BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.319 of 2015

Date of Instt. 28.07.2015

Date of Decision :25.05.2016

Vinod Kumar Sablok, aged about 65 years son of Late Wasti Ram, R/o Plot No.403, Chadha Complex, C-Block, Lajpat Nagar, Jalandhar-144001.

..........Complainant

Versus

1. Max Bupa Health Insurance Company Limited, having its office at Plot No.88, Kunal Tower, Mall Road, Near Bharat Nagar Chowk, Ludhiana through its Branch Manager/Branch Head.

2. Max Bupa Health Insurance Company Limited, having its registered office at B-1/1-2, Mohan Cooperative Industrial Estate, Matura Road, New Delhi-110044 through its Managing Director/CEO and also at Max Bupa Health Insurance Company Limited., Max House, House-1, Dr.Jha Marg, Okhla, New Delhi-110020 through its Managing Director/CEO.

3. Vijay Sharma, Agent/Advisor of Max Bupa Health Insurance Company Limited, Agent Code No.LUD0106695, R/o House No.344, Lajpat Nagar, Ward No.53, Jalandhar.

.........Opposite parties

Complaint Under Section 12 of the Consumer Protection Act.

Before: S. Bhupinder Singh (President)

Sh.Parminder Sharma (Member)

Present: Sh.Balwinder Singh Adv., counsel for the complainant.

Sh.AK Gandhi Adv., counsel for the Ops No.1 & 2.

OP No.3 exparte.

Order

Bhupinder Singh (President)

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act against the opposite parties on the averments that the wife of the complainant namely Late.Kusam Sablok got insurance policy bearing No.30364766201400 dated 30.9.2014 (Family First Silver Plan) covering medical expenses to the tune of Rs.5 Lacs plus Rs.15 Lacs. The complainant and his wife jointly had another insurance policy bearing No.30257863201300 for the period from 23.9.2013 to 22.9.2014. Kusam Sablok suffered from general weakness and anemia and she was admitted in Patel Hospital, Civil Lines, Jalandhar for the period from 16.10.2014 to 21.10.2014 and a sum of Rs.1,44,250/- was incurred on her treatment. Kusam Sablok died on 21.10.2014. Intimation was given to the OP regarding the admission and death of Kusam Sablok insured. Claim was lodged with the Ops for payment of Rs.1,44,250/- the expenses incurred on the medical treatment of Kusam Sablok vide claim No.116362 dated 6.1.2015. Ops repudiated the claim through SMS dated 23.2.2015 on frivolous grounds. The complainant then submitted representation dated 8.6.2015 to the Ops to reconsider the claim but Ops refused to do so. On such like averments, the complainant has prayed for directing the Ops to pay the claim amount of Rs.1,44,250/- alongwith compensation and litigation expenses.

2. Upon notice, OPs No.1 & 2 appeared through counsel and filed written reply pleading that the wife of the complainant late Smt.Kusam Sablok in order to get health insurance policy from Ops No.1 & 2 filled in proposal form for herself and her daughter in law Mrs.Preena Sablok. Complainant's wife was required to disclose her medical history as per clause 6 but the complainant did not disclose any medical history, stating her medical status as “good”. So, assuming that the proposer late Smt.Kusam Sablok is a healthy person and the risk involved in insuring her is within acceptable limits, a Family First Silver Plan covering Rs.5 Lacs plus Rs.15 Lacs having policy No.30364766201400 was issued covering period from 30.9.2014 to 29.9.2015 with sum insured Rs.5 Lacs individual and Rs.15 Lacs as floater sum. The policy documents were duly received by the complainant. Kusam Sablok insured was hospitalized at Patel Hospital, Jalandhar on 16.10.2014 and she was diagnosed with Myelodysplatic syndrome and she had been mentioned suffering from this disease since December 2013. However, Kusam Sablok had not disclosed the same in the proposal form. Kusam Sablok also did not disclose that prior to taking the present policy from the OP, she was admitted in various hospitals for the operation of Hernia, blood transfusions, etc. She had undergone surgery for Hernia in 2009. She had been on medicine of iron for the last 2-3 years and now she had started course of iron injections. All this proves that the current ailment for which Kusam Sablok was admitted in Patel Hospital, Jalandhar, was having pre-existing disease even before the policy inception as the policy began from 30.9.2014 whereas insured Kusam Sablok was on treatment since 2011 but all these facts were not mentioned by insured Kusam Sablok in the proposal form. The complainant did not disclose any medical history and answered all the questions in negative by stating that she had possessive “good health". Earlier, Kusam Sablok alongwith her husband i.e. complainant Vinod Kumar Sablok took insurance policy bearing No.30257863201300 with a sum of Rs.2 Lacs for the period from 23.9.2013 to 22.9.2014 and they got renewed the said policy vide policy No.30257863201401 from 23.9.2014 to 22.9.2015. However, Kusam Sablok alongwith her daughter-in-law Mrs.Preena Sablok got another policy namely First Family Silver Plan I.e policy in question bearing No.30364766 201400 with sum insured Rs.5 Lacs plus Rs.15 Lacs on 30.9.2014 fully knowing that she was suffering from serious diseases and was hospitalized for the treatment of the same before taking this policy and by concealing the aforesaid facts. Ops submitted that complainant obtained the policy in question by concealment of aforesaid facts. Therefore, OP has rightly repudiated the claim of the complainant vide letter dated 8.10.2015. Ops No.1 & 2 denied other material averments of the complainant.

3. Notice of this complaint was given to the OP No.3 but nobody has turned-up despite service and as such it was proceeded against exparte.

4. In support of her complaint, complainant has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C6 and closed his evidence.

5. On the other hand, learned counsel for opposite parties No.1 and 2 has tendered affidavit Ex.OP-A alongwith copies of documents Ex.OP1 to Ex.OP9, Ex.O-10 and closed evidence.

6. 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.

7. From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that the wife of the complainant namely Late.Kusam Sablok got insurance policy bearing No.30364766201400 dated 30.9.2014 Ex.C3 (Family First Silver Plan) covering medical expenses to the tune of Rs.5 Lacs plus Rs.15 Lacs. The complainant and his wife earlier jointly took insurance policy bearing No.30257863201300 for the period from 23.9.2013 to 22.9.2014 Ex.C2 . Kusam Sablok suffered from general weakness and anemia and she was admitted in Patel Hospital, Civil Lines, Jalandhar for the period from 16.10.2014 to 21.10.2014 and a sum of Rs.1,44,250/- was incurred on her treatment. However, Kusam Sablok died on 21.10.2014. Intimation was given to the OP regarding the admission and death of Kusam Sablok insured. Bill regarding treatment of Kusam Sablok is Ex.C4 and death certificate is Ex.C5. Claim was lodged with the Ops for payment of Rs.1,44,250/- the expenses incurred on the medical treatment of Kusam Sablok vide claim No.116362 dated 6.1.2015. However, Ops repudiated the claim through SMS dated 23.2.2015 on frivolous grounds. The complainant then submitted representation dated 8.6.2015 Ex.C6 to the Ops to reconsider the claim but Ops refused to do so. The learned counsel for the complainant submitted that all this amounts to deficiency in service on the part of the OPs qua the complainant.

8. Whereas the case of the OPs No.1 & 2 is that the wife of the complainant late Smt.Kusam Sablok in order to get health insurance policy from Ops No.1 & 2 filled in proposal form for herself and her daughter in law Mrs.Preena Sablok. Complainant's wife was required to disclose her medical history as per clause 6 but the complainant did not disclose any medical history stating her medical status as “good”. So, assuming that the proposer late Smt.Kusam Sablok is a healthy person and the risk involved in insuring her is within acceptable limits, a Family First Silver Plan covering Rs.5 Lacs plus Rs.15 Lacs having policy No.30364766201400 Ex.C3 was issued covering period from 30.9.2014 to 29.9.2015 with sum insured Rs.5 Lacs individual and Rs.15 Lacs as floater sum. The policy documents were duly received by the complainant. Kusam Sablok insured was hospitalized at Patel Hospital, Jalandhar on 16.10.2014 and she was diagnosed with Myelodysplatic syndrome and she had been mentioned suffering from this disease since December 2013. However, Kusam Sablok had not disclosed the same in the proposal form. Kusam Sablok also did not disclose that prior to taking the present policy from the OP, she was admitted in various hospitals for the operation of Hernia, blood transfusions, etc as is evident from the medical record of the complainant at Patel Hospital, Jalandhar Ex.OP5 which proved that she had been suffering from anemia for the last 2-3 years and she had been frequently hospitalized for blood transfusions since 2-3 years. She had undergone surgery for Hernia in 2009. She had been on medicine of iron for the last 2-3 years and now she had started course of iron injections. All this proves that the current ailment for which Kusam Sablok was admitted in Patel Hospital, Jalandhar, was having pre-existing disease even before the policy inception as the policy began from 30.9.2014 whereas insured Kusam Sablok was on treatment since 2011 but all these facts were not mentioned by insured Kusam Sablok in the proposal form in clause 6 of the proposal form annexed with the policy Ex.C3. The complainant did not disclose any medical history and answered all the questions in negative by stating that she had possessive “good health”. Earlier, Kusam Sablok alongwith her husband i.e. complainant Vinod Kumar Sablok took insurance policy bearing No.30257863201300 Ex.C2 with sum of Rs.2 Lacs for the period from 23.9.2013 to 22.9.2014 and they got renewed the said policy vide policy No.30257863201401 from 23.9.2014 to 22.9.2015. However, Kusam Sablok alongwith her daughter-in-law Mrs.Preena Sablok got First Family Silver Plan i.e. policy in question bearing No.30364766201400 Ex.C3 with sum insured Rs.5 Lacs plus Rs.15 Lacs on 30.9.2014 fully knowing that she was suffering from serious diseases and was hospitalized for the treatment of the same before taking this policy Ex.C3 and by concealing the aforesaid facts. Learned counsel for the Ops submitted that complainant obtained the policy in question by concealment of aforesaid facts. Therefore, OP has rightly repudiated the claim of the complainant vide letter dated 8.10.201 Ex.OP8. Learned counsel for the OPs No.1 & 2 submitted that there is no deficiency of service on the part of the OPs qua the complainant.

9. From the entire above discussion, we have come to the conclusion that complainant alongwith his wife late Smt.Kusam Sablok took insurance policy on 23.9.2013 Ex.C2 bearing No.30257863201300 for the period from 23.9.2013 to 22.9.2014 and got renewed the same for the period from 23.9.2014 to 22.9.2015. Thereafter, on 30.9.2014 wife of the complainant late Smt.Kusam Sablok got another insurance policy bearing No.30364766201400 dated 30.9.2014 Ex.C3 (Family First Silver Plan) for herself and her daughter-in-law Mrs.Preena Sablok. In order to take this policy Ex.C3, Kusam Sablok filled in and signed the proposal form attached with this policy Ex.C3 and was required to disclose her medical history as per clause 7. But the proposer did not disclose her medical history correctly rather stated that her medical status was good. In the proposal form, she submitted that she never admitted in any hospital and she was not suffering from any disease nor she has consulted any doctor/medical practitioner for any disease. On the basis of that proposal form, the OP issued “First Family Silver Plan” policy Ex.C3 with sum insured Rs.5 Lacs individual plus Rs.15 Lacs as floater sum covering period from 30.9.2014 to 29.9.2015. The policy documents were duly received by the complainant. Kusam Sablok insured was hospitalized at Patel Hospital, Jalandhar on 16.10.2014 and she was diagnosed with Myelodysplatic syndrome and she had been mentioned suffering from this disease since December 2013. Kusam Sablok remained admitted in that hospital upto 21.10.2014. However, she expired on 21.10.2014. An amount of Rs.1,44,250/- was incurred on her medical treatment at Patel Hospital, Jalandhar. The claim was lodged with the OP by the complainant regarding aforesaid medical treatment of Kusam Sablok insured. The OP repudiated the claim vide letter dated 8.10.2015 Ex.OP8 on the ground that Kusam Sablok insured got the policy in question Ex.C3 by concealment of facts and she did not disclose the material facts regarding her health status in this regard. The Ops have produced the record of Patel Hospital, Jalandhar where insured Kusam Sablok got her medical treatment. The matter was thoroughly investigated by TPA of Max Bupa Health Insurance Company Limited. The investigation report in this regard is Ex.OP5 and the OP collected the entire medical record pertaining to previous health status of insured Kusam Sablok. As per this record Ex.OP5 and other information collected and mentioned in this investigation report, insured Kusam Sablok was admitted in hospital for operation of Hernia in 2009. She had been frequently hospitalized in Patel Hospital, Jalandhar for blood transfusions for the last 2-3 years. She had been on medicine of iron for the last 2-3 years and later on she had started course of iron injection as is evident from medical record of Kusam Sablok insured Ex.OP5. The complainant could not deny this documentary evidence produced on record by the OP regarding previous health status of insured Kusam Sablok. No only this, complainant Vinod Kumar Sablok himself in his statement recorded by the investigator under the signatures of the complainant, himself has admitted all these facts that Kusam Sablok was suffering from anemia deficiency of red blood cell for the last 2-3 years and they used to hospitalize her in Patel Hospital, Jalandhar for blood transfusions periodically. He has also admitted that Kusam Sablok was admitted in hospital for operation of Hernia in 2009 before the inception of the policy in question. All this fully proves that insured Kusam Sablok has concealed the aforesaid material facts while taking the policies in question Ex.C2 and Ex.C3. Thereby, she has obtained the policy in question by concealment of facts. It has been held by Hon'ble Supreme Court of India in case “Satwant Kaur Sandhu Vs. New India Assurance Company Limited”, (2009) 8 SCC 316 that “When information on a specific aspect is asked for in the proposal form, the assured is under a solemn obligation to make a true and full disclosure of the information on the subject which was within his/her knowledge. Whether the information sought for is material for the purpose of the policy is a matter not to be determined by the proposer”.

10. The agreement of insurance is of utmost faith and the insured is duty bound to disclose all the material facts which were in his/her knowledge at the time of making proposal for the insurance policy. Here in this case, insured Kusam Sablok had obtained the policy in question by concealment/misrepresentation of facts and the OP was justified in repudiating the claim in question regarding the medical treatment of Kusam Sablok at Patel Hospital, Jalandhar for the period from 16.10.2014 to 21.10.2014.

11. Consequently, we hold that complaint is without merit and same is hereby dismissed with no order as to cost. 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

25.05.2016 Member President