Punjab

Ludhiana

CC/21/66

Parveen Kumar - Complainant(s)

Versus

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

Nitin Kapila Adv.

02 Aug 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:66 dated 05.02.2021.                                                 Date of decision: 02.08.2023.

 

Parveen Kumari Sachdeva aged about 56 years wife of Late Sh. Krishan Kumar Sachdeva, r/o. Super Dyer and Dry Cleaners, Kohara Road, Sahnewal, District Ludhiana.                                                                                                                                                                                         ..…Complainant

                                                Versus

Max Bupa Health Insurance Company Limited, having its Branch Office at Plot No.88, 2^nd Floor, Kunal Towers, Mall Road, Ludhiana through its Manager.

2^nd Address:

 Registered Office at Max House 1, Dr. Jha Marg, Okhla, New Delhi-110020 through its Manager.                                                                                                                                                                        …..Opposite party 

Complaint Under Section 35 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Nitin Kapila, Advocate.

For OP                           :         Sh. Varun Gupta, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the complaint are that the husband of the complainant namely Late Sh. Krishan Kumar Sachdeva availed health insurance policy bearing No.30157961201200 from the opposite party having validity from 26.12.2012 to 25.12.2013 having medical cover of Rs.5,00,000/- + Rs.15,00,000/- in terms of family first silver policy and the sum assured was Rs.25,00,000/-. The complainant stated that her husband was hale and hearty at the time of issuance of policy and never suffered from any serious ailment and all medical conditions were duly informed to the opposite party by mentioning in the pre-existing condition of the policy and medical tests were conducted by opposite party at the time of issuing the policy.

                   The complainant further stated that the policy was got renewed from time to time from opposite party. During the policy, Sh. Krishan Kumar Sachdeva suddenly fell ill during the period of policy No.30157961 and was admitted in Fortis Hospital on 06.11.2018 and was discharged on 18.11.2018 with medical advise and paid Rs.6,03,588/- to Fortis Hospital, Chandigarh Road, Ludhiana. Thereafter, Sh. Krishan Kumar Sahcdeva was shifted to Sidhu Hospital, Doraha where he died on20.11.2018. The complainant lodged the claim No.395480 for Rs.6,03,588/- spent on treatment of her husband and supplied all the requisite documents including bills and policy documents as per demand of opposite party but the opposite party has failed to pay the claim despite regular requests and repudiated her claim vide letter dated 25.04.2019 with the reason that “the conditions arising due to abuse or misuse of alcohol which is not covered as per policy terms and conditions and CLD since 10 years, which is non-disclosure. Hence, denied as per policy terms and conditions.”  The complainant further stated that her husband was paying the premium from 26.12.2012 and claim for his treatment in the year 2017 was duly paid by the opposite party. Sh. Krishan Kumar Sachdeva died on 20.11.2018. Repudiation of the claim is not justified which amounts to deficiency in service on the part of the opposite party due to which the complainant suffered mental pain, agony, torture and physical harassment for which she is entitled to compensation of Rs.1,00,000/-.In the end, the complainant prayed for issuing direction to the opposite party to pay Rs.6,03,588/- incurred on the treatment of her husband along with interest and to pay compensation of Rs.1,00,000/-.

2.                Upon notice, the opposite party appeared and filed written statement by taking preliminary objections that the complaint is not maintainable, lack of jurisdiction; lack of cause of action; the complainant has not come to the court with clean hands; concealment of material facts by the complainant etc. The opposite party stated that after evaluating the claim under the policy, it was found that the insured concealed his cardiac disease. The non-disclosure was vital as the assured was under a bounden duty to disclose the true and correct facts as regards to his medical history as the same was important to underwrite the correct risk in issuance of the policy but the insured did not disclose the correct information. Had the true and correct facts been known to the opposite party, the policy would not have been issued to the assured. The claim was repudiated on the grounds that the assured failed to disclose correct health status at the time of purchasing the policy. According to the opposite party, the proposal form is not merely a document to be signed and submitted for formality. It is the basis for the contract of insurance. It is the mode of providing information to the insurer so as to enable them to exercise a lawful right to evaluate the life before providing its services by covering the life. As per Regulation 2(2) (d) of IRDA (Protection of Policyholder’s Interests) Regulations, 2002 which provides that “Proposal Form” means a form to be filled by the proposer for insurance, for furnishing all material information required by the insurer in respect of a risk, in order to enable the insurer to decide whether to accept or decline, to undertake the risk, and in the event of acceptance of risk, to determine the rates, terms and conditions of a cover to be granted. The opposite party further stated that intricate questions of law and facts are involved in the matter and the parties have to lead evidence by examining the witnesses and the other party should have to cross examine the witnesses and as such, the matter cannot be decided in summary manner. Moreover, the company has repudiated the claim under the said policy by a speaking order which lists out the specific reasons for the decision. So there is no deficiency in service on its part.

                   Under the heading of brief facts, the opposite party stated that on the basis of the proposal form submitted by the insured, the company issued a policy No.30157961 for a sum assured of Rs.10,00,000/- and the complainant continued the policy with the opposite party. Policy kit and documents were duly delivered to the complainant by giving opportunity to verify and examine the benefits, terms and conditions of the policy but the complainant never approached the opposite party stating that any information given in the policy schedule was incorrect. According to the opposite party, it received a claim from the complainant for reimbursement of expenses incurred on her husband for treatment in Fortis Hospital, Ludhiana from 06.11.2018 to 18.11.2018 but her husband was earlier admitted on 16.10.2018 to 18.10.2018 for generalized weakness with body aches for 2 weeks.  On scrutiny of the claim as per terms and conditions of the policy, the claim was rejected with remarks that the patient was CLD (Chronic Liver Disease) since last 10 years which was not disclosed at the time of purchasing the policy from the opposite party. Even in the medical document it was clearly mentioned that the insured was suffering from CLD since last 10 years i.e. prior to purchase of the policy and the complainant was very well aware about this fact but has concealed the same to get undue benefits. The said claim was repudiated on 02.01.2019. Moreover, all the claims are paid by any insurance company out of the common pool of funds belonging to all policyholders of the Company which makes it obligatory upon the Insurance Company to check the genuineness and admissibility of each claim before honoring it in the later interest of a the policy holders.

                   On merits, the opposite party reiterated the crux of averments made in the preliminary objections. The opposite party has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                In support of her claim, the complainant tendered her affidavit Ex. CA in which she reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of policy welcome letter dated 28.12.2012 along with receipts etc., Ex. C2 is the copy of renewal letter dated 27.12.2013  and policy documents, Ex. C3 is the copy of repudiation letter dated 25.04.2019, Ex. C4 is the copy of death certificate of Sh. Krishan Kumar Sachdeva, Ex. C5 is the copy Aadhar card and PAN card of the complainant, Ex. C6 is the copy of Aadhar card of Krishan Kumar, Ex. C7 is the copy of LAMA summary of Fortis Hospital, Ludhiana, Ex. C8 is the copy of  receipt/bills of Fortis Hospital, Ludhiana, Ex. C9 is the copy of account statement of the complainant and closed the evidence.

4.                On the other hand, counsel for opposite party tendered affidavit Ex. RA of Sh. Bhuwan Bhashker, Authorized Signatory of Niva Bupa Health Insurance Co. Ltd., 2^nd Floor, Plot D-5, Logix Infotech Park Sector-59, Noida-201301, Uttar Pradesh along with document Ex. R1 is the copy of  policy documents etc. containing 244 pages  and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.      

6.                On the basis of information summary sheet dated 28.12.2012 Ex. R1 page 9, the opposite party  issued policy bearing No. 30157961201200 namely Family First Silver 5 Lacs + 15 Lacs having a sum insured of Rs.25,00,000/- to Mr. Krishan Kumar Sachdeva now deceased (hereinafter called as insured). On 06.11.2018, the insured Krishan Kumar Sachdeva was got admitted in Fortis Hospital, Ludhiana in unconscious, unresponsive state on 06.11.2018 at 03:30 PM and was discharged on 18.11.2018 against LAMA (Leaving Against Medical Advise) and his condition at the time of discharge is mentioned that patient is in critical condition, needs ventilatory support and care for CVC & U-cath. An expenditure of Rs.6,03,588/- were incurred by the complainant. Unfortunately, Sh. Krishan Kumar Sachdeva expired on 20.11.2018 at Sidhu Hospital, Doraha as per death certificate Ex. C6. The complainant lodged claim under the policy which was repudiated vide claim intimation letter Ex. C3 dated 25.04.2019 on the disallowance reason that “Due to gross non disclosure of material facts such as CLD since 10 years, the claim stands rejected in accordance with policy T&C.”

7.                At the very outset, it has been noticed that neither in the written statement or in the affidavit nor in the repudiation letter Ex. C3, the opposite parties has not referred to any of the terms, conditions or clause which was invoked to deny the claims of the complainant. The recitals of this document are general in nature and it has been only mentioned that the claim stands rejected due to gross non disclosure of material facts such as CLD since 10 years. The opposite party has referred to the Medical Questions of the life assured in “Information Summary Sheet” at page No.9 of Ex. R1 where the answer to the relevant questions has been stated to be given “NO” by the insured Krishan Kuamr Sachdeva except the one question i.e. within the last 2 years have you consulted a doctor or a healthcare professional?, the answer of which is “YES”. Further, it has been mentioned in the written statement that Krishan Kuamr Sachdeva was suffering from CLD (Chronic Liver Disease) since last 10 years prior to issuance of the policies on the basis of LAMA summary dated 18.10.2018 of Fortis Hospital, Ludhiana. Neither the report nor the affidavit of the investigator nor any medical record was produced by the opposite party to substantiate their claim with regard to treatment of Krishan Kumar Sachdeva insured. These documents were material in nature and its non-production has certainly caused dent in the authenticity of investigation and legality of repudiation letters. It is also pertinent to note that the insured had disclosed his “Pre-existing condition” as ‘Diabetes Mellitus’ at page No.4 of Ex. R1 which shows his bonafide approach in disclosing the true credentials at the time of obtaining the policy.  In the given set of facts and circumstances, the repudiation of the claim of the complainant is not justified and it would be just and appropriate if the opposite party is directed to settle and reimburse the claim of the complainant regarding hospitalization of Krishan Kumar Sachdeva from 06.11.2018 to 18.11.2018 strictly in accordance with terms and conditions of the policy along with composite costs of Rs.10,000/-. 

8.                As a sequel of above discussion, the complaint is partly allowed with direction to the opposite party to settle and reimburse the claim of the complainant regarding hospitalization of Krishan Kumar Sachdeva from 06.11.2018 to 18.11.2018 strictly in accordance with terms and conditions of the policy within 30 days from the date of receipt of copy of order. The complainant is entitled for a composite costs of compensation of Rs.10,000/- (Rupees Ten Thousand only). Payment of this amount be made within 30 days from the date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

9.                Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                       President         

 

Announced in Open Commission.

Dated:02.08.2023.

Gobind Ram.

 

 

 

Parveen Kumari Vs Max Bupa Health Insurance                      CC/21/66

Present:       Sh. Nitin Kapila, Advocate for complainant.

                   Sh. Varun Gupta, Advocate for OP.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with direction to the opposite party to settle and reimburse the claim of the complainant regarding hospitalization of Krishan Kumar Sachdeva from 06.11.2018 to 18.11.2018 strictly in accordance with terms and conditions of the policy within 30 days from the date of receipt of copy of order. The complainant is entitled for a composite costs of compensation of Rs.10,000/- (Rupees Ten Thousand only). Payment of this amount be made within 30 days from the date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                       Member                     Member                                       President         

 

Announced in Open Commission.

Dated:02.08.2023.

Gobind Ram.