Chandigarh

DF-I

CC/374/2019

Rajbir Singh - Complainant(s)

Versus

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

Devinder Kumar

13 Aug 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

 

                               

Consumer Complaint No.	:	RBT CC/374/2019
Date of Institution	:	09/05/2019
Date of Decision	:	13/08/2019

 

 

Rajbir Singh son of Sh. Harkirat Singh, aged 33 years, House No.1714/3, Near Kwality Sales Corporation, Shimlapuri, Ludhiana, Punjab.

… Complainant

V E R S U S

1.     Max Bupa Health Insurance Company Limited, SCO No.55-56-57, Second Floor, Sector 8-C, Madhya Marg, Chandigarh through its Branch Manager.

2.     Max Bupa Health Insurance Company Limited, Corporate Office : Block B1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi -110044 through Managing Director

… Opposite Parties

 

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                     

 

ARGUED BY	:	Sh. Devinder Kumar, Counsel for complainant
	:	Sh. Gaurav Bhardwaj, Counsel for OPs

Per Rattan Singh Thakur, President

1.         The long and short of the allegations are, on being allured by the agent of OPs, complainant initially on 4.8.2016 had purchased a health insurance policy in which his father, Sh. Harkirat Singh and mother, Smt. Parminder Kaur were insured for the period from 17.8.2016 to 16.8.2017 on payment of premium of Rs.41,240/-. The policy was subsequently renewed for the period from 17.8.2017 to 16.8.2018 on payment of premium of Rs.54,007/- and thereafter from 17.8.2018 to 16.8.2019 on payment of premium of Rs.57,300/-. 

                Complainant’s case is, on 3.11.2018, his father, Sh. Harkirat Singh was admitted in the PGI, Chandigarh for tongue cancer treatment on being confirmed by the doctor of ENT.  The complainant had spent total sum of Rs.2,74,889/- for the treatment and claim was initially submitted to the OPs duly verified by the Medical Superintendent, PGI, Chandigarh.  However, the same was not processed as it was noticed, father of the complainant was suffering from pre-existing illness i.e. history of Non Alcoholic Steatohepatitis (NASH) 6 years back which fact was concealed by the complainant. OPs, as per the terms and conditions of the policy, issued notice for the cancellation of the policy.  As a matter of fact, neither Sh. Harkirat Singh, father of the complainant was alcoholic nor had any such problem of Steatohepatitis for the last six years. But, instead had such problem for last six months.  However, the doctors had written the words ‘years’ instead of ‘months’. The record was produced and since office of OP-1 is situated at Chandigarh, therefore, this consumer complaint was preferred for direction to OPs to pay a sum of Rs.2,74,889/- alongwith interest; compensation of Rs.1,00,000/- and Rs.25,000/- as litigation charges. 

2.         OPs contested the consumer complaint and filed their joint reply.  Crux of their reply is, initially the complainant submitted bills of Rs.1,79,512/- which were not processed as the complainant or his father had suppressed the material information as he had a history of Non Alcoholic Steatohepatitis (NASH) for last six years.  Thus, in other words, on the date of purchase of the policy, Sh. Harkirat Singh was suffering from the aforesaid disease which was concealed and the policy was issued in good faith as the contract of insurance is based on doctrine of uberrimae fide and besides it, complainant was found to be suffering from hypertension and cirrhosis of liver. Hence, the expenses of cancer treatment were not processed and the claim was repudiated. On these lines, the cause is sought to be defended.
3.         The complainant filed rejoinder alongwith the affidavit of his father, Sh. Harkirat Singh to the reply filed by OPs claiming, itching of the tongue was detected six months prior to the date of admission in PGI which comes out to April 2018 and there was a problem of tongue itching for which medicine was given. It was a routine matter, but, when it did not disappear, then on diagnosis it was found to be a tongue cancer which was operated upon.  Complainant further denied, his father Sh. Harkirat Singh was alcoholic and was a patient of liver cirrhosis.  The reiteration of the allegations made in the rejoinder are supported with affidavit of his father, Sh. Harkirat Singh i.e. the insured.  The claim preferred in the consumer complaint was reiterated.
4.         Parties led evidence by way of affidavits and documents.
5.         We have heard the learned counsel for the parties and gone through the record of the case. After scanning of record, our findings are as under:-
6.         Per pleadings of the parties, the undisputed and admitted facts are, on 4.8.2016, first time health insurance policy was taken by the complainant for his father and mother effective from 17.8.2016 to 16.8.2017 and sum assured was Rs.25.00 lakhs for his father, Sh.Harkirat Singh and mother, Smt. Parminder Kaur. It is pertinent to note here, initially hefty amount of Rs.41,240/- was paid as premium.  Not only this, even second time policy was renewed on 17.8.2017 on payment of premium by the complainant of hefty amount of Rs.54,007/- and then again on payment of hefty amount of Rs.57,300/- the policy was renewed which was valid from 17.8.2018 to 16.8.2019.  In other words, OPs have already usurped amount of more than Rs.1,50,000/- towards premium of the health insurance policy paid by the complainant to the OPs.  For first two years no claim was preferred on account of health insurance.  As such, OPs ought to have deeply scrutinized the claim made by the complainant which was supported by verification from PGI doctors.
7.         A perusal of the averments made in the consumer complaint are supported by way of affidavit and further certification of the claim to the extent of Rs.1,79,512/- by the PGI for surgery and other bills and receipts on being recommended by Christian Medical College and Hospital, Ludhiana; Delta Heart Centre (P) Ltd., Ludhiana alongwith Guru Teg Bahadur Sahib (C) Hospital, Ludhiana, details of bills have been given in Annexure C-5.  It was connected initially with the diagnosis by the other hospitals and then PGI.  Photocopies of the bills and receipts stood attached with the consumer complaint.  In the reply furnished, no allegations have been made that these bills of Christian medical College and other hospitals before the treatment of PGI were manufactured ones. These are not the allegations at all.  Initially the claim was preferred by the complainant confining to the bills verified by the PGI to the tune of Rs.1,79,512/- but while preferring the present consumer complaint on 9.5.2019, other amounts spent on the treatment have also been added.  Not only this, even the amount spent prior to being admitted in the PGI for the purpose of surgery when the diagnosis was being settled, said bills have also been annexed with the consumer complaint which comes out total to Rs.2,74,889/- i.e. the claimed amount.  There is no dispute with regard to these facts.
8.         The bills which were verified by the PGI and annexed and supported by way of affidavit of the complainant. The case of the complainant appears to be genuine one.  Moreover, this serious ailment was diagnosed and surgery was performed by the PGI at Chandigarh.  The genuineness of the bills and the report from PGI Chandigarh and other reputed hospitals of Ludhiana could hardly be doubted.  Thus, per pleadings of the parties and the evidence adduced, we conclude complainant had spent an amount of Rs.2,74,889/- for treatment of his father and even the treatment may be continuing as of now in view of the serious nature of the disease.  There is no dispute or any doubt with regard to this amount spent by the complainant for the treatment of his father, Sh. Harkirat Singh for this ailment. 
9.         Now we shall look into the grounds of repudiation put forth by the OPs.  The insurer i.e. OPs had not at all conducted their investigation and they have perused the record submitted by the complainant alongwith other medical bills claiming reimbursement of aforesaid amount. From scanning of this record, OPs had concluded there was a reference of the complainant suffering from Non Alcoholic Steatohepatitis since six years and liver cirrhosis alongwith hyper tension. These diseases were allegedly concealed by the complainant at the time of taking the policy.  We have already referred, this policy was in continuation for the last about 2½ years.  If the complainant’s father, Sh. Harkirat Singh insured had alcoholic steatohepatitis since six years, then most likely he was treated continuously for the last 6 years, but, he had not preferred the claim of two years i.e. to say from 16.8.2016 to 2018.  This itself shows, the consumer complaint is genuine and this explanation is believable that the doctor instead of six months had written six years i.e. Non Alcoholic Steatohepatitis because the policy was in operation for the last about 2½ years and even was got renewed second time and the treatment was taken of itching of tongue.
10.         The complainant’s father had furnished affidavit disclosing, first time prior to admission in PGI six months prior to that, he had noticed itching in his tongue for which he was administered routine medicines by the doctor.  This affidavit also leads to the fact, the person insured, Sh. Harkirat Singh was alright six months before his admission in the PGI, Chandigarh.
11.         Not only this, even the scrutiny of the record annexed with the consumer complaint i.e. the documents attached with Annexure C-21, history annexed with the discharge card shows even the PGI doctor had observed as under: -

“Pt. was apparently alright 6 mo  back, then he noticed a growth in the (L) lateral border of tongue……”

The above observation of the doctor was ignored by the OPs in which it was found, patient was apparently alright six months back from the date of admission in PGI which comes out to say March/April 2018. There was some problem of itching in the tongue which was not cured with medicines and the disease was finally diagnosed in the PGI, though the CMC and other hospitals, record of which has been annexed, has also corroborated the claim of the complainant, the diagnose was being settled. 

12.         The disease which allegedly the complainant had concealed was Non Alcoholic Steatohepatitis on the date of admission.  This itself shows, problem of liver had no connection with the alcohol intake as it had been diagnosed as non-alcoholic, therefore, another circumstances mentioned that Sh. Harkirat Singh was chronic alcoholic also falls to the ground as the liver problem was non-alcoholic and not related to alcoholism.  Even from the record, it is not made out who has laid the information before the PGI who had told them of Sh. Harkirat Singh being chronic alcoholic.  No substantive evidence brought in, he was alcoholic and even the Non Alcoholic Steatohepatitis had no connection with the alcohol intake and it was non-alcoholic in nature.  Even the record does not show, cancer had any connection with the disease Non Alcoholic Steatohepatitis or liver cirrhosis alongwith the alcohol intake. Though as per record it is not established on the date of purchase of the policy by the complainant in the year 2016, Sh. Harkirat Singh had pre-existing disease of Non Alcoholic Steatohepatitis or say liver cirrhosis or hypertension. The claim was not to be repudiated merely on assumptions and presumptions.  There had to be a concrete evidence to this effect before it was repudiated as hefty amount of more than Rs.1.50 lakhs had already been received by the OPs and they had also the chance to get the complainant or the person insured medically examined from their authorised medical officer for the detection of any pre-existing disease having been suffered by Sh. Harkirat Singh. This record leads to the irresistible conclusion, no information with regard to the pre-existing disease was suppressed by the complainant while initially taking the policy in the year 2016 and onwards.  Even in March or April, 2018, second renewal of the policy was in existence though the disease for which Sh. Harkirat Singh was treated was detected in October 2018.  Prior to that, research work/investigations were going on in various hospitals.  We find there was no concealment of pre-existing disease.  As such the claim was wrongly repudiated.  This tantamounts to deficiency in service on the part of the OPs and the present consumer complaint deserves to succeed.
13.         In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed.  OPs are directed as under :-

1. OPs to withdraw notice of cancellation of policy (Annexure C-6) and revive the insurance policy for the period it was valid, and pay the claim amount of Rs.2,74,889/- to the complainant alongwith interest @9% per annum w.e.f.26.4.2019 i.e. the letter vide which the policy was proposed to be cancelled;
2. OPs to pay an amount of Rs.35,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. OPs to pay Rs.15,000/- to the complainant as costs of litigation.

14.         This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
15.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
13/08/2019	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	Member	President