BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.293 of 2016
Date of Instt. 14.07.2016
Date of Decision: 27.11.2018
Amrit Pal Singh son of Pritpal Singh resident of 167, GTB Nagar, Jalandhar.
..........Complainant
Versus
1. Max Bupa Health Insurance Co. Ltd. 2nd Floor, Kunal Tower, Mall Road, Ludhiana through its Branch Head Hitesh Aggarwal.
2. Max Bupa Health Insurance Co. Ltd. B-1-7-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi- 110044, through its Authorized Representative.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Harvimal Dogra (Member)
Present: Sh. Karan Kalia, Adv Counsel for the Complainant.
Sh. AK Gandhi, Adv Counsel for the OPs.
Order
Karnail Singh (President)
1. The instant complaint has been filed by the complainant, wherein alleged that the complainant had been taking health insurance policy for himself and his daughter for one year and took a policy bearing No.30111483201503 for the sum assured Rs.25,00,000/- from the OP for the period 03.07.2015 to 02.07.2016 after making payment of the premium of Rs.15,333/- to the OP. The said policy planned opted namely family first silver 5 Lacs + 15 Lacs. In the last week of December, 2015 the complainant, insurer of the health insurance policy of the OP got the problem in Left Hydrocele and he was advised to go through the surgery by the doctor. On 02.01.2016, the complainant was admitted in Sood Hospital Pvt. Ltd. Adda Basti Sheikh, Jalandhar and was operated by Dr. Rajiv Sood MBBS MS on 02.01.2016 for Left Hydrocele and was discharged on 03.01.2016 by the said hospital. Even after discharge from the hospital, he had to take medicine as per advise of the doctor and approximately Rs.12,354/- was spent on the treatment of the complainant. Insurance policy cover, record of medical treatments and claim rejection letter are attached.
2. That on 08.03.2016, the complainant informed the OP regarding his operation and submitted the claim of expenses incurred for the treatment of the complainant with the office of OP No.1. Later on, the OP referred the matter of the complainant to OP No.2 for settlement and on 27.04.2016, the complainant received a letter from OP No.2 declining the claim of the complainant on the ground that “a claim cannot be payable as this is a ped condition and 48 months exclusion in chosen plan for the Hydrocele and Spermapocele, hence claim stands repudiated as per policy clause 4(a) of the policy terms and conditions considering the date of the inception of the policy as 03.07.2012”. The OPs have wrongly rejected the claim of the complainant by taking a false and frivolous ground. It is pertinent to mention here that earlier the complainant on 06.03.2015 got operated for right Hydrocele and the claim for the same of Rs.9300/- was paid by the OP on the submission of the claim. By disallowing legal and genuine claim of the complainant by the OP, it tantamount to callous approach of the OP, which clearly reflects negligence on the part of the OP, which is totally illegal, vague on the part of the OP and accordingly, necessity arose to file the present complaint with the prayer that complaint of the complainant may be accepted and OPs be directed to pay medical expenses borne by the complainant, to the tune of Rs.12,354/- and further OPs be directed to pay Rs.30,000/- as medical negligence on their part and further OPs be directed to pay compensation for mental agony and harassment and be also directed to pay litigation expenses of Rs.11,000/- as well as interest @ 18% upon the claim amount, till realization.
3. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared through its counsel and filed joint reply, whereby contested the complaint by taking numerous preliminary objections, out of which relevant are that the present complaint is false, vexatious and has been filed with a malafide intention just to harass the OP and further alleged that the complainant did not disclose any medical history in the Policy Proposal Form. Therefore, assuming that the proposer is a healthy person and risks involved in insuring him are within the acceptable limits, the OP issued health insurance policy opted by the complainant and further averred that the complainant was hospitalized for treatment of Left Hydrocele on 02.01.2016 and was discharged on 03.01.2016. However, the OP was intimated on 08.03.2016 i.e. after a delay of over two months, without assigning any reason whatsoever for the same and further submitted that the claim of the complainant has been rightly repudiated as per policy clause 4(a) of the policy terms and conditions. On merits, the averments made in the complaint in regard to purchase of policy and submitting of claim and repudiation of the same, is not denied, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.
4. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavit Ex.CA along with some documents Ex.C-1 to Ex.C-11 and then closed the evidence.
5. Similarly, counsel for OPs tendered into evidence affidavit of Sh. Shital Patwa as Ex.OP/A along with some documents Ex.OP-1 to Ex.OP-5 and closed the evidence.
6. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
7. Before imparting with the issue in dispute, we like to discuss a plea taken by the OP, which has not been taken in the repudiation letter, the said plea has been taken by the OP in Para No.7 of the preliminary objection in regard to delay intimation to the OP after about two months from the discharge from the hospital. We find when this plea has not been taken by the OP in repudiation letter Ex.OP-5, then the OP is not at liberty to take any new plea in the written statement because the claim of the complainant has been repudiated only on the basis of the plea taken in the repudiation letter Ex.OP-5 and therefore, the new plea of the OP is not tenable in the eyes of law.
8. Coming to the matter in dispute, the complainant alleged that his medical insurance claim has been wrongly and illegally repudiated by the OP, which tantamount to negligence and deficiency in service on the part of the OP. One thing also explained by the complainant in para No.5 of the complaint that previously he was also got operated on 06.03.2015 for right Hydrocele and also submitted a claim for the same of Rs.9300/-, which was passed by the OP, but in response to reply of Para No.5 of the complaint, the OP has given evasive reply, if reply is not specifically given in regard to the allegation and if the same is evasive, then it considered that the factum so under reply is indirectly admitted. The OP has not categorically denied that previous insurance medical claim of the complainant in regard to admission in the hospital on 06.03.2015, amounting to Rs.9300/- was passed or not. So, if the previous medical insurance claim was paid to the complainant in the year 2015, then why the policy clause 4(a) of the policy terms and conditions is made applicable after one year of the previous ailment, which is exactly a deficiency and unfair trade practice on the part of the OP. We find that if Clause 4 (a) of policy terms and conditions is not applicable in the previous ailment of the complainant, then the same is also not applicable in the present case rather the same has been illegally and wrongly made applicable by the OP just to deprive the complainant from eating the fruits of the insurance claim and thus, we reached to the conclusion that the medical insurance claim of the complainant has been wrongly and illegally repudiated by the OP, vide repudiation letter Ex.OP-5 dated 23.07.2016 and therefore, the same is quashed hereby.
9. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to pay medical insurance claim of Rs.12,354/- with interest @ 12% per annum from the date of repudiation i.e. 23.07.2016, till realization and further OPs are directed to pay compensation for causing mental harassment to the complainant, to the tune of Rs.15,000/- and litigation expenses of Rs.5000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
10. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Harvimal Dogra Karnail Singh
27.11.2018 Member President
