Chandigarh

DF-II

CC/688/2018

Supriya Arora - Complainant(s)

Versus

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

Kanchan Bala Adv.

24 Jul 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	688 of 2018
Date  of  Institution	:	04.12.2018
Date   of   Decision	:	24.07.2019

 

 

 

 

1]  Supriya Arora daughter of Sh.Manohar Lal Arora, resident of House No.65, Seori Bitna, Pinjore, Kalka, District Panchkula.

 

2]  Manohar Lal Arora son of Late Sh.Pratap Chand Arora, resident of House No.65, Seori Bitna, Pinjore, Kalka, District Panchkula.   

          

             ……..Complainants

 

Versus

 

1]  Max Bhupa Health Insurance Co. Ltd., B-1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi 110044

 

2]  Max Bupa Health Insurance Co. Ltd., SCO No.55-56-57, Sector 8-C, Madhya Marg, Chandigarh.

 

………. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN        PRESIDENT

SMT.PRITI MALHOTRA    MEMBER

         SH.RAVINDER SINGH     MEMBER

 

 

Argued By:       Complainant in person.

Sh.Gaurav Bhardwaj, Adv. for OPs.

 

 

PER PRITI MALHOTRA, MEMBER

 

                                The case of the complainants in brief is that they purchased an insurance policy from OPs as ‘Family First Silver 5 Lacs+ 15 Lacs” policy having sum insured of Rs.25 lacs (Ann.C-1) effective from 8.11.2016 to 7.11.2017. The Opposite Parties issued the said policy to the complainants only conducting medical tests (Ann.C-2).  It is averred that the complainant on being diagnosed with Kidney Failure, was admitted in Fortis Hospital, in May, 2017, for peritoneal dialysis and sent the claim papers to OPs for cashless facility, which was denied.  The complainant did not prefer to seek reimbursement of claim after the treatment. Thereafter, the policy was renewed for the period 8.11.2017 to 7.11.2018.  It is stated that though the complainant No.2 was not taking any medicine for Diabeties or Hypertension, but still it was disclosed in the policy about the alleged pre-existing disease at the time of purchasing the policy in the year 2016-17. 

         It is submitted that in April, 2018, the complainant No.2 was admitted in Fortis Hospital, Mohali, where while undergoing the treatment, the papers were sent for claim, which were rejected by the Opposite Parties on the ground that complainant No.2 was suffering from Diabetes and Hypertension for the last 17 years. It is submitted that in the Claim Form, wherein the mention was to be made by the doctor regarding the existence of Diabetes, in the said column, instead of writing 2017, the doctor written it as 17 and it was presumed that the disease was 17 years old, whereas later on, the Senior Doctor of Fortis Hospital, Mohali clarified on his letter head that the patient was suffering from B.P. and Diabetes since 2017.  But inspite of the fact, the OPs never accepted the same and rather cancelled the claim of the complainant, vide email dated 20.6.2018, under the policy on account of concealment of disease (Ann.C-4 colly.). It is stated that the complainant incurred expenses to the tune of Rs.7,80,630/- while his treatment at Fortis Hospital, Mohali (Ann.C-5). The complainant No.2 again remained admitted in Fortis Hospital, Mohali from 18.4.2018 to 23.4.2018 on account of Varicella known as Chickenpox and incurred expense to the tune of Rs.80,239/-, which too was submitted with the OPs (Ann.C-6).  However, the Opposite Parties did not honour the claim of the complainant no.2 and rejected the same on flimsy ground and even cancelled the policy.  Hence, this complaint has been filed alleging the said act & conduct of the Opposite Parties as deficiency in service and unfair trade practice.

 

2]       The Opposite Parties No.1 & 2 have filed reply and while admitting the factual matrix of the case, stated that the complainant had disclosed having Diabetes since 2012 in the proposal form and during statement given at the time of investigation of claim, mentioned that he has diabetes since 2017.  It is stated that the claim of the complainant for reimbursement for the treatment of Chronic Kidney Disease (CKD) was denied since there was a specific waiting period of 24 months for the treatment of the same.  It is also stated that chronic renal failure has a specific waiting period exclusion under the member benefit. It is further stated that the treatment of Chicken pox was denied due to misrepresentation in duration of DM and HTN along with Non-disclosure regarding hip surgery done in 2005 and on medication of voveron.  It is submitted that the policy was already terminated on 20.6.2018, therefore the Opposite Party Company is under no obligation to act upon the alleged demand of complainant.  It is submitted that the Forum cannot pass any order in contravention to the terms & conditions of the policy contract. Pleading no deficiency in service and denying other allegations, the Opposite Parties have prayed for dismissal of the complaint. 

 

3]       Rejoinder has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of the OPs made in their reply.

 

4]      Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the entire record.

 

6]       Admittedly, the complainants availed ‘Family First Silver 5 Lacs+ 15 Lacs” Mediclaim insurance policy (Ann.C-1) effective from 8.11.2016 to 7.11.2017.  In the proposal form filed while availing the policy, it was clearly mentioned that the complainant No.2 is suffering from Diabetes since 2012.  The Opposite Parties after scrutinizing the proposal form accepted the same and issued policy for the period 8.11.2016 to 7.11.2017 (Ann.C-1) with due mentioning about pre-existing condition of complainant No.2 i.e. Diabetes Mellitus & Hypertension disease. There is also no dispute that the said policy was got renewed by the complainants for further period from 8.11.2017 to 7.11.2018.  During the currency of the insurance coverage for the period8.11.2017 to 7.11.2018, the complainant No.2 took the treatment on two occasions from 1.4.2018 to 15.4.2018 and 18.4.2018 to 23.4.2018, at Fortis Hospital, Mohali and the same is admitted.  It is also admitted that the claims lodged by complainants for reimbursement of medical expenses incurred on the treatment of complainant no.2 on two occasions, referred above, have been rejected by the OPs. 

 

7]       Vide present complaint, it has been disputed that the claims lodged for reimbursement under the policy in question as well the pre-authorization requests for cashless treatment were wrongly declined by the OPs.  Thorough probe of evidence on record reveals that the OP insurance company declined the claims of the complainant No.2 stating that the treatment which the complainant No.2 underwent, is not covered under the policy and falls within the waiting clause. To clarify what is submitted in the written statement in Para No.5 is reproduced as under:

“5. That the present compliant is liable to be dismissed on ground that the under the policy no benefit is payable for the claims intimated to the Op company. In the instant case two claims were sent to the company.  As per the investigation of the company and hospital records it was found that the Insured Person i.e. Manohar Lal Arora was known case of Diabetes and Hypertension Since 17 years, and had also suffered Hp Fracture in 2005 for which he was taking Voveron on Daily basis and the said problems were not disclosed at the time of taking the policy.  Furthermore Chronic renal failure has a specific waiting period exclusion under the member benefit.  As per policy terms & conditions treatment and complication for diabetes, hypertension, ischemic heart disease, cerebrovascular accident falls under specific and personal waiting period of 2 years hence the claim was repudiated as.”  

 

         In our opinion, both the reasons assigned for rejection of the claims are invalid. When once we look back at the insurance certificate issued to the complainants Ann.C-1 (Page 31), it specifically mentions the Personal Waiting Period for the mentioned pre-existing conditions as under:-   

Name of the Insured Person(s)	Age	Gender	Relationship with the Policy Holder	Pre Existing Condition	Personal Waiting Period	Co-pay (applicable at 65 years and above)
Mr.Manohar Lal Arora	62	Male	Father	1.Diabetes Mellitus 2. Hypertensive diseases	1.Ischaemic heart diseases 2. Cerebrovascular Diseases	100	NA

  

 

8]       To specify it is apt to mention that the complainant No.1 vide email addressed to OPs duly conveyed her acceptance to counter offer and exclusion as was asked for by the Opposite Parties vide their email dated 8.11.2016.  Both the copies of emails have been submitted by the complainant No.1 at the time of arguments and then the matter was open for evidence & arguments, so those documents were made part of the record.  It is after the receipt of the acceptance about specific waiting period, the same got mentioned in the policy document/certificate itself, as tabulated above.

 

        It is well clear from the Insurance Certificate Ann.C-1 (Page 31) and from the proposal form that the complainant No.2 at the time of availing the policy clearly mentioned about his pre-existing diseases i.e. Diabetes Mellitus and Hypertension suffering since 2012. No authentic document has been made part of the record by the Opposite Parties to establish that complainant No.2 was suffering from Hypertension and Diabetic Mellitus since 17 years.  Thus no question of any concealment or misrepresentation about duration of pre-existing medical condition arose and rejection of claim as well as cancellation of policy on this ground is highly objectionable and not justified. In our considered opinion special mentioning of the specific personal waiting periods in the policy for particular diseases supersedes general exclusion clause of the policy, specifically pertaining to the waiting periods.  Therefore, it can safely be concluded that the claim for reimbursement of expenses incurred on treatment during the currency of policy in question, has wrongly been rejected by the Opposite Parties.  Acting arbitrarily, the Opposite Parties have not even issued any notice to the complainants before cancellation of the policy.  

 

9]       In the same manner, the claim of complainant No.2 for the reimbursement of the expenses incurred on the treatment taken by him for disease ‘Chicken Pox’ at Fortis Hospital, Mohali during the subsistence of the policy in question has also wrongly been declined by the Opposite Parties on wrong pretext of non-disclosure.  The same is also duly payable to the complainants as there is no specific waiting period or clause mentioned in the policy whereby the treatment taken by the insured for said disease is not payable.

 

10]      From the discussion above, it is our concerted view that the Opposite Parties not only wrongly & illegally rejected both the claims of complainant No.2, but they had also illegally cancelled the policy in question depriving them from the benefit of the policy availed by them.  It has duly been proved on record that the complainant No.1 applied for the renewal of the policy by submitting cheque amounting to Rs.41,000/- (Ann.C-9) towards the premium, but the same was declined by the Opposite Parties and the policy was not renewed, which further amounts to deficiency in service on the part of Opposite Parties.

 

11]      Taking into consideration, the above facts & circumstances of the case, we are of the opinion that the OPs have wrongly & illegally rejected the genuine claims of complainant No.2 following with wrong cancellation of the policy in question with further wrongly refusing to renew the same despite being duly approached for by the complainant No.1. Hence the deficiency in service on the part of Opposite Parties is proved.  Therefore, the present complaint is allowed against the Opposite Parties with following directions:-

1. To restore the policy in question in the name of subscriber/insured with upto date benefits and renew the policy with same coverage in favour of the insured(s), so applied by the complainants on receipt of the requisite premium from complainants (if not paid);
2. To reimburse the claim amount of Rs.7,80,630/- & Rs.85,329/-  to the complainant No.2 along with interest @8% p.a. from the date of filing the complaint i.e. 04.12.2018 till realization;
3. To pay an amount of Rs.15,000/- as compensation for causing harassment & mental agony to the complainant;
4. To pay an amount of Rs.7000/- towards litigation expenses.

 

         This order be complied with by the OPs within a period of 30 days from the date of receipt of its certified copy, failing which they shall also be liable to pay additional cost of Rs.25,000/- apart from the above relief.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

24^th July, 2019                                                              Sd/-

                                                                   (RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER