Punjab

Ludhiana

CC/20/104

Rajat Sood - Complainant(s)

Versus

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

Dalip Batish

14 Oct 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 104 dated 15.07.2020.                                                        Date of decision: 14.10.2022.

 

Rajat Sood aged about 47 years Son of Sh. Davinder Singh Sood, R/o. 429, Govt. College Road, Civil Lines, Ludhiana.

Office Address:

M/s. Geeta Enterprises, C-3-4, Industrial Area-A Extension, NR York Export, Ludhiana.

                                                                                      ..…Complainant 

•  

Max Bupa Health Insurance Company Ltd., Corporate Office at Block B1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi-110044, registered office at Max House 1, Dr. Jha Marg, Okhla, New Delhi-110020, through its Director/Managing Director/Authorized Representative.                                                                                                      …..Opposite party 

Complaint under Section 12 of the Consumer Protection Act,      1986.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Complainant Sh. Rajat Sood in person.

For OPs                          :         Sh. Varun Gupta, Advocate.

 

ORDER

PER K.K. KAREER, PRESIDENT

 

1.                In brief, the case of the complainant is that he had subscribed to a health insurance policy of United India Insurance Company Limited in the year 2010 which was renewed from time to time and as per the said policy, the complainant was entitled to reimbursement in respect of all diseases after a mandatory period of three years. The said policy was ported with the OP and the OP issued policy bearing No.30107835201900 which was valid from 09.09.2019 to 08.09.2020. The entire family of the complainant was covered under the policy.

2.                It is further alleged that in the month of December 2019, the complainant suffered gall stone in gallbladder for which he was hospitalized with S.G.L. Super Sepciality Hospital, Garha Road, Jalandhar from 20.12.2019 to 23.12.2019. The complainant obtained medical approval of Rs.38,000/- from the OP on 17.12.2019. Thereafter, all the documents were submitted with the OP regarding the claim but the claim was rejected on the ground of pre-existing diseases and non-disclosure of the fact that the complainant has been suffering from hypertension for the last nine years. As a matter of fact, the complainant never suffered from any such disease. Therefore, the question of non-disclosure does not arise. The complainant has not taken any medicine for hypertension. The complainant spent an amount of Rs.14,876/- on his treatment. Non-payment of the claim amounts to deficiency of service on the part of the OP. In the end, it has been requested that the OP be directed to reimburse the claim of Rs.14,876/- along with interest @24% per annum and further the OP be made to pay compensation of Rs.1,00,000/-.

3.                The complaint has been resisted by the OP. In the written statement filed by the OP, it has been, inter alia, pleaded that the complaint is not maintainable. According to the OP, the policy was issued on 09.09.2019. On investigation, it was found that the complainant concealed that he was suffering from hypertension and was on regular medicine for the last nine years. Had the complainant disclosed the correct facts to the OP, the policy would not have been issued to him. It has been pleaded that even at the time of porting the policy, as per the IRDA circular dated 09.09.2011, the policy holder is bound to disclose the true and complete facts about his/her self health conditions. According to the OP, the policy was cancelled on 27.01.2020 after serving a notice of cancellation upon the complainant. According to the OP, after the receipt of entire documents from the concerned hospital, it was found that the complainant was suffering from hypertension for the last nine years and as a result, the policy was cancelled. The other allegations made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

4.                The complainant filed rejoinder reiterating the submissions made in the complaint and controverting those made in the written statement.

5.                In evidence, the complainant tendered his affidavit Ex. CA along with documents Ex. C1 to Ex. C24 and closed the evidence.

6.                The OP did not formally tender any evidence. However, affidavit of Sh. Bhuwan Bhasker, authorized signatory of OP along with documents Ex. OP1/A to Ex.OP1/7 are on the file.

7.                We have heard the arguments advanced by the counsel for the parties and have also gone through the record.

8.                It is evident from the discharge summary Ex. C19 that the complainant was admitted in the hospital on 20.12.2019 and was discharged on 23.12.2019. As per the discharge summary, the complainant was diagnosed with acute chronic calculus cholecystitis and was also mentioned to have been suffering from hypertension. As per the discharge summary Ex. C19, the complainant underwent cholecystectomy i.e. removal of stone in the gall bladder. Apparently, the disease of cholecystectomy has no nexus with the disease of hypertension. Moreover, it is not disputed that initially the policy was obtained by the complainant from the year 2010. The fact that the policy was ported from United India Insurance Company Limited is not disputed by the OP in para No.2 of the written statement. Therefore, even if the complainant was suffering from hypertension which has no nexus with the disease of cholecystectomy, the repudiation of the claim on the ground of non-disclosure of hypertension cannot be said to be justified. In the given circumstances, in our considered view, it would be just and proper if the OP is directed to consider and reimburse the claim in respect of hospitalization of the complainant from 20.12.2019 to 23.12.2019 for cholecystectomy strictly in accordance with the terms and conditions of the policy along with composite cost and compensation of Rs.7,000/-.

9.                As a result of above discussion, the complaint is allowed with direction to the OP to consider and reimburse the claim in respect of hospitalization of the complainant from 20.12.2019 to 23.12.2019 for cholecystectomy in accordance with the terms and conditions of the policy within 30 days from the date of receipt of copy of the order. The OP shall further pay a composite cost of Rs.7,000/- (Rupees Seven Thousand only) to the complainant 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.

10.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:14.10.2022.

Gobind Ram.

Rajat Sood Vs Max Bupa Health Insurance                              CC/20/104

Present:       Complainant Sh. Rajat Sood in person.

                   Sh. Varun Gutpa, Advocate for OP.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is allowed with direction to the OP to consider and reimburse the claim in respect of hospitalization of the complainant from 20.12.2019 to 23.12.2019 for cholecystectomy in accordance with the terms and conditions of the policy within 30 days from the date of receipt of copy of the order. The OP shall further pay a composite cost of Rs.7,000/- (Rupees Seven Thousand only) to the complainant 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.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:14.10.2022.

Gobind Ram.