Chandigarh

DF-I

CC/399/2017

Harish Sharma - Complainant(s)

Versus

Max Bupa health Insurance Co. Ltd. - Opp.Party(s)

Namit Khurana

18 Sep 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

                               

Consumer Complaint No.	:	CC/399/2017
Date of Institution	:	15/05/2017
Date of Decision	:	18/09/2018

Harish Sharma, age 60 years son of late Sh. R.L. Sharma, resident of H.No.165-B, Luxmi Garden, Yamuna Nagar, Tehsil Jagadhri, Distt. Yamuna Nagar.

… Complainant

V E R S U S

1.     Max Bupa Health Insurance Company Limited, Corporate Office : B1/1-2, Mohan Cooperative Industrial Estate Mathura Road, New Delhi, through its Branch Chairman/Director/ Authorised Signatory.

2.     Max Bupa Health Insurance Company Limited, SCO No.55-57, Sector 8-C, Madhya Marg, Chandigarh 160009 through its Branch Manager.

… Opposite Parties

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                     

ARGUED BY	:	Sh. Baljeet Nain, Vice Counsel for Sh. Namit Khurana, Counsel for complainant
	:	Sh. Gaurav Bhardwaj, Counsel for OPs

 

Per Rattan Singh Thakur, President

1.         The long and short of allegations are, agent of OP-1/Insurance Company namely Sh. Sumit Bhandari met the complainant and showed him various plans providing better health facility to the customers. The complainant on 10.2.2015 had taken a policy for himself as well as his wife and had paid the premium of Rs.29,832/-. During the period of this medical insurance cover, there arose no necessity to claim the amount as the complainant and his wife did not fall ill.  In the first health insurance policy, the wife of the complainant, Smt. Shobha Sharma was properly medico legally examined by the OPs.  It is the case, in the next year i.e. w.e.f. 6.1.2016 the complainant had renewed the policy on payment of premium of Rs.31,516/-. The complainant had informed the OPs about the previous disease/surgery like hypertension, eye, vocal cord surgery, ligament repair, but, even then the policy was issued by the OPs. It was a cashless policy.  After his retirement on 31.5.2016, the complainant approached Max Super Specialty Hospital, Mohali on 6.6.2016 for his knee check up on which knee replacement was advised. However, pre authorisation was not given by the OPs.  The complainant had undergone surgery of knee replacement and paid the total amount of Rs.5,29,777/- to the hospital.  The claim, on being submitted, was repudiated by the OPs for the reason, complainant had suppressed material facts viz. pre-existing disease/surgery detailed above. Hence, on these averments prayer is made for indemnification of the claim of Rs.5,29,777/- alongwith compensation and costs of litigation.
2.         OPs contested the consumer complaint, filed their joint reply and, inter alia, raised preliminary objections of consumer complaint being not maintainable.  The crux of the defense is, there was exclusion clause in the policy that in the event of concealment of material fact qua pre-existing disease, claim was to be repudiated.  It is also the case, terms and conditions of the policy were supplied to the complainant regarding the exclusion clause of the policy and his consent was asked for issuance of letter. In the free look period of 30 days, the said policy was not cancelled, therefore, the said terms and conditions of the exclusion clause were accepted in totality by the complainant and now he cannot wriggle out from the same. On these lines, repudiation of the claim has been justified.
3.         Rejoinder was filed and averments made in the consumer complaint were reiterated.
4.         Parties led evidence by way of affidavits and documents.
5.         We have heard the learned counsels for the parties and gone through the record of the case.  After appraisal of record, our findings are as under:-
6.         Per pleadings of the parties, the existence of the health insurance policy on the date of surgery of the complainant is not in dispute before us.  It is also the admitted case, there was an exclusion clause in the health insurance policy vide which the claim was to be excluded in case of suppression of material facts qua the pre-existing disease. 
7.         It is also the admitted case in affirmative of the complainant himself, he had undergone previous surgeries/pre-existing disease of hypertension, eye surgery, vocal cord surgery, ligament repair.  It is his case, these diseases were explained to the OPs, but, even then they proceeded with providing the health insurance cover. However, we are not in agreement with this plea for the simple reason that, as per record, the complainant is an educated person and had served as a Chief Engineer in the private sector and it is the case of the OPs, after the insurance cover was provided, the policy was sent to the complainant and in the freelook period of thirty days, the policy was not cancelled. Therefore, the complainant had accepted the terms and conditions of the policy.  To this, complainant has no reply to offer and he has not denied the receipt of the proposed terms and conditions which were supplied to him.   
8.         It is the case of the complainant, one Sh. Sumit Bhandari, agent of the OP Insurance Company, had facilitated the issuance of the health insurance policy and the pre-existing disease/surgeries, referred above, were apprised to him, but, even then the company proceeded with providing health insurance cover.  In this situation, furnishing of the affidavit of said Sh. Sumit Bhandari in support of the claim of the complainant was a sine qua non as he acted as an agent on behalf of the OPs. Non furnishing the affidavit in support of the claim of the complainant shows, these are merely lame excuses put forth in the consumer complaint.
9.         We have also perused the contents of the reply as well as the documents produced.  There were specific questions put at the time of furnishing the declaration. It was denied by the complainant of having suffered pre-existing disease and undergone surgeries as mentioned in the consumer complaint.  The parties cannot travel beyond the terms and conditions agreed to by them at the time of issuance of the insurance policy. The complainant is an educated man and retired as a Engineer.  Now the complainant cannot say, he was not aware of the terms and conditions and there was no concealment of material facts qua the diseases as well as surgeries on his part.  
10.         It is the case, even at the time of taking the policy, there was problem in the ligament of leg of the complainant and this knee replacement surgery had a nexus with the said disease. So, this finding cannot be recorded that knee replacement surgery had no link with pre-existing surgical problems of the complainant. There was justification in repudiation of the claim of the complainant and we find no deficiency in service on the part of the OPs.  
11.         In view of the above discussion, the present consumer complaint, being meritless, is dismissed.  Parties are left to bear their own costs.
12.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
18/09/2018	[Suresh Kumar Sardana]	[Rattan Singh Thakur]
hg	Member	President