Order-20.
Date-30/03/2017.
Smt. Sangita Paul, Member.
This is an application u/s.12 of the C.P. Act, 1986.
The case of the complainant in short is that complainant took a mediclaim policy from Max Bupa Health Insurance Co., Kolkata Branch being No.30142415201402. Sum insured was Rs.4,00,0000/- for the period from 22/10/2014 to 21/10/2015. The name of the policy was Family First Gold for which complainant paid Rs.82,482/- as premium. Complainant’s wife was admitted to Belle Vue Clinic on 19/01/2015. She was suffering from high fever followed by cough and loose motion. Complainant’s wife was admitted there up to 25/01/2015. She was also transferred to ICU. On 26/01/2015 his wife was shifted to Medica Super Specialty Hospital. Complainant placed a bill of his wifeamounting to Rs.1,99,337/- of hospitalization expenses. Complainant wrote a letter on 21/04/2015 seeking status report of the claim. On 22/04/2015 O.P.-2 i.e. Regional Manager, Max Bupa Health Insurance Co. informed that complainant’s claim has been repudiated showing that the patient is a K/C/OHTN urticarial and depression for six years and treated for liver abscess in January,2012 which was suppressed at the time of inception of policy. She was admitted to hospital for liver abscess in January,2011. Medica Hospital has allowed the claim of Rs.2,71,503/- whereas Max Bupa Health Insurance Co. disallowed the claim. O.P.-2 informed that the patient is a known case of hypertension, urticarial depression and liver abscess. In October,2012, when the policy was first taken, no medical history was sought by Max Bupa for ascertaining current health status before issuing the insurance policy.
In response to the letter dated 07/05/2015 of complainant, O.P.-2 replied on 08/05/2015 that request for consideration the claim has been forwarded to the concerned department for review, but till now no correspondence has been made by O.P.-2. In this case complainant has continuous coverage and the policy exceeds 24 months from inception of the first policy i.e. October,2012. Complainant submitted medical claim after expiry of 27 months. Complainant submitted medical bills as per terms and conditions of the policy.
Complainant prays for allowing the medical claim bill amounting to Rs.1,99,337/- along with litigation cost of Rs.50,000/- and compensation of Rs.50,000/- for mental agony.
In the written version O.ps. state that the said complaint has been has been filed with oblique motive in order to extract money from the O.Ps. The complaint is baseless, vague and devoid of merit. Complainant, at the time of inception of the policy did not mention any pre-existing disease. So the policy was issued to complainant. The policy was also renewed from time to time. One of the terms of the policy was that at the time of entering into the policy, the insured must disclose the previous ailments which he or she might suffer or has suffered. For non-disclosure of such information entails rejection of such insurance claim as also specified in the terms of policy. It is to be mentioned that the patient did not avail of cashless facility for the treatment of Belle Vue Clinic. But afterwards she submitted a claim for treatment at Belle Vue Clinic and the claim of complainant was rejected. So there has been no deficiency in service on the part of the O.Ps. From Belle Vue Clinic she was admitted to Medica Super Specialty Hospital where an expense of Rs.2,71,603/- was incurred and Max Bupa Allowed the claim.
It is denied and disputed that complainant responded to the letter dated 04/05/2015. It is also denied that the medical practitioner contacted complainant during verification of the claim. No medical history was sought at the time of inception of the policy. Max Bupa is considering the claims highly, there is no chance of error. The claim is rejected as complainant is not entitled to the claim. All the statements of complainant are untrue, incorrect, baseless and devoid of merit. So the complaint should be dismissed.
Decision with Reasons
Upon travelling over documents on record i.e. complaint petition, written version, evidence in chief and other documents, it is revealed that complainant took the mediclaim policy viz. Family First Gold from Max Bupa Health Insurance Policy, Kolkata, being No.30142415201402. It was a family health insurance policy. Complainant took the policy for himself, his wife, his son, his daughter and his daughter in law. Sum insured was Rs.4,00,0000/- for the period from 22/10/2014 to 21/10/2015. Complainant paid Rs.82,482/- as premium and he has been paying the premium since October,2012. Complainant’s wife was admitted to Belle Vue Clinic on 19/01/2015 for fever, cough and loose motion. She was admitted to Nursing Home up to 25/01/2015. As her condition was growing serious ,she was also admitted to ICU. The hospital authority raised a bill of Rs.1,99,337/-. The complainant submitted the claim to the insurance company. On 04/05/2015 the patient’s claim was repudiated on the ground that she had hypertension and depression for six years and also treated for liver abscess but in Max Bupa Gold Mediclaim policy the patient is entitled to claim after 24 months of the inception of the policy. We find that Complainant in fact took the policy in the year October,2012 and renewed since thereafter and the disease occurred after 27 months of inception of the policy. In reply complainant stated that he provided all the relevant documents at the time of taking the policy. Without any cogent ground of preexisting disease the O.Ps. have repudiated the legitimate claim. Complainant has submitted genuine medical supporting documents, claiming legitimate medical bill because hospitalization expenses amounting Rs.2,71,503/- of the same patient was allowed by Medica super specialty hospital, where wife of complainant was admitted from Belle Vue Clinic. On 8th May,2015 the insurance company informed complainant that they are reconsidering the bill but at last they repudiated the claim. Earlier disease of complainant has no connection with this disease. She was admitted to Belle Vue Clinic for fever. That it is the deficiency of service on the part of the O.Ps. not to allow the medical bill of complainant. The O.Ps. rejected the bill on frivolous ground. These activities amount to unfair trade practice. So complainant is entitled to get the claim and compensation as well.
In result, the case succeeds.
Hence,
Ordered
That the instant case be and the same is allowed on contest against the O.ps. with cost of Rs.10,000/-.
O.Ps. are jointly and severally directed to reimburse the medical expenses of Rs.1,99,337/- within one month from the date of this order.
O.Ps. are jointly and severally directed to pay an amount of Rs.10,000/- as compensation for causing harassment to complainant within the stipulated period.
Failure to comply with the order will entitle the complainant to put the order into execution u/s.25 read with Section 27 of the C.P. Act and in that case OP shall be liable to pay penal damage at the rate ofRs.5,000/- per month to be paid to this Forum till full and final satisfaction of the decree.
