Delhi

East Delhi

CC/1114/2014

SHIV OM - Complainant(s)

Versus

MAX BUPA HEALTH INS - Opp.Party(s)

09 Sep 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 1114/14

 

Shri Shiv Om

IX/7, Main Road, Kailash Nagar

Delhi- 110031

Also at

D-107, D-Block, Ganga Vihar,

Delhi- 110094                                                                                                                                                                              ….Complainant

Vs.

Max Bupa Health Insurance Co. Ltd.

Through its Managers

Having Office At:

B-1/1-2, Mohan Estate, Mathura Road,

New Delhi- 110044         

   …Opposite parties

 

Date of Institution:03.12.2014

Judgement Reserved on: 09.09.2019

Judgement Passed on: 12.09.2019

 

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By: Harpreet Kaur Charya (Member)

JUDGEMENT

The present complaint has been filed by Shri Shiv Om, the complainant against Max Bupa Health Insurance Co. Ltd., (OP) under Section 12 of the Consumer Protection Act, 1986 for unfair trade practice and deficiency in services.

Briefly stated the facts of present complaint are that the complainant was covered under mediclaim policy bearing no. 31195742201401for cover from 17.03.2013 to 16.03.2014. The complainant had stated that he had been maintaining mediclaim policy, since 15.03.2007 continuously. On 15.03.2009, the complainant got his daughter also covered. Though, the complainant was in possession of insurance policy commencing from 15.03.2011 issued by Oriental Insurance Co. Ltd.

On 14.03.2014, the son of the complainant, Master Kartik Singhal was admitted in Taneja Hostpital, 281, North Civil Line, Railway Road Muzzfarnagar, UP for treatment of Submandibular adenitis excision and was discharged on 17.03.2014. It has been stated that request for cashless treatment was sent to OP, which was rejected. Consequently, the complainant had to pay                 Rs. 31,292/-, for which claim for reimbursement was lodged alongwith all the necessary documents. Ultimately, in the month of May 2014, the complainant came to know that the claim had been repudiated on the ground “Disease falls under 24 months specific waiting period, hence claim denied.” It has been stated that OP had ignored the fact what there was no previous history of the disease, further the complainant had submitted all the policies of previous 4 years commencing from 15.03.2011, thus the waiting period of 24 months was over. Despite, several personal visits the claim of the complainant was not settled, thereby, the complainant has alleged deficiency in service on the part of OP.

Hence, the present complainant with prayer for directions to OP to pay Rs. 31,292/- as the claim amount, Rs. 2,371/- towards medical bills and                    Rs. 61,000/- as compensation on account of mental agony and harassment.

The complainant has annexed insurance certificate issued by National Insurance Co. Ltd. for period 15.03.2012-14.03.2013, policy certificate issued by OP for period 17.03.2013-16.03.2014 and 17.03.2014-16.03.2015 as               Annexure -1, certificate of insurance issued by Oriental Insurance Co. Ltd. for period 15.03.2011-14.03.2012 as Annexure-2, repudiation letter dated 26.04.2014 of claim no. 76750 as Annexure-3, claim form as Annexure-4, case summary as Annexure-5 and discharge slip as Annexure-6.

Reply was filed on behalf of OP upon service of the Notice. In their defence they have submitted that policy No. 30195742201300 was issued to complainant with cover from 17.03.2013 to 16.03.2014. The complainant was insured with OP since 17.03.2013 and he had not got his previous policy ported from the previous insurer, therefore, the complainant had taken fresh policy, so he could not claim benefit of continuity, as there was no portability. Moreover, the complainant had not disclosed any details regarding his previous insurance policies in Section III of policy proposal form. The complainant had further checked “NO” against the option under section II of policy proposal form, which was pertaining to hospital cash benefit. Therefore, the complainant was not entitled to cashless benefit. The said policy documents was delivered to the complainant alongwith policy terms and conditions, premium receipts and proposal form and again the said policy was subsequently renewed for the period from 17.03.2014 to 16.03.2015 and further on 17.03.2016. Policy kit for 2013-2014 has been annexed as Annexure OP-2 and insurance certificates for 2014-2015 and 2015-2016 are Annexure OP-3.

           The registration of claim no. 76750 by the complainant has been admitted and the same alongwith bills is annexed as Annexure OP-4. It has been further submitted that according to the discharge summary, the son of the complainant was suffering from Submandibular adenitis and underwent surgery for its removal and as per clause 4(c)(2) of the policy terms and conditions, there was specific waiting period of 24 months, since, the date of policy inception, thus, the claim for treatment of Submandibular gland was excluded.  The claim rejection letter is annexed as Annexure OP-5.

           It was also submitted that complainant had filed pre and post hospitalization claim vide claim No. 83920, since, main claim was not payable; claim no. 83920 was also not tenable. Claim forms are annexed as                  Annexure OP-6 and Annexure OP-7 respectively. It was submitted that the complainant had failed to understand the terms and conditions of the policy. They have denied rest of the contents of the complaint and prayed for dismissal of the same.

           Rejoinder to the Written Statement of OP was filed by the complainant, where he has stated that the fact of continued insurance had been expressly mentioned in insurance policy commencing from 15.03.2011 duly issued by Oriental Insurance Co. Ltd. The complainant had further stated that OP had failed to consider the fact that the treatment was taken for disease, which was existent from last 10 days and there was no previous history of the same. The complainant has stated that the copy of the policy certificate issued by Oriental Insurance Co. Ltd. have been annexed as Annexure-2 (Colly.) Rest of the contents of the Written Statement has been denied and those of complaint have been re-affirmed.

Evidence by way of affidavit was filed by the complainant, where he has deposed on oath the contents of the complaint. The complainant has relied upon, copy of insurance policy as Annexure-1, copy of insurance certificate from 15.03.2011 to 14.03.2012 with remark “insurance without break since 4 years” as Annexure-2, copy of downloaded claim repudiation report as Annexure-3 and the annexure annexed with the complaint.   

OP got examined Shri Sumeet Bajaj, Head (Legal), on their behalf. He has relied on authority letter dated 01.04.2015 as Annexure OP1, Policy kit for the year 2013-2014 as Annexure OP2; insurance certificates for the year            2014-2015 and 2015-2016 as Annexure OP3, the claim form and medical documents alongwith bills are Annexure OP4.

The claim rejection letter is Annexure OP5, where the claim of the complainant had been rejected as per Clause 4 (c) (2), wherein there is a specific waiting period of 24 months from the date of policy inception for treatment of adenoids. Annexure OP6 and Annexure OP7 are pre and post hospitalization claim forms

We have heard the arguments on behalf of Ld. Counsel for the Complainant and Ld. Counsel for OP. We have also perused the material placed on record. The complainant has invoked the jurisdiction of this Forum on being aggrieved by non-reimbursement of the expenses of Rs. 31,292/- incurred by him on the treatment of his son.

The complainant had medical insurance cover and his son was treated for Submandibular Adenitis Excision surgery on 14.03.2014, the claim for which was rejected.

The Ld. Counsel for Complainant has argued that OP had rejected the claim on the ground that the treatment had a specific waiting period of 24 months. Further it has been argued by the Ld. Counsel for Complainant that he had got his policy ported from previous insurer to OP. So, in brief the complainant has alleged that his policy was ported so it should be treated to be continuous, the specific waiting period of 24 months did not apply.  

If we look at Annexure-1 (Colly.),  which are the previous polices issued to the complainant, one is issued by National Insurance Company Ltd. for the period from 15.03.2012 to 14.03.2013 and Annexure-2, the certificate of insurance issued by Oriental Insurance Co. Ltd., which is for period from 15.03.2011 to 14.03.2012 and bears endorsement “Insurance without break since 4 years”.

On the other hand Ld. Counsel for OP has stated that in the proposal form dated 04.03.2013, which is Annexure OP-1 (Colly.), the complainant under Section II: Coverage selection

1) Do you want to apply for a hospital cash benefit?

          Yes            No.

And

Section. III:  General Information:

1)……

2)……

3) Existing Insurance Details

Is the proposer or any of the persons proposed to be insured already insured under or proposed for health insurance policy for inpatient hospitalization with Max Bupa Health Insurance Co. Ltd. or any other company?

The said column is left blank.

Considering arguments addressed by both the parties and evaluating material placed on record, it is seen that complainant has placed previous policies i.e. Annexure-2, which is certificate issued by Oriental Insurance Co. Ltd., where it has been stated “Insurance without break since 4 years” further, Annexure-1, which is policy for the period 15.03.2012-14.03.2013 and the policy issued by OP, which is for the period 17.03.2013-14.03.2014, thus the complainant has successfully proved his averment that he was having policy since 2007. Omission in getting the previous policy details mentioned in the proposal form is a mere technical irregularity, which should not come in the way of dispensing substantial justice.

 Therefore, in the facts and circumstances of the present complaint, we direct OP to pay Rs. 31,292/- as the claim amount. The non settlement of the claim by OP definitely amounts to deficiency in service. Hence, complainant is also entitled to Rs. 10,000/- as compensation on account of mental agony and harassment, this is inclusive of litigation expenses.

Order be complied within 30  days from the date of receipt of this order.

Copy of the order be supplied to the parties as per rules.

File be consigned to Record Room.

          

 

  (HARPREET KAUR CHARYA)                                                                (SUKHDEV SINGH)                                                                            

                Member                                                                                            President