Chandigarh

DF-I

CC/302/2022

Salil Talwar - Complainant(s)

Versus

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

Jaspreet Singh

07 Nov 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/302/2022
Date of Institution	:	28.2.2022
Date of Decision	:	7/11/2023

 

Salil Talwar S/o Arun Talwar, resident of House No.574, Sector 18-B, Chandigarh.  

… Complainant(s)

V E R S U S

Max Bupa Health Insurance Company Ltd. (Now Niva Bupa Health Insurance Company Ltd.)  B-1/1-2 Mohan Cooperative Industrial Estate, Mathura Road, New Delhi 110044. .

… Opposite Party

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

 

                                                                               

ARGUED BY	:	Sh. Jasreet Singh, Advocate for complainant
	:	Sh. Gaurav Bhardwaj, Advocate for OP

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by the complainant under Section 35 of the Consumer Protection Act 2019 against the opposite parties  (hereinafter referred to as the OP). The brief facts of the case are as under :-

1. It transpires from the averments as projected in the consumer complaint that the complainant purchased Health Insurance policy namely Health Companion Variant having No.30963799201900 (hereinafter to be referred as subject policy) vide Annexure C-1 from the OPs by paying gross premium of Rs.16,496/-.  Under the subject policy the complainant was covered for inpatient care, hospitalization, medical expenses, and other related services.  On 8.6.2019, the complainant met with an accident at railway station, Mumbai and after  taking mild treatment at Mumbai, the complainant was admitted in Max Hospital, Mohali on 10.6.2019.  He was diagnosed with facture of shaft of radius of right wrist and was discharged on 13.6.2019. The discharge summary is annexed as Annexure C-3.  The complainant opted for cashless claim and the approval for the said request was denied by the OP on 11.6.2019.  The pre-authorization form for cashless claim and denial of authorization is annexed herewith as Annexure C-5 and C-6.  Thereafter on 15.7.2019 OP had sent notice to the complainant for cancellation of the subject policy  on the ground of non disclosure of pre-existing disease and was asked for the documents to review the case of the complainant  and in the said notice the OP had asked about the pre-existing medical condition qua history of seizure disorder since 2005 and hepatitis in 1999 and Lipoma excision in 2005 the copy of notice is Annexure C-7. The said notice was properly replied by the complainant as asked by the OP. However, despite of receiving  all the documents and explanation from the complainant, the OP had decided to cancel the policy of the complainant. As the OP had not reimbursed the amount spent by the complainant on his treatment to the tune of Rs.1,33,946/-,  the complainant was compelled to pay the same from his own pocket. Thereafter the complainant had issued legal notice to the OP, which was replied by the OP. Copy of legal notice and reply thereof by OP are annexed as Annexure C-10 and C-11.  As the genuine claim of the complainant was denied by the OP, the aforesaid act amounts to deficiency in service and unfair trade practice on the part of OP. OP were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OP resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability,  concealment of fact and also that the complainant has not approached the Commission with clean hand. However, it is admitted that the complainant had  purchased the subject policy from the OP but alleged that as during investigation non disclosure of material fact of seizure disorder 3 episodes  with last episode in 2008 and hepatitis in 1999 and lipoma emission in the year 2005 were discovered which had never been disclosed by the complainant before purchase of the subject policy and the said non disclosure of material fact by the complainant is gross violation of the terms and conditions of the policy as a result of which the cashless request was denied and the complainant was served with notice for cancellation of the subject policy. It is further alleged that the complainant had not submitted the documents as asked by the OP qua his previous ailments. On merits it is alleged that the complainant had filed the claim of reimbursement request for the duration of hospitalization  from 10.6.2019 to 13.6.2019 upon submission of claim documents and thereafter the subject claim was sent for investigation and the claim was denied on the basis non-disclosure of material facts in accordance with clause 10.21  of the policy. It is further alleged that upon cancellation of the policy, the complainant had issued legal notice which was properly replied by the OP. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. Despite grant of numerous opportunities, no rejoinder was filed by the complainant to rebut the stand of the OP.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had purchased the subject policy from the OP which was valid w.e.f. 10.5.2019 to 9.5.2020 as is also evident from copy of policy Annexure C-1 and further that the complainant met with an accident and after taking mild treatment at Mumbai hospital, he came to Max Hospital, Mohali and remained admitted there  from 10.6.2019 to 13.6.2019 where he was diagnosed with fracture of shaft of radius of right wrist  and when the cashless request was made by the complainant through hospital to the OPs the same was denied by the OP insurance company and had also cancelled the policy on the ground of non-disclosure of material facts at the time of purchase of the subject policy, the case is reduced to a narrow compass as it is to be determined if  the OP  is unjustified  in repudiating the claim of the complainant on the ground of non-disclosure of material facts by the complainant qua the pre-existing disease and the complainant is entitled for relief as prayed for, as is the case of the complainant or if the OP is justified in repudiating the claim of the complainant on the ground of non-disclosure of material fact by him to the OP at the time of purchasing the subject policy and the complaint is liable to be dismissed being not maintainable.
   2.  Perusal of Annexure C-1 clearly indicates that the OP insurance company has vested with the authority to cancel the subject policy in case of non-disclosure of material fact by the insured. However, in the present case as the claim of the complainant was denied by the OPs on the ground that the complainant had not disclosed about the pre-existing  ailment which he had suffered in the year 1999, and in 2005 in the light of the terms and conditions of the subject policy in question without determination if the disease from which the complainant had suffered in the aforesaid years comes under the definition of pre-existing disease or not. Annexure C-2 and Annexure C-12(colly)   are the bills, which indicate the amounts spent by the complainant for his treatment.
   3. Perusal of Annexure C-4 the repudiation letter indicates that the OP itself has admitted the billed amount of Rs.1,33,946/- which further indicates the ground on which the claim of the complainant was denied.  The relevant portion whereof is as under:-

Disallowance Reason

“Non disclosure- As per submitted documents and investigation done by us, it is found that there is non-disclosure of History of Seizure disorders since 2005, hepatitis in 1999 and Lipoma excision in 2005. All these details has not been disclosed by the insured at the time of proposal, hence, claim rejected under policy clause 10.21.”

 

4. In this regard clause 5.1 under the heading of pre-existing of the subject policy is reproduced as under:-

“Pre-existing diseases

All existing Diseases shall not be covered until 48 months of continuous coverage have elapsed since the inception of the first policy with Us for insured persons to whom variant 1plan is applicable as specified in the  Product Benefits Table and until 36 months of continuous coverage have elapsed since the inception of the First Policy with Us for insured persons to whom Variant 2, variant 3 plans and family First Policy are applicable as specified in the  product Benefits Tables.”

 

 

5. As  there is no dispute between the parties that the complainant had taken treatment of the diseases of which  he had suffered i.e. Lipoma in 1999, Hepatitis in 2005 and Seizure disorder in 2005, whereas  on 8.6.2019 onwards the complainant had taken  treatment of fracture of shaft of radius of right wrist which was suffered by him in the accident i.e. after more than 48 months of the inception of policy and the same has no connection with the earlier pre-existing disease. Onething is clear that the earlier pre-existing disease  from which the complainant had earlier suffered long back in 1999 and 2005 have no nexus with the treatment which the complainant had taken  from Max Hospital, Mohali in 2019 onwards.Even as per the clause 5.1, the case of the complainant does not comes in the definition of pre-existing disease.
6. Moreover, when it has come on record that whatever ailment from which the complainant was suffering prior to the purchase of the subject policy i.e. Lipoma in 1999, Hepatitis in 2005 and Seizure disorder in 2005 has no connection with the disease with which the complainant was diagnosed by the treating hospital i.e. fracture of shaft of radius of right wrist and was admitted & treated in the treating hospital, hence the act of the OPs in repudiating the claim of the complainant certainly amounts to deficiency in service and unfair trade practice. Here we are strengthened by the order passed by the Hon’ble National Commission in Neelam Chopra Vs. Life Insurance Corporation of India &Ors., IV (2018) CPJ 321 (NC) and the operative part of the same reads as under :-

                12. In the present case, clearly the cause of death is cardio respiratory arrest and this disease was not existing when the proposal form was filled. Clearly, there is no suppression of material information in respect of this disease, which is the main cause of death. The other disease of LL Hansen, which was prevailing for five weeks on the date of admission on 1.8.2003 was also not existing when the proposal was filed by the DLA. The fact of DLA having been treated in the year 2002 for LL Hansen is not supported from any direct evidence though PGI Chandigarh in its certificate has mentioned that disease was treated in 2002. Moreover, this disease does not have any correlation with the cause of death in the present case. Hon’ble Supreme Court in Sulbha PrakashMotegaonkar and Ors. v. Life Insurance Corporation of India, Civil Appeal No.8245 of 2015, decided on 5.10.2015 (SC) has held the following:

        “We have heard learned Counsel for the parties.

                It is not the case of the Insurance Company that the ailment that the deceased was suffering from was a life threatening disease which could or did cause the death of the insured. In fact, the clear case is that the deceased died due to ischaemic heart disease and also because of myocardial infarction. The concealment of lumbar spondylitis with PID with sciatica persuaded the respondent not to grant the insurance claim.

                We are of the opinion that National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischaemic heart disease and myocardial infarction had nothing to do with this lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified.”

7. In view of the foregoing discussion and the ratio of law laid down above, it is clear that the OPs have not been able to connect the previous diseases/ ailments with the present diseases/ailments, for which he had taken treatment from the treating hospital.  Hence, it is unsafe to hold that the OPs were justified in repudiating the claim of the complainant and the present consumer complaint deserves to succeed. 

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP  is directed as under :-

1. to pay ₹1,33,946/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of claim i.e. 15.7.2019 till onwards.
2. to pay an amount of ₹10,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OP within 45 days from the date of receipt of its certified copy, failing which, it 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.
6. Pending miscellaneous application(s), if any, also stands disposed off.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 7/11/2023 mp			Sd/- [Pawanjit Singh] President
			Sd/-
			[Surjeet Kaur] Member
			Sd/-
			[Suresh Kumar Sardana] Member