BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.276 of 2015

Date of Instt. 23.06.2015

Date of Decision :18.05.2016

1. Sajida Begum aged about 45 years Wd/o Sh.Mohammed Rafi;

2. Aqsha Malik aged about 19 years D/o Late Sh.Mohammed Rafi;

3. Malik Farhat Rafi (minor) aged about 16 years son of Late Sh.Mohammed Rafi;

4. Malik Zunaid Rafi (minor) aged about 13 years S/o Late Sh.Mohammed Rafi;

(Complainants No.3 & 4 through complainant No.1 being their mother and natural guardian)

All residents of House No.288, Mohalla Panj Piplan, Bahadurpur, Hoshiarpur.

..........Complainants

Versus

Max Bupa Health Insurance Company Limited, Corporate Office:-Block B-1/I-2, Mohan Co-operative Industrial Estate, Mathura Road, New Delhi-110044 through its Managing Director/Chief Executive Officer.

.........Opposite party

Complaint Under Section 12 of the Consumer Protection Act.

Before: S. Bhupinder Singh (President)

Sh.Parminder Sharma (Member)

Present: Sh.PS Nayyar Adv., counsel for the complainants.

Sh.AK Gandhi Adv., counsel for opposite party.

Order

Bhupinder Singh (President)

1. The complainants have filed the present complaint under section 12 of the Consumer Protection Act against the opposite party on the averments that Mohammed Rafi son of Jan Mohammed, husband of complainant No.1 and father of complainants No.2 to 4 purchased health insurance policy bearing No.30045145201403 from the OP for the period from 28.7.2014 to 27.7.2015 with sum insured Rs.5 Lacs. Insured Mohammed Rafi was admitted in Patel Hospital, Civil Lines, Jalandhar on 20.8.2014 with complaint of epigastric burning in abdomen region and vomiting for 2/3 days. The patient was managed/treated conservatively and was discharged on 24.8.2014 and spent Rs.29,794/- as per bill dated 24.8.2014. Complainant submitted that Mohammed Rafi remained admitted in different hospitals lateron and unfortunately expired on 7.9.2014. Complainant lodged reimbursement claim with the OP vide letter dated 1.5.2015 alongwith relevant documents with the OP but the OP repudiated the claim of the complainant vide email intimation dated 6.6.2015 on the ground that as per submitted documents and investigation done by the OP, it was found that insured has past history of DM for the last 10 years. Patient was on insulin since long and the insured has not disclosed the same at the time of taking policy in question. As such, complainant has concealed material facts and as per terms and conditions of the policy, the claim stands repudiated as per policy clause 4(a). Complainant submitted that insured Mohammed Rafi for the first time availed health insurance policy from the OP for the period from 28.7.2011 to 27.7.2012 vide policy No.30045145201100. At that time, the insured was not suffering from any disease of diabetes mellitus nor he had any knowledge regarding that disease nor he had received any treatment with regard to diabetes mellitus and other as mentioned in the repudiation letter. The said diseases were allegedly diagnosed for the first time on 11.6.2014 when the insured was hospitalized in IVY Hospital, Hoshiarpur. Complainant submitted that the OP has wrongly repudiated the claim of the complainants regarding reimbursement of the amount of medical treatment of Mohammed Rafi under the policy in question. On such averments, the complainants have prayed for directing the OP to reimburse the amount of Rs.29,794/-. They have also claimed compensation and litigation expenses.

2. Upon notice, OP appeared through counsel and filed written reply pleading that the present case is a clear cut case of concealment of material facts and misrepresentation. As per their investigation, the insured was suffering from Diabetic Nephropathy with Diabetes Mellitus type 1 for the last 10 years and hypertension 8 to 10 years. The deceased insured was on insulin since long. The patient/insured was admitted in the hospital on 20.8.2014 due to suffering from various ailments. The patient was diagnosed with Insulin-dependent Diabetes Mellitus with renal complications, Diabetic Nephropathy, DMT2, Gastritis, Comorbid-Cardiomyopathy/ IHD/LVEF 30%. These ailments arose due to diabetes and its related complications. The insured did not disclose these pre-existing diseases at the time of inception of the insurance policy. Therefore, it is case of concealment of material facts, as such, the claim is not admissible as per clause 4(a) of the terms and conditions of the policy. OP has rightly repudiated the claim of insured Mohammed Rafi. OP denied other material averments of the complainants.

3. In support of their complaint, learned counsel for the complainant has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C5 and closed evidence.

4. On the other hand, learned counsel for the OP has has tendered affidavit Ex.OPA alongwith copies of documents Ex.OP1 to OP7and closed evidence.

5. We have heard the Ld. counsel for the parties, minutely gone through the record and have appreciated the evidence produced on record by both the parties with the valuable assistance of Ld. counsels for the parties.

6. From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that Mohammed Rafi son of Jan Mohammed, husband of complainant No.1 and father of complainants No.2 to 4 purchased health insurance policy bearing No.30045145201403 from the OP for the period from 28.7.2014 to 27.7.2015 with sum insured of Rs.5 Lacs. Insured Mohammed Rafi was admitted in Patel Hospital, Civil Lines, Jalandhar on 20.8.2014 with complaint of epigastric burning in abdomen region and vomiting for 2/3 days. The patient was managed/treated conservatively and was discharged on 24.8.2014 as per discharge summary Ex.C2 and the complainant spent Rs.29,794/- as per bill dated 24.8.2014 Ex.C3 and Ex.C4. Complainant submitted that Mohammed Rafi remained admitted in different hospitals later on and unfortunately expired on 7.9.2014. Complainants then lodged reimbursement claim with the OP vide letter dated 1.5.2015 alongwith relevant documents with the OP but the Op repudiated the claim of the complainant vide email intimation dated 6.6.2015 Ex.C5 on the ground that as per submitted documents and investigation done by the OP, it was found that insured has past history of DM for the last 10 years. Patient was on insulin since long and the insured has not disclosed the same at the time of filling in proposal form for taking policy in question. As such, complainant has concealed material facts and as per terms and conditions of the policy, the claim stand repudiated as per policy clause 4(a). Learned counsel for the complainant submitted that insured Mohammed Rafi for the first time availed health insurance policy from the OP for the period from 28.7.2011 to 27.7.2012 vide policy No.30045145201100. At that time, the insured was not suffering from any disease of diabetes mellitus nor he had any knowledge regarding that disease nor he had received any treatment with regard to diabetes mellitus and other as mentioned in the repudiation letter. The said diseases were allegedly diagnosed for the first time on 11.6.2014 when the insured was hospitalized in IVY Hospital, Hoshiarpur. Counsel for the complainant submitted that the OP has wrongly repudiated the claim of the complainants regarding reimbursement of the amount of medical treatment of Mohammed Rafi under the policy in question and all this amounts to deficiency in service on the part of the OP qua the complainant.

7. Whereas the case of the OP is that the present case is a clear cut case of concealment of material facts and misrepresentation. As per their investigation, the insured was suffering from Diabetic Nephropathy with Diabetes Mellitus type 1 for the last 10 years and hypertension 8 to 10 years. The deceased insured was on insulin since long. The patient/insured was admitted in the hospital on 20.8.2014 due to suffering from various ailments. The patient was diagnosed with Insulin-dependent Diabetes Mellitus with renal complications, Diabetic Nephropathy, DMT2, Gastritis, Comorbid-Cardiomyopathy/ IHD/LVEF 30%. These ailments arose due to diabetes and its related complications. The insured did not disclose these pre-existing diseases at the time of inception of the insurance policy. Therefore, it is case of concealment of material facts, as such, the claim is not admissible as per clause 4(a) of the terms and conditions of the policy. Learned counsel for the OP submitted that OP has rightly repudiated the claim of insured Mohammed Rafi. As such, there is no deficiency in service on the part of the OP qua the complainant.

8. From the entire above discussion, we have come to the conclusion that Mohammed Rafi purchased health insurance policy bearing No.30045145201403 from the OP for the period from 28.7.2014 to 27.7.2015 with sum insured of Rs.5 Lacs. Insured Mohammed Rafi was admitted in Patel Hospital, Civil Lines, Jalandhar on 20.8.2014 and was discharged on 24.8.2014 as per discharge summary Ex.C2 and paid Rs.29,794/- to the aforesaid hospital as per bill Ex.C3 and Ex.C4. The claim was lodged with the OP for reimbursement of the aforesaid amount under the policy in question on 1.5.2015 but the OP repudiated the claim vide email communication dated 6.6.2015 Ex.C5 on the ground that insured Mohammed Rafi, per investigation done by the OP, had past history of DM for the last 10 years. The patient was on insulin since long and insured did not disclose these facts at the time of taking policy. So, present case is of pre-existing disease, as such, claim is not payable as per policy clause 4(a).

9. It may be mentioned here that Mohammed Rafi expired on 7.9.2014 and the complainants being only legal heirs are entitled to lodge claim regarding reimbursement of the amount spent by insured/deceased Mohammed Rafi under the policy in question against the OP. OP has produced on record policy Ex.OP1, pre-authorization form cashless Ex.OP2, information on summery sheet Ex.OP3 as the policy was online policy. In this document, OP has admitted that the policy commencement date is 28.7.2011 which proves that insured Mohammed Rafi got insurance policy from the OP for the first time the policy No.30045145201100 for the period from 28.7.2011 to 27.7.2012. It means that insured Mohammed Rafi had been duly insured medically with the OP since 28.7.2011. The OP could not produce any evidence prior to 28.7.2011 that the insured Mohammed Rafi was suffering from diabetes mellitus and was on insulin or was suffering from hypertension. The OP has produced on record their own investigation report Ex.OP4 in which the OP could not produce any previous medical record of insured Mohammed Rafi to prove that Mohammed Rafi insured was suffering from DM or that he was on insulin or was suffering from hypertension. The OP could not produce any medical treatment record of insured Mohammed Rafi nor OP could record the statement of any medical expert or doctor who medically treated the insured Mohammed Rafi for the aforesaid diseases nor the OP could produce any medical prescription slip or treatment chart of insured to prove that insured Mohammed Rafi was taking any medicine or was ever medically treated for the aforesaid diseases nor the OP could produce affidavit of any medical expert/doctor to prove that he ever medically treated the insured for the aforesaid disease prior to the inception of the policy taken by the complainant in 2011 when the insured has taken the policy from the OP for the first time and has been continuously taking policy from the OP. Nor the OP could produce any evidence except the discharge summary Ex.C2 dated 24.8.2014 of the aforesaid hospital in which the insured had taken medical treatment and was admitted in the year 2014. It has been held by Hon'ble National Commission in case United India Insurance Co.Ltd Vs. Anumolu Rama Krishan 2012(3) CPC 44 that “where there was no history suggesting MI and history of chest pain was only of one weeks duration. Policy was issued after medical examination which also did not indicate that patient was suffering from any pre-existing disease. A person suffering from “silent diseases” may not even be aware until condition aggravates and overt symptoms appear”. The Hon'ble National Commission in case Life Insurance Corporation of India & Anr Vs Naseem Bano 2012(3) CPJ 208 has held that “Bed-Head Ticket can not be the conclusive proof. It does not mention the name of any person who disclosed the past history of the patient. No evidence that prior to filling-up of policy form, record of any hospital, slips of doctors, any prescriptions showing the name of medicines which deceased must be taking, came to light. Heart-attack has no nexus with ailments like Diabetic Mellitus and Hypertension”.

9. Therefore, we have come to the conclusion that the OP has failed to prove on record that deceased life insured Mohammed Rafi was suffering from Diabetes Mellitus or hypertension prior to the inception of the policy for the first time in 2011 and that he had concealed these fact. Resultantly, we hold that OP has wrongly repudiated the claim of the complainant vide email communication dated 6.6.2015 Ex.C5.

10. Consequently, we allow the complaint with cost and the OP is directed to reimburse the amount Rs.29,794/- as per bill Ex.C3 and Ex.C4 spent by the complainants on the medical treatment of insured Mohammed Rafi alongwith interest @Rs.9% per annum from the date of repudiation of claim till the payment is made to the complainants. OP is also directed to pay cost of litigation to the complainant to the tune of Rs.2000/-. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Parminder Sharma Bhupinder Singh

18.05.2016 Member President