Chandigarh

DF-I

CC/610/2018

Sanjeev Kumar Nagrath - Complainant(s)

Versus

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

Deepak Aggarwal

10 Dec 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

 

                    

Consumer Complaint No.	:	CC/610/2018
Date of Institution	:	27/11/2018
Date of Decision	:	10/12/2019

 

 

Sanjeev Kumar Nagrath son of Sh. Kewal Kumar Nagrath resident of House No.1012/1, Sector 45-B, Chandigarh-160047.

… Complainant

V E R S U S

1. Max Bupa Health Insurance Company Ltd., through its Managing Director/Director/Authorised Signatory, SCO No.55-56-57, Second Floor, Sector 8-C, Madhya Marg, Chandigarh 160018.

2^nd Address :

Corporate Office, Block B1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi 110044.

2. Tarsem Prabhakar, Agent of Max Bupa Health Insurance Company Ltd., Agent Code CHD0128785, resident of House No.3594, Sector 23-D, UT, Chandigarh-160023.

… Opposite Parties

 

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

                                               

 

For complainant	:	Sh. Deepak Aggarwal, Advocate
For OP-1	:	Sh. Gaurav Bhardwaj, Advocate
For OP-2	:	OP-2 ex-parte.

Per Rattan Singh Thakur, President

1.      The summary of allegations are, on projection of certain benefits by agent of OP-1 i.e. OP-2, complainant had switched over from United India Insurance Company Ltd. and was issued policy bearing No.30637245201700 by OP-1 on 24.2.2017. The policy covered the complainant and his family members – spouse, daughter and son. The case of the complainant is while replacing the handle cover of a cricket bat of a customer (who was a doctor at Government Medical College Hospital, Sector 32, Chandigarh) in the first week of March 2017, he developed pain in abdomen.  On the advice of said doctor, complainant got himself checked in the said hospital in the first week of March 2017. The diagnosis was par umbilical hernia and surgery was advised which was done by the doctors under general anesthesia. He remained admitted in the hospital from 11.3.2017 to 13.3.2017 and the amount spent on treatment/ surgery was Rs.54,648/-. On claim being submitted, OP-1 repudiated the same as the complainant had concealed the disease as he was suffering from umbilical swelling since 6-8 months and he had pre-existing disease. Therefore, per exclusion clause, claim was repudiated. Hence, alleged there was deficiency in service on the part of the OPs and prayer was made for payment of Rs.54,000/- alongwith interest, compensation of Rs.1.00 lakh and Rs.35,000/- as litigation expenses.
2.     OP-2 did not contest the consumer complaint and he was presumed to have been served.  However, in spite of that, OP-2 had not put in appearance and, therefore, vide order dated 22.1.2019 he was proceeded ex-parte.
3.     OP-1 filed its written reply and claimed even in a portable policy, complainant was supposed to disclose the pre-existing disease.  The complainant had the said disease for the last 6-8 months which fact was concealed and, therefore, the case of the complainant fell in the exclusion clause and the claim was rightly repudiated. Reference was made to the various precedents. On these lines, the cause is sought to be defended.
4.     Rejoinder was filed and averments made in the consumer complaint were reiterated.
5.     Parties led evidence by way of affidavits and documents.
6.     We have heard the learned counsel for OP-1 and gone through the record of the case, including the written arguments submitted on behalf of the complainant. After perusal of record, our findings are as under:-
7.     Per pleadings of the parties, the admitted facts are, issuance of the health policy by OP-1 in favour of complainant and his family members whose names were mentioned in the policy and the same was issued on 24.2.2017.  There is no dispute with regard to the payment of premium, therefore, the complainant hired the services of OP-1 for health benefits. There is no dispute with regard to these facts at all.
8.     The sole opposition of OP-1 is the disease hernia was in existence on the date of issuance of the policy i.e. 24.2.2017 and this fact was also mentioned in Annexure C-2 i.e. the discharge and follow up card issued by Government Medical College Hospital, Sector 32, Chandigarh where the history disclosed was patient had umbilical swelling since 6-8 months. It is on this ground it was held there was a pre-existing disease on the date of issuance of the policy i.e. 24.2.2017 and it was concealed. The claim of the complainant fell in the exclusion clause and was rightly repudiated. We will examine the validity of this repudiation order and the reasons recorded therein.
9.     It is the admitted case of the parties, earlier to the insurance policy in question, the complainant was insured with another insurance company i.e. United India Insurance Company Ltd. for the last three consecutive terms vide different policies and then had got his policies ported with OP-1 on 24.2.2017.  It is a case of tacking and succession of the policies and duties and responsibilities by OP-1 as it succeeded those policies on account of portability.  This shows at the time of taking the initial policies with different insurance company, there was no such disease or complaint of any swelling. 
10.     The date of the policy is 24.2.2017 and date of admission in the hospital is 10.3.2017 and date of discharge is 13.3.2017. In the body of the consumer complaint as well as the affidavit furnished, complainant claimed, while he was replacing the handle cover of the cricket bat in the first week of March 2017 to a doctor of GMCH, Chandigarh, he developed a pain and was asked by the said doctor, who happened to be his customer, to visit the said hospital for the check up and thereafter he visited the said hospital.  The said symptoms were felt in March 2017 i.e. after taking of the policies.  Even if we take there is mention in Annexure C-2 patient had umbilical swelling since 6-8 weeks months, it does not show diagnosis of the disease was confirmed i.e. hernia which needed surgery as well as treatment.  How a simple swelling in the umbilical cord can be taken to be hernia or disease which warrants surgical procedure and subsequent treatment thereof. Thus, per record produced, it cannot be construed on date of issuance of the policy i.e. 24.2.2017, complainant was suffering from hernia which needed surgery and treatment and there is simple reference in the discharge and follow up card of patient had umbilical swelling since 6-8 months.  It is not for the person insured for himself to diagnose on the date of policy that it is a confirmed case of hernia which needed surgical procedure and treatment. 
11.     The complainant had got his policies ported with OP-1. If OP-1 had any doubt with regard to the disease, it could have got the complainant medically examined to ascertain the pre-existing disease, if any. There are many chemical reactions in the body anatomy which are not per se perceptible unless some signs and symptoms appear and were reliably diagnosed by the doctor concerned.  How it can be attributed that the complainant had himself diagnosed simple swelling as a confirmed case of hernia which warrants surgical procedure. For that matter, simply putting a question to the complainant and without taking any steps of medical examination of the person insured it could not be construed that complainant had felt actively the disease of hernia which needed surgical procedure. Hence, under these circumstances, it cannot be construed there was a pre-existing disease on the date of issuance of the policy i.e. 24.2.2017 and it was hidden by the complainant consciously that means knowing fully well he was a patient of hernia and then deliberately concealed the said disease.  Thus, the grounds of repudiation are illogical and are not sufficient to non petition the claim of the complainant qua OP-1. However, OP-2 simply happens to be agent of the insurance company/OP-1 and his acts bind the principal and no liability on agent can be affixed particularly so when the claim was repudiated by OP-1 and the contract of insurance was also entered inter se complainant and OP-1.
12.     In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OP-1 is directed as under :-

1. to pay Rs.54,000/- to the complainant alongwith interest @ 9% per annum from the date of denial/repudiation i.e. 28.4.2017 till realization.
2. to pay an amount of Rs.15,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay Rs.10,000/- to the complainant as costs of litigation.

13.     This order be complied with by OP-1 within thirty 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.
14.     Since no deficiency in service has been proved qua OP-2, therefore, the consumer complaint qua it stands dismissed with no order as to costs. 
15.     The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
10/12/2019	[Suresh Kumar Sardana]	[Rattan Singh Thakur]
hg	Member	President