex.R6 of date 14.6.2014 and is signed by Dr.Harsimran.

7.                 Complainant himself claims to have been employee of Ops and conversant with the terms and conditions of the policy and as such, he was bound to disclose the exact and true facts qua sufferance from disease of his wife while submitting the proposal form. Even if the insurance may have been subject to medical check before issuance of the policy, despite that insurer not absolved from the responsibility of mentioning true facts about his health in the proposal form. That in fact is 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). So, even if medical examination of the complainant or his wife may have taken place, despite that they were duty bound to explain the factual position qua sufferance of Menorrhagia by Smt.Vandana Jain at the time of submission of the proposal form, particularly when the complainant being employee was supposed to be acquainted with the terms and conditions of the policy. Moreover, as per law laid down in case of Paramjit Kaur vs. Bajaj Allianz Life Insurance Company Limited-2015(4)CLT-590(Punjab State Consumer Disputes Redressal Commission, Chandigarh), if at the time of submission of proposal form, the same is signed in English, then the proposer supposed to be acquainted with the terms and conditions of the policy. Proposal form Ex.R10 of this case is signed by the complainant in English with date of submission of proposal as 29.4.2011 and as such, certainly complainant being an employee of Ops and Bajaj Allianz Company earlier was fully aware as to what he is disclosing about the health conditions of his wife. At page no.5 of this proposal form Ex.R10, it is mentioned as if Smt.Vandana Jain suffered from Skin allergy and hormones imbalance problems six months ago and she was consuming tablets and was to get further treatment. However, it is mentioned in this proposal form as if she did not have any experience of any health problem or medical conditions for seeking advise of a doctor within the last three months.     Problem of sufferance from miscarriage was not mentioned in this              proposal form at all. However,in para no.4 of the complaint, it is mentioned as if problem from sufferance of miscarriage once by the wife of the complainant was disclosed in the proposal form. So, it is obvious that by keeping in view the contents of para no.4 of the complaint itself, it is made out that the complainant deliberately did not disclose about the problem qua sufferance from miscarriage. If at page no.5 of Ex.R10 mention qua sufferance from skin allergy and hormones imbalance for the last 6 months with respect to health of Smt.Vandana Jain could have been made, then why mention of sufferance from miscarriage once not made in Ex.R10, qua that due explanation is not at all submitted. Even mention regarding sufferance from disease of heart and cancer by parents of Smt.Vandana Jain not made at all, though, it is so claimed in para no.4 of the complaint. So, it is obvious that the complainant has put forth afterthought versions qua disclosure made about the miscarriage of Smt.Vandana Jain. Being so, story regarding mistaken    mention of sufferance from Menorrhagia for the last five years instead of miscarriage by Dr.Tejinder Singh put forth in para no.7 of the complaint is not at all believable. Rather, despite sufferance from Menorrhagia for the last five years prior to 16.1.2014, the same was not mentioned in Ex.R10 filled on 29.4.2011. So, certainly submissions advanced by counsel for Ops has force that complainant has suppressed the material facts qua sufferance form Menorrhagia by Smt.Vandana Jain even at the time of submission of proposal form.

8.                 Ex.C1 to Ex.C3 are the documents produced for establishing as if the complainant received Welcome Letter along with insurance policy and premium certificate and policy terms and conditions and that he had been purchasing the policy continuously for self and his wife and daughter. Mention regarding sufferance from Uterus Cancer/Breast Cancer by mother of Smt.Vandana Jain made in Ex.C8, the Out Patient Card of PGI, Chandigarh only. This record is of date 13.10.2012. Mention of this sufferance by mother of Smt.Vandana Jain is not at all made in Ex.R10 and as such, it is obvious that virtually the complainant has concocted story in this respect qua disclosure made in Ex.R10, the proposal form. This story as an afterthought has been made, so that it may be claimed that true facts not concealed, but after knowing well that Ops may lay hand to Ex.C8.

9.                 Ex.C10 to Ex.C29 is the record of treatment or of bills only, but that record will be relevant only, in case, claim of the complainant found sustainable. Denial of authorization for cashless facility took place through letter Ex.C30 qua which there is no denial by Ops and repudiation of claim took place through letter Ex.C31. If earlier complainant able to get the claim twice passed qua anemia treatment, then due to that alone, it cannot be inferred that the complainant has got right to get this claim also passed, particularly when Ops now able to find out concealment of material facts by the complainant regarding history of Menorrhagia for the last five years by wife of the complainant. It is so because an illegality cannot be allowed to be perpetuated. Rather, the parties are governed by the terms and conditions of the contract of insurance and nothing can be added or subtracted thereto by this Forum. Rights and obligations under the contract of insurance are strictly governed by the terms and conditions of the policy.                                   No exception or relaxation thereto permissible legally is the settled proposition of law laid down in cases Ind Swift Limited vs. New India Assurance Co.ltd and others-IV(2012)CPJ-148(N.C.); Usha Sharma and others vs. New India Assurance Co.Ltd and others-I(2012)CPJ-488(N.C.); United India Insurance co.Ltd. vs. Harchand Rai Chandan Lal-IV(2004)CPJ-15(S.C.) and Deokar Exports Private Limited vs. New India Assurance co.Ltd-I(2009)CPJ-6(S.C.).

10.               When there is mis-representation or suppression of material facts relating to medical conditions of the insured, then it cannot be said that it was bonafide suppression or was without any malafide intention. Whenever there is concealment of facts exclusively in the knowledge of the insured, then detection of the same is possible by the insurer only after conduct of reasonable and practical inquiry. This in fact   is the law laid down in case of Life Insurance Corporation of India vs. Santosh Devi-2014(4)CLT-89(N.C.). As the fact regarding sufferance from Menorrhagia by Smt.Vandana Jain or of once miscarriage were even within the knowledge of the complainant or his wife exclusively, but those were suppressed while submitting the proposal form Ex.R10 and as such, owing to suppression of material facts, repudiation of claim is justified as per the terms and conditions of the insurance policy in question.

11.               It is not the duty of Consumer Fora to find out nexus between the accidental death and diseases suppressed by the insured is the proposition of law laid down in case of LIC of India and others vs. Ramamani Patra and another-2015(3)CLT-487(N.C.). As such, after finding suppression of material facts, this Forum not justified in interfering with the order of repudiation of the claim or of rejection of the claim qua cashless facility. Ignorance of terms and conditions of the policy cannot be a justification for not adhering thereto is also the proposition of law laid down in case of Authority under Yeshashwini Wima Yojna vs. Shahinbanu and others-2011(4)CLT-674(N.C.). However, complainant of this case being employee of insurance company was fully aware of the terms and conditions of the policy and as such, he was fully aware that suppression of material facts qua sufferance from earlier disease of Menorrhagia may result in repudiation of    the claim at any stage.

12.               After going through Ex.R9, it is made out that Anemia is not a diagnosis, but it is a manifestation of an underlying disorder. So, diagnosis of Anemia on earlier occasion was just a manifestation of an underlying disorder. Perusal of Ex.R7 reveals that Menorrhagia can be caused by abnormal blood clotting, disruption of normal hormonal regulation of periods or disorders of the endometrial lining of the uterus. Depending upon the cause, it may be associated with abnormally painful periods (dysmenorrheal). Fibroids can cause Menorrhagia. These causes of Menorrhagia with above referred symptoms bound to be in the knowledge of wife of the complainant alone and those should have been mentioned at the time of submission of proposal form Ex.R10.

13.               There may be many causes of heavy menstrual bleeding including hormonal imbalance as per contents of Ex.R8. Heavy or prolonged menstrual periods, or Menorrhagia are the most common type of abnormal bleeding from the uterus. Periods are considered heavy, if there is enough blood to soak a pad or tampon every hours for several consecutive hours as per contents of Ex.R8. These facts of heavy bleeding or prolonged menstrual periods bound to in the knowledge of wife of the complainant or the complainant. Even facts regarding hormonal imbalance causing Menorrhagia bound to be in the knowledge of complainant or his wife, but those were not disclosed and as such, in view of suppression of material facts regarding sufferance from Menorrhagia, repudiation of claim is justified as per clause 4a of the terms and conditions of the insurance policy Ex.R5, which provides that benefits will not be available for pre-existing diseases until 48 months of continuous coverage have elapsed since the inception of the first policy with Ops. As per claim of the complainant himself, inception of the policy started w.e.f.30.4.2011, but the claim with respect to treatment for period from 13.1.2014 to 16.1.2014 put forth in third year of continuity of the policy. Being so, repudiation     of claim is justified, particularly when there is suppression of material facts discussed in detail above. Even if certificate Ex.C32 may have been produced on record to show that Smt.Vandana Jain got treatment during period from 13.1.2014 to 16.1.2014 is unrelated to the prior disease, but despite that suppression of     facts qua pre-existing disease is material because the terms and conditions of the insurance policy are binding and nothing can be added or subtracted thereto. It is not the declaration of Menorrhagia by the doctor alone, but suppression of material facts qua earlier miscarriage even taken into consideration, for holding the claim of repudiation justified.

14.               As a sequel of above discussion, complaint dismissed without any order as to costs. Copies of order be supplied to parties free of costs as per rules.

15.               File be indexed and consigned to record room.

 

                              (Param Jit Singh Bewli)                           (G.K. Dhir)

                                     Member                                               President

Announced in Open Forum.

Dated:14.02.2017. 

GurpreetSharma