Punjab

Ludhiana

CC/21/20

Parveen Rani - Complainant(s)

Versus

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

Gaganpreet Singh

01 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 20 dated 11.01.2021.                                                Date of decision: 01.07.2024. 

Parveen Rani W/o. Sh. Ravinder Kumar, R/o. H. No.1056, Phase-I, Dugri, Urban Estate, Ludhiana through her authorized person/husband Sh. Ravinder Kumar.

                                                                                      ..…Complainant

                                                Versus

1. Max Bupa Health Insurance Company Ltd., having its Corporate Office at D-1, 2^nd Floor, Saleon Ras Vilas, District Centre, Sabet, New Dellhi-110017.
2. Max Bupa Health Insurance Company Ltd., having its registered office at Max House 1, Dr. Jha Marg, Okhla, New Delhi-110020.
3. Max Bupa Health Insurance Company Ltd., having its branch office at Plot No.88, 2n Floor, Kunal Tower, Mall Road, Opposite Axis Bank, Ludhiana-141001.                                                                                                                                              …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Gaganpreet Singh, Advocate.

For OPs                          :         Sh. Varun Gupta, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that Ravinder Kumar, husband of the complainant is holder of Cashless Medical Policy with the OPs for himself and the complainant vide policy No.30080043201907 w.e.f. 25.02.2019 to 24.02.2020. Ravinder Singh had been getting the policy renewed every year since 2010. On 26.12.2019, the complainant was admitted in Dayanand Medical College and Hospital, Ludhiana due to hypertension with Morbid Obesity. Husband of the complainant filed claim for reimbursement of her medical expenses vide claim intimation No.278564 by submitting all the necessary documents with the OPs and also submitted all the bills of Rs.2,52,156/- along with reports. But the OPs vide letter dated 14.01.2020 illegally rejected the claim of the complainant on the ground due to gross non-disclosure of material facts – urethroplasty in 2013. However, the complainant never suffered from any such disease in the year 2013. According to the complainant, the OPs have falsely rejected her legal claim due to which she suffered mental stress. The act of the OPs amounts to deficiency in service and unfair trade practice. The complainant approached the OPs but they prolonged the mater on one pretext or the other. The complainant also sent a legal notice dated 28.09.2020 posted on 30.09.2020 upon the OPs through her counsel. Reply to notice was received by the complainant  vide which the OPs replied that her service quest No.5225981 is in process and they are working on it and will update her. Even the complainant received E-mail that the service request number has been resolved. Thereafter, the complainant visited the office of OPs and submitted all the required documents but this time again the OPs started dilly delaying the matter on one pretext or the other and later on refused to pay the claim amount. The complainant has suffered agony, tension and physical harassment due to deficiency in service and unfair trade practice on the part of the OPs. In the end, the complainant has prayed for issuing directions to the OPs to reimburse the claim amount of Rs.2,52,156/- along with compensation of Rs.50,000/- and litigation expenses of Rs.22,000/-.

2.                Upon notice, the OPs appeared and filed written statement and assailed the complaint by taking preliminary objections on the ground of maintainability; lack of jurisdiction and cause of action; suppression of material facts and also took the plea of estopple. The OPs stated that the complainant has not provided the requisite documents as necessary for proceed the realization of the claim amount till time. As such, the claim is still pending and the OPs are ready to pay the entire claim amount as per policy terms and conditions and this fact also disclosed to her through reply of legal notice sent by the complainant.

                   In the column Brief Facts, the OPs stated that it received a duly filled and signed proposal form from Ravinder Kumar, husband of the complainant for issuance of insurance policy for himself and his spouse i.e. the complainant. Believing the information and details of the proposer including his medical history in the form, the OPs issued the policy. The policy documents  along with policy kit and relevant documents including terms and conditions were delivered to the proposer. The OPs further stated that they received a claim from the hospital for cashless treatment as the complainant was admitted on 26.12.2019 at DMC & Hospital, Ludhiana. A cashless facility was applied by the complainant through hospital authorities, which was initially approved but after independent investigation also done and various documents received and found that the insured concealed so many facts about their health at the time of purchasing the policy. As such, the claim of the complainant was rejected under the policy as per terms and conditions of the policy. The OPs further stated that they received the reimbursement claim from the complainant which was rejected under the policy terms and conditions with remarks that the insured has been suffering from History of Tubal ligation, tubectomy 20 years, LL surgery (Domestic fall) 15 years, urethroplasty 2013, which was not disclosed at the time of taking policy and the claim was repudiated as per clause 12.20.

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

3.                In evidence, the complainant tendered her affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 is the copy of Authority Letter, Ex. C2 is the copy of Cashless Denial Letter dated 14.01.2020, Ex. C3 is the copy of repudiation letter dated 17.02.2020, Ex. C4 is the copy of E-mail dated 14.02.2020, Ex. C5 to Ex. C7, Ex. C16, Ex. C17, Ex. C19 are the test reports, Ex. C8 is the copy of radio diagnosis report dated 01.01.2020, Ex. C9 is the copy of radio diagnosis and imaging report dated 26.12.2019, Ex. C10 is the copy of Proposal Form dated 15.02.2012, Ex. C11 is the copy of certificate dated 04.02.2020 issued by doctors of DMC Hospital, Ludhiana, Ex. C12 is the copy of  detail bill dated 15.01.2020, Ex. C13 is the copy of In-Patient Final Bill dated 15.01.2020 and discharge summary, Ex. C14 and Ex. C15 are the copies of E-mails, Ex. C18 is the copy of Investigation Flowsheet, Ex. C20 is the copy of legal notice dated 28.09.2020, Ex. C21 to Ex. C23 are the postal receipts and closed the evidence.

4.                On the other hand, the counsel for the OPs tendered affidavit  Ex. RW1 of Ms. Manisha Rani, Authorized Signatory of the OPs along with documents Ex. R1 is the copy of  reply dated 15.10.2020 to legal notice 28.09.2020 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 statement along with affidavit and documents produced on record by both the parties.

6.                Undisputably, the complainant remained hospitalized in DMC, Ludhiana from 26.12.2019 to 15.01.2020 and she was diagnosed having Hypertension, Morbid Obesity, Post-Tah with BSO (For Uterine Fibroid), Paralytic Ileus, Severe Anemia, Diastolic Heart Failure Type 2. Her pre-authorization cashless treatment was declined vide Cashless Denial Letter dated 14.01.2020 Ex. C2. However, she submitted the reimbursement for an amount of Rs.2,51,156/-  with the opposite parties. The OPs also declined the claim of the complainant vide repudiation letter dated 17.02.2020 Ex. C3, the operative part of which is reproduced as under:-

“Non-disclosure-nondisclosure- As per received medical documents & investigation done by us it was found insured has been suffering from History of Tubal ligation, tubectomy 20 years, LL surgery (Domestic fall) 15 years, urethroplasty 2013 since which has been not disclosed to us at inception of policy which is suppression of material information so claim is repudiated as per clause 12.20.”

 

However, the OPs in their written statement  in para No.2 of the preliminary objections stated that the complainant has not provided the requisite documents as necessary for proceed the realization of the claim amount till time to them. Hence the claim is still pending and they are ready to pay entire claim amount as per policy terms and conditions. Even vide their reply dated 15.10.2020 Ex. R1 to the legal notice dated 28.09.2020 Ex. C20 issued by the complainant, the OPs demanded certain documents from the complainant for reimbursement of her claim. The operative part of Ex. R1 is reproduced as under:-

“Without delving into the merits of the matter Max Bupa Health Insurance co. Ltd. (hereinafter referred to as, “the Company”) as a goodwill gesture wishes to propose settlement of the dispute by making payment of Rs.2,49,584/- with the deduction of non-payable amount (Admission charges 1550, Gluco meter 522, Diet 500) to your client subject to her withdrawing the instant notice forthwith and further furnishing a declaration that all/any claim related to claim id 505179 is satisfied and no further litigation would be instituted by her pertaining to the subject claim id.

1. You are requested to advise your client to provide her consent along with (i) a declaration that this settlement has been entered with free will without any coercion or duress from any corner whatsoever in addition to her (ii) bank details, (iii) copy of cancelled cheque and (iv) KYC (Aadhar/Pan Card copy) and (v) one recent passport size photo)”

However, the complainant instead of completing the formalities required by the OPs vide reply Ex. R1, preferred this complaint. The insurance companies are required to be more liberal in their approach without being too technical while settling the genuine claims.

7.                In this regard, reference can be made to 2022(2) Apex Court Judgment 281 (SC) in case title Gurmel Singh Vs Branch Manager National Insurance Company Ltd. whereby it has been held by the Hon’ble Supreme Court of India that the insurance company has become too technical while settling the claim and has acted arbitrarily. The appellant has been asked to furnish the documents which were beyond the control of the appellant to    procure and furnish. Once, there was a valid insurance on payment of huge sum by way of premium and the Truck was stolen, the insurance company ought not to have become too technical and ought not to have refused to settle the claim on non­submission of the duplicate certified copy of certificate of registration, which the appellant could not produce due to the circumstances beyond his control. In many cases, it is found that the insurance companies are refusing the claim on flimsy grounds and/or technical grounds. While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control. In the given set of circumstances, it would be just and appropriate if the complainant is directed to submit the above said documents as per reply dated15.10.2020 Ex. R1 with the  opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties shall consider and reimburse claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant. 

8.                As a result of above discussion, the complaint is partly allowed with an order that the complainant is directed to submit the documents as per reply dated15.10.2020 Ex. R1 to the opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties shall consider and reimburse the claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant, failing which the complainant shall be held entitled to interest @8% per annum on the settled amount from the date of order till its actual payment.  However, there shall be no order as to costs. Copies of the order be supplied to the 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)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:01.07.2024.

Gobind Ram.