Chandigarh

DF-II

CC/185/2019

Rajender Sharma - Complainant(s)

Versus

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

Adv. A.K. Bakshi

22 Jun 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	185 of 2019
Date  of  Institution	:	29.03.2019
Date   of   Decision	:	22.06.2020

 

 

 

 

 

Rajender Sharma, H.No.568-C, sector 46-A, Chandigarh.

             …..Complainant

 

Versus

 

1]  Max Bupa Health Insurance Co. Ltd., B-1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi 110044, through its Managing Director

 

2]  Max Bupa Health Insurance Co. Ltd., SCO 55-57, Madhya Marg, sector 8-C, Chandigarh, through its Branch Manager.

 

    ….. Opposite Parties

 

 

BEFORE:  SH.RAJAN DEWAN              PRESIDENT

         SMT.PRITI MALHOTRA             MEMBER 

                    SH.B.M.SHARMA                      MEMBER

                               

For Complainant      :    Sh.A.K.Bakshi, Advocate

For OP(s)            :    Sh.Gaurav Bhardwaj, Advocate

 

 

PER PRITI MALHOTRA, MEMBER

          Briefly stated, the complainant obtained one family floater mediclaim policy initially from M/s Royal Sundaram Alliance Insurance Co. Ltd. on 29.3.2014 and ported out the said policy with OPs-Max Bupa Health Insurance Co. Ltd. on 10.3.2018.  Accordingly, the OPs issued policy document effective from 29.3.2018 to 28.3.2019 (Ann.C-1).  It is stated that the wife of the complainant Mrs.Anjana Sharma developed Post Sub Capsular Cataract in left eye in Dec., 2018 and was advised Cataract surgery with IOL Implant Left Eye (Ann.C-2).  Thereafter, the complainant’s wife got her eye operated at Grewal Eye Institute on 3.1.2019, as advised and was discharged on the same day in evening (Ann.C-3). It is also stated that at the time of admission in hospital, the hospital authorities sent the case to TPA of the OPs and the OPs conveyed initial approval of Rs.27,000/- to the Hospital, but at the time of final settlement of bill, the OPs refused to pay any claim.  As such, the complainant has to pay the bill of the hospital amounting to Rs.52,826/- (Ann.C-4 to C-7).  Thereafter, the complainant lodged claim with the OPs for reimbursement of said medical expenses, but the same was rejected by them vide letter dated 5.2.2019 on the ground that he did not disclose at the time of taking policy that his wife had blurred vision since 2017, hearing loss since 2016 and thyroid problem since 2014, which amounts to non-disclosure. Alleging the said repudiation as illegal and a deficient act, hence this complaint has been filed.

 

2]       The OPs have filed joint reply and while admitting the factual matrix of the case, stated that the proposer at the time of submitting the proposal form, did not disclose the correct information about health of his wife Anjana Sharma and as per the submitted documents/investigation done by the company, it was found that the insured was suffering from Blurring Vision since March, 2017, hearing Loss since 2016 and thyroid Problem since 2014 and the same was not disclosed at the time of policy portability with Max Bupa, hence the claim was not payable.  It is submitted that the repudiation of the claim under the subject policy was on the grounds of misstatement of information, suppression of material information and furnishing of false information in the Proposal Form and has not provided details of her existing medical problems. Denying all other allegations and pleading no deficiency in service, the OPs have prayed for dismissal of the complaint.

 

3]       Parties led evidence in support of their contentions.

 

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

 

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

 

6]       It is undisputed that the complainant’s medi-claim policy initially obtained from M/s Royal Sundaram Alliance Insurance Company in March, 2014 was ported out with OPs-Max Bupa Health Insurance Company in March, 2018 and it was effective from 29.3.2018 to 28.3.2019, which proves that the complainant & his family members, as mentioned in policy, remained duly covered under the said health insurance policies since March, 2014 to March, 2019, without any gap. It is also not in dispute that the complainant’s wife namely Anjana (insured), was treated for Cataract Surgery of her left eye during the currency of health insurance policy coverage period from 29.3.2018 to 28.3.2019 and incurred expenses thereupon. 

 

7]       The claim lodged with the OPs, after initial approval, was later rejected at the time of final settlement of bill, by the OPs vide communication dated 5.2.2019 (Ann.C-10) besides on the ground of alleged requirement of specific waiting period, also on the ground of non-disclosure of true facts about pre-existing disease at the time of availing the policy.

 

8]       After having meticulously gone through the documents placed on record and giving due consideration to the repudiation letter of the OPs, it has been observed that the genuine claim of the complainant has been rejected by taking very hyper technical opinion by the officials of the OP Insurance company.

 

9]       It is a well settled preposition of law that the waiting period shall not however apply in the case of the insured person/s having been covered under any individual health insurance scheme with any of the Indian General/Health Insurer for a continuous period of preceding 24 months without any break.

 

         As per Key Feature Document of the policy in question, as mentioned on Page 41 (Ann.R-2), it is stipulated as under:-

“Portability Benefits: Waiver of waiting period(s) is provided to the extent of period and sum insured already covered continuously and without a break with any previous Indian retail health insurance policy as Insured, based on portability guidelines. 

 

         However, the OPs despite of the above, still took one of the ground as ‘senile cataract is a specific waiting period exclusion under the member benefit’ for rejecting the claim of the complainant, which is wrong and unjustified.

 

10]      As regards pre-existing disease, an another ground taken by OPs for rejecting the claim, it is opined that even for the sake of argument if we believe that the complainant was suffering from any pre-existing disease at the time of taking treatment in question in the year 2019, even then her case is covered under the policy, being much beyond the waiting period of 36 months under Variant 2 & 3 of pre-existing disease and she is fully entitled for the claim.  

 

11]      In our opinion, the complainant shall not be deprived of his right recoursing to the technical view taken by the OP Company.  The OPs cannot escape from their liability to pay the genuine claim to the complainant.  Admittedly, the complainant & his wife remained covered under M/s Royal Sundaram Alliance Insurance Company Limited since 2014 till he shifted to OP Company and that too without any gap of single day.  Thus, the complainant is duly entitled for the continuation benefit and his case has wrongly been processed by the OP Insurance Company.

 

12]      From the above discussion and findings, we are of the opinion that the OPs have wrongly rejected the genuine claim of the complainant and thereby rendered deficient services. Therefore, the present complaint is allowed with directions to the Opposite Parties to reimburse an amount of Rs.50,800/- (Ann.C-4 to C-6) to the complainant.  The OPs are also directed to pay compensation amount of Rs.5000/- to the complainant for causing mental agony, harassment, along with litigation cost of Rs.5000/-.

         This order shall be complied with by the OP within a period of 30 days from the date of receipt of copy of this order, failing which they shall also be liable to pay additional cost of Rs.10,000/-apart from above relief.

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

Announced

22^nd June, 2020                                                                                                                                                                      sd/-

(RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

 

Sd/-

(B.M.SHARMA)

MEMBER