CONSUMER DISPUTES REDRESSAL COMMISSION – X

                           GOVERNMENT OF N.C.T. OF DELHI

                     Udyog Sadan, C – 22 & 23, Institutional Area

                                       (Behind Qutub Hotel)

                                        New Delhi – 110016

    Case No.210/2019

Sh. Pappan Aggarwal

R/o A-1/172, Second Floor

Shanti Niwas, Hastal Road

Uttam Nagar, Delhi-110059                                     …..COMPLAINANT

Vs.   

1.  Ashish Mehtotra

Managing Director and Chief Executive Officer

Max Bupa Health Insurance Company Ltd.

D-1, 2^nd Floor, Salcon Ras Vilas

District Centre, Saket

New Delhi-110017.

2. Max Bupa Health Insurance Company Ltd.

Block B1/1-2, Mohan Cooperative Industrial Estate

Mathura Road, New Delhi                                              .…..RESPONDENTS

          Date of Institution-04.09.2019

          Date of Order- 04.10.2024

  O R D E R

RITU GARODIA-MEMBER

1. The complaint pertains to deficiency in service in rejecting the health claim of the complainant.

2. The complainant purchased a medi-claim policy no.3018448220300 on 28.02.2013 from OP. The complainant was examined by the empaneled doctors of OP before the issuance of the policy.  It is alleged that the complainant had to undergo medical tests every two years after the policy.

3.  The complainant started suffering from acute knee pain and was advised to undergo knee replacement surgery from Venkateshwara Hospital, Delhi.  He was operated on 15.04.2019 and was discharged from hospital on 20.04.2019.

4. The complainant applied for pre-auth/reimbursement of the claim.  OP, instead of allowing the claim, sent a notice of cancellation of policy no.3018448220300 through email on grounds of pre-existing illness. OP stated in the said email that the complainant was ‘known case of OA knees 2011.’

5. The complainant submits that he had paid Rs.1,51,314/- approximately to the OP in lieu of premium of policy for 7 years.

6. The complainant had answered several health related questions on 26.02.2013 before the issuance of policy:

7. The complainant prays for claim amount of Rs.4,61,000/- alongwith benefit accrued thereon, Rs.11,000/- for litigation and Rs.1,00,000/- towards compensation for physical harassment and mental agony.

8. OP in its reply submits that the complainant took a policy no.3018448220300 for sum assured of Rs.3,00,000/- for the period from 20.02.2013 to 19.02.2014. The same was renewed from time to time and was valid up to 19.02.2020. The complainant had informed OP about ischemic heart disease which was mentioned as a pre-existing condition.

9. On 10.04.2019, OP received a preauthorization request for cashless facility for the patient, Mr. Pappan Aggarwal, with complaints of pain in both knees and difficulty in walking. However, no copy of such request is placed on record.

10.  OP issued an additional information request letter dated 09.04.2019 to provide below mention information:

“Certify from treating doctor exact duration of HTN and Heart Disease with first consultation paper.

This letter dated 09.04.2019 is purportedly sent before the request of pre-authorization. The OP received a reply from the hospital. However, no detail/copy of reply is placed on record.

11. OP denied the cashless facility on the ground that the details submitted   alongwith the preauthorization suggest the patient had adverse medical condition.

12. A claim bearing no.440845 was filed by complainant for reimbursement of medical expenses incurred during hospitalization from 04.04.2019 to 20.04.2019. The complainant was diagnosed with a Bilateral OA(Osteoarthritis) knee with final claimed amount of Rs.4,67,955/-.

13. After receipt of the claim, OP carried out an investigation.  OP was informed by the insured that he was suffering from knee problem for last two year and CAD was carried out in Mata Chanan Devi Hospital. OP has relied on discharge summary of Mata Chanan Devi Hospital. As per the said discharge, the patient was a K/C/O HTN with (Osteoarthritis). It is submitted that the patient informed that he has hypertension (BP) problem since 01.01.2011 and is on regular medication.  Hence his claim stands repudiated as per clause 12.20 of the policy terms and condition. 

14. The complainant has filed rejoinder in consonance with the averments made in the complaint.

15. The complainant has filed his evidence by way of affidavit and exhibited the following documents:-

1. Copy of health insurance is exhibited as Ex.CW-1/A.
2. Copy of discharge summery is exhibited as Ex.CW-1/B.
3. Copy of medical bills is exhibited as Ex.CW-1/C.
4. Copy of emails is exhibited as Ex.CW-1/D.
5. Copy of rejection letter is exhibited as Ex.CW-1/E.
6. Copy of legal notice is exhibited as Ex.CW-1/F.
7. Copy of documents/letter to OP is exhibited as Ex.CW-1/G.

16. OP1 and OP2 have filed their evidence by way of affidavit and exhibited the following documents:-

1. Copy of certificate of incorporation is exhibited as EX.RW-1/A.
2. Copy of letter of authorization is exhibited as EX.RW-1/B.
3. Copy of information form is exhibited as EX.RW-1/C.
4. Copy of policy document is exhibited as EX.RW-1/D.
5. Copy of preauthorization request form is exhibited as EX.RW-1/E.
6. Copy of additional information request letter is exhibited as EX.RW-1/F.
7. Copy of denial of authorization is exhibited as EX.RW-1/G.
8. Copy of legal notice and reply is exhibited as EX.RW-1/H & I.
9. Copy of claim form is exhibited as EX.RW.1/J.
10. Copy of investigation report is exhibited as EX.RW-1/K
11. Copy of discharge summary is exhibited as EX.RW-1/L.
12. Copy of claim repudiation is exhibited as EX.RW-1/M.
13. Copy of cancellation of policy is exhibited as EX.RW-1/N.

17. The Commission has considered the material and documents on record.  It is admitted by both the parties that the complainant was insured by OP from 20.02.2013.  

18. The relevant portion of discharge summery by Venkateshwara Hospital is as follows:
2393. : 14/04/2019   11:17                DOD:20/4/2019   11:57
690813162539. :  BILATERAL OA KNEE

PROCEDURE DONE: BILATERAL TKR Gold knee, Maxx done on 15.04.2019.

19. The pre-authorization claim was repudiated vide letter dated 11.04.2019 by giving reasons- ‘known case of OA knees 2011’. The policy was also cancelled by the same letter.

20. OP has relied on discharge summery of Mata Chanan Devi Hospital dated 11.06.2011. The complainant was admitted with chest pain. The diagnoses was for acute coronary syndrome. One of the observation was that the patient is a known case of OA knees and hypertension. 

21. Both the parties have relied on terms and conditions of the complaint. The relevant terms and conditions are as follows: “We shall not be liable under this Policy for any claim in connection with or in respect of the follow:

1. Pre-Existing Conditions

Benefits will not be available for pre-existing conditions until 48 months of continuous coverage have elapsed since the inception of the first Policy with Us.’

22. Thus, it is clear that any benefit from a policy for pre-existing condition will be available after 48 months of coverage.  The policy commenced after medical examination by empaneled doctors on 20.02.2013 and 48 months elapsed on 20.02.2017.  The complainant was hospitalized on 04.04.2019 much beyond the time for exclusions. The bill of Venkateshwara Hospital amounts to Rs.4,60,897/-.

23. Hence we find OP guilty of deficiency in service for rejecting the claim of the complainant and direct it to pay-

1. Rs.4,60,897/- with 7% interest from date of discharge of the complainant till realization.
2. Rs.10,000/- towards compensation for mental harassment.
3. Rs.5,000/- for litigation.

24. Order to be uploaded and file be consigned to record room.