Chandigarh

DF-II

CC/378/2021

Lalit Kumar - Complainant(s)

Versus

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

Vipin Kumar adv

22 May 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	378 of 2021
Date  of  Institution	:	17.06.2021
Date   of   Decision	:	22.05.2024

 

 

 

 

 

Lalit Kumar s/o Sh.Vijay Kumar, presently Resident of H.No.32-B, Near Shiv Temple, Khuda Lahora, Chandigarh

Permanent Address:- 1118/1, Mohinder Nagar, Near Manav Chowk, Ambala City Ambala, Haryana.

 

             …..Complainant

 

Versus

Max Bupa Health Insurance Company Limited having its office at SCO No.55, 56 & 57, 2nd Floor, Sector 8-C, Madhya Marg, Chandigarh.

2^nd Address: Office on SCO 84-85, Second Floor, Sector 8-C, Madhya Marg, Chandigarh.

3^rd Address:- Max House, 1 Dr.Jha Marg, Okhla, New Delhi 110020 through its authorized signatory.

     ….. Opposite Parties

BEFORE:  MR.AMRINDER SINGH SIDHU,       PRESIDENT

                MR.B.M.SHARMA,                 MEMBER

                               

Argued by:-     Sh.Vipin Kumar, Counsel for the complainant.

Sh.Gaurav Bhardwaj, Counsel for OP

 

 

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

 

1]       The complainant has filed the present complaint pleading that he opted for cashless plan with ‘Re-Fill’ feature namely as ‘Health Companion Variant 2’ and got himself, his wife and his child insured with OP vide Health Insurance Policy Ann.C-1  on 30.12.2017 and got it renewed from time to time till 30.12.2020 and thereafter till 29.12.2021 (Ann.C-9). The said policy was for sum insured of Rs.5 lacs and Re-fill benefit of the same amount.  It is stated that  during policy, the son of the complainant namely Master Kartik aged 13 years felt pain in his abdomen, diagnosed with Ileocecal Intussuscepion (Ann.C-3) and treated at Paras Bliss Hospital from 2.5.2020 to 9.5.2020 where a part of intestine having disease was removed through major surgery (Ann.C-4).  It is stated that the removed part was examined through biopsy and disease was identified as malignant Tumor (Cancer) Ann.C-5. Thereafter, the child was given 6 chemotherapies each lasting for 5 days at a stretch from 27.5.2020 till 13.9.2020, out of which two preventive Chemos were given at Max Hospital (Ann.C-6). It is pleaded that the complainant utilized the service of the OP by exhausting the sum assured amount of Rs.5 lacs plus Rs.4 lacs as No Claim Bonus i.e. total Rs.9 lacs.  Unfortunately the child of the complainant got high fever, admitted in Max Hospital for the same on 10.10.2020 where he was diagnosed with Covid-19 and Covid related Pneumonia with Fungal & Bacterial infections.  The child was discharged on 05.11.2020 (Ann.C-7).  On the said treatment, the complainant spent an amount of Rs.16 lacs, which was timely informed to OP for the claim under the ‘Re-Fill’ that allows for auto refill of the insured value.  However, the OP failed to give cashless benefit so the complainant on 10.11.2020 applied for the claim of an amount of Rs.10,88,354/- i.e. the amount spent on Hospital Main Bill (Ann.C-8).  The complainant also sent all requisite documents to the OPs.  However, the OP without going through the investigation reports, rejected the claim on 16.1.2021 by stating that “claim is rejected on the terms and conditions of the policy”.  Later the OP vide email dated 09.02.2021 stating that the claim is rejected because the complainant had consumed maximum limit of the policy.  It is pleaded that the OP failed to give services of Refill Amount of Rs.5 lacs under the policy and took three months to reject the claim.  It is also pleaded that the OP wrongly & illegally rejected the claim of the complainant despite being covered under the insurance in ‘Re-Fill Feature’, which amounts to deficiency in service and unfair trade practice.  Lastly the complainant has prayed for the acceptance of the complaint and to direct the OPs to reimburse the insured amount under Re-Fill feature of the policy for the treatment of his son and to pay compensation as well as litigation expenses.

  

2]       After service of notice, the OP appeared before this Commission through his counsel and filed written version and while admitting the factual matrix of the case about issuance of the policy in question and reimbursement of medical bill of insured Kartik Jindal during policy period, stated that the claim reimbursement bearing No.586717 with respect to the treatment of Master Kartik Jindal for an amount of Rs.10,88,354/- was denied on account of the fact that the complainant had consumed maximum limit mentioned in the policy.  It is submitted that as per Clause 2.12 of the policy, the Refill sum insured can only be utilized for different illness and therefore, keeping in view the reimbursement amount claimed by the complainant for his son Master Kartik Jindal for year 2020-2021, with respect to the same treatment at Max Super Speciality Hospital, Mohali and on this account, the same was denied by the OP.  It is pleaded that the claim was rightly denied as per terms & conditions of the policy.  Denying other allegations, the OP has prayed for dismissal of the complaint.

 

3]       Replication has been filed by the complainant controverting the assertions made by the OP in its written version.

        

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the contesting parties and have gone through the entire record including written submission. 

 

6]        From the submissions of the parties and the documentary evidence on record, it is observed that the OP has denied the benefit of Re-fill under the policy as per Clause 2.12 of the terms & conditions of the policy wherein it is stated that Re-fill sum insured can only be utilized for two different illness and therefore, the Re-fill sum insured amount claimed by the complainant for the treatment of his son namely Master Kartik Jindal for the year 2021, with respect to the same treatment taken by Max Super speciality Hospital, Mohali. 

 

7]       The defence of the OP, on the said ground is not sustainable, as the son of the complainant namely Master Kartik Jindal had been previously treated for Ileocecal Intussusception at Paras Bliss Hospital, Panchkula and disease was indentified as malignant Tumor (Cancer) and he was given chemotherapies and the fresh claim has been made for treatment of Covid-19 and related Pneumonia with Fungal & Bacterial infections at Max Hospital, Mohali.  Thus, both these treatments are for different diseases and treated by different medical experts.  Hence, the complainant is entitled to get the benefit of Refill Sum Insured under the policy in question which is equal to 100% of base sum insured i.e. Rs.5 lacs.  Therefore, the claim of the complainant has wrongly been rejected by the OP which amounts to deficiency in service and unfair trade practice.

 

8]      It has been argued on behalf of the complainant that the representatives of the OP has got the signatures of the complainant on blank proposal form and the same were filled up later on by the OP as per their requirement and the terms and conditions of the policy have neither been supplied nor explained to the insured. Thus, the burden is shifted upon the OP to prove that the terms and conditions of the policy were ever supplied or explained to the complainant. However, the OP has failed to place on record any documentary evidence in this regard. Therefore, the terms and conditions of the Insurance Policy are not binding upon the complainant.  Otherwise also, the complainant is bona fide consumer of the OP, but the representatives of the OP did not disclose the actual terms and conditions of the Insurance Policy but sold out the same in a deceptive manner which not only amounts to unfair trade practice but also deceptive trade practice. Hence, the OP is liable for the acts and conducts of their representatives/agents.

 

9]       It is further observed that several complaints from different consumers having different backgrounds and residing at different parts of the country are making similar allegations that the representatives/agents of the Insurance Companies are not disclosing the actual terms and conditions of the insurance policies but sell out the policies in a deceptive manner. Hence, the persons from different walks of life cannot make similar allegations, who are residing in the different parts of the country, having different backgrounds without element of truth in the above said pleadings that agents sell out the policy in deceptive manner in order to achieve the target or for the sake of their commissions.

 

10]      A similar view is taken in Modern Insulators Ltd. v. Oriental Insurance Co. Ltd. (2000) 2 SCC 734, “(8) It is the fundamental principle of insurance law that utmost good faith must be observed by the contracting parties and good faith forbids either party from non-disclosure of the facts which the parties know. The insured has a duty to disclose and similarly it is the duty of the Insurance Company and its agents to disclose all material facts in their knowledge since the obligation of good faith applies to both equally.”

 

11]      It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sorts of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich”.

12]      Taking into consideration the above discussion & findings, the present complaint deserves to be partly allowed and the same is accordingly partly allowed. The OP Company is directed to pay to the complainant a sum of Rs.5 lacs (Five Lacs only) being Refill Sum insured amount under the policy in question towards reimburse of remaining mediclaim of the complainant, along with interest @6% per annum from the date of rejection of the claim i.e. 09.02.2021 (Ann.C-11) till the date of its actual payment.

         This order be complied with by the OPs jointly and severally, within ninety from the date of receipt of its certified copy.

13]      The pending application(s) if any, stands disposed of accordingly.

        The Office is directed to send certified copy of this order to the parties, free of cost, as per rules & law under The Consumer Protection Rules & Act accordingly. After compliance file be consigned to record room.

Announced

22.05.2024                                                                    Sd/-

                                                            (AMRINDER SINGH SIDHU)

PRESIDENT

 

 

Sd/-

(B.M.SHARMA)

MEMBER