BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.59 of 2018
Date of Instt. 12.02.2018
Date of Decision:26.04.2022
Kunal Kapoor aged about 34 years son of Shri Ashok Kapoor resident of House Number 1236 A. Ajit Nagar, Nakodar Chowk, Jalandhar, Punjab.
..........Complainant
Versus
1. Max Bupa Health Insurance Company Limited, Block B-1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi- 110044.
2. Max Bupa Insurance Company Limited, G. T. Road, 1st Floor, 917/918 Namrita Complex 144001, Jalandhar, Punjab.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Paras Chadha, Adv. Counsel for the Complainant.
Sh. Gautam Kumar, Adv. Counsel for OPs No.1 & 2.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein he has alleged that the representative of the OPs approached him on phone call and explained features of insurance policy covering all critical illness. The insurance agent further induced him to obtain insurance policy from the OPs as its insurance premium will be exempted under the provisions of Income Tax Act. The agent claimed that insurance policy provides life insurance cover against terminal illness, critical illness, permanent disability etc on payment of Rs.1581/- towards yearly premium and the complainant preferred to avail critical illness insurance from the OPs. The complainant paid the yearly insurance premium of Rs.1581/- to the OPs through HDFC Credit Card of his brother. The OPs issued policy cover note bearing policy no.30530926201701 commencing from 24.05.2017 to 23.05.2018 and renewable on payment of further premium. The OPs assured to cover benefit of life and health of the complainant under the said insurance policy for the said period by paying lump-sum insurance claims. The OPs have not sent any terms and conditions of the said insurance policy to the complainant till date of filing of the present complaint. In the month of September, 2017 the complainant had chief complaints of abdominal fullness and deceased appetite. Consequently, the complainant avoided consumption of acidic food besides taking other precautions. On 24.09.2017 the complainant had gone to Ludhina in connection with his business affairs. At Ludhiana, the complainant suffered acute problems in abdomen and was rushed to DMC Hospital, Ludhiana for treatment and providing medical assistance. The doctor attended the complainant, who admitted in the hospital. Under medical supervision various tests including ECG etc. were carried out to, investigate the diseases of the complainant. Many tests like Hematology, Biochemistry, Viral Markers, Lipid Profile, Cardiac Enzymes etc. were carried out under consultations of Dr. Gurpreet Singh Wander, Dr. Diptiman Kaul and Dr. Abhishek Goyal etc. Dr. Rohit Tandon MD (Medicine) Consultant Non-Invasive Cardiology and Dr. Gurpreet S. Wander, DM (Cardiology Prof and Chief Cardiologist) diagnosed on the basis of above said tests and evaluated in echocardiograph report. The Doctors attending the complainant arrived on the conclusion that the complainant had suffered heart failure and many other diseases like Acute LVEF, CAD, Severe LV & RV Systolic Dysfunction, Mild Mitral Regurgitation and others. The complainant was discharged from the said hospital after treatment on 27.09.2017 on request of complainant. The doctors attending in the said hospital managed the complainant with antiplatelet, statins, diuretics, ARTs and other supportive measures. The complainant was discharged from the said hospital on 27.09.2017. Thereafter the complainant had started taking more precautions about his health issue specifically concerning heart. As per the insurance policy issued by the OPs, the complainant was entitled for lump-sum insurance amount of Rs.5,00,000/- as the complainant had suffered from the above said diseases. Thus, for availing the insurance policy benefits, the complainant lodged claim with the OPs. However, the OPs vide letter dated 29.11.2017 repudiated the insurance claim of the complainant under the false pretext that as per medical records the diseases suffered by the complainant were not covered under the critical illness benefit of the policy so no benefit of insurance claim is payable to the complainant. The OPs have wrongly interpreted the purported policy terms and diseases diagnosed by the Doctors in order to save their liability arising out of the insurance policy. Admittedly the OPs has not communicated any of the alleged policy terms to the complainant. The letter dated 29.11.2017 was wrongly issued by the OPs against the alleged insurance policy terms and conditions, which were never communicated to the complainant. The diseases of the complainant are covered under the critical illness and the OPs had wrongly concluded that the complainant has not suffered from the disease which is not covered under the critical illness. In view of the repudiation of the insurance claim, the complainant is suffering from financial losses and mental agony in view of the unfair trade practice and deficiency in service on the part of the OPs. The complainant is already heart patient and is now suffering mental agony from the hands of the OPs and as such necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay Rs.5,00,000/- with consequential payments with interest @ 18% per annum from 24.09.2017 onwards till actual date of realization of the amount to the complainant and compensation of Rs.2,00,000/- and Rs.44,000/- as cost of litigation.
2. Notice of the complaint was given to the OPs, who filed joint written reply and contested the complaint by taking preliminary objections that the complaint filed by the complaint is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead the Commission. It is further averred that the complainant has suppressed material facts from this Commission and as such, the complaint is liable to be dismissed. The OP company has acted strictly as per the policy terms and conditions and have acted within the four corners of the statutory provisions, no case of deficiency in service can be said to have arisen, and as such, the present complaint is not maintainable before this Commission. It is further averred that the present complaint is not maintainable. As per the terms of the policy contract if the policy is not suitable, the policy holder may get his/her policy reviewed by returning the policy and policy documents within 15 days from the day the policy holder received the policy. The insurance company will return the premium paid to the policy holder after making certain deductions specified therein. In the policy terms and conditions all these facts have been made clear to the complainant. Thus, same is not payable as per terms and conditions of the policy. It is further averred that this Commission has no jurisdiction to entertain the present complaint. The complainant has failed to demonstrate any deficiency in service on the part of the replying OP. The complaint has been filed with ulterior motive and malafide intention to cause harassment and prejudice to the OP, which is a company of high credibility and repute and to extract money from it without just cause or valid reason. On merits, the factum with regard to availing Critical Illness Insurance Policy from the OPs is admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. In order to prove his case, the complainant alonwith his counsel tendered into evidence his duly sworn affidavit Ex.CA alongwith some documents Ex.C-1 to Ex.C-7 and closed his evidence.
4. In order to rebut the evidence of the complainant, the counsel for the OPs tendered into evidence affidavit Ex.OP1/A alongwith some documents Ex.OP-1/1 to Ex.OP-1/7 and closed the evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file as well as written arguments submitted by counsel for both the parties, very minutely.
6. It is admitted and proved that the complainant purchased the critical illness insurance from the OP and paid Rs.1581/- through HDFC Credit Card. Ex.C-1 is the premium receipt which shows that on 24.05.2017 the complainant purchased the health insurance policy. Ex.C-2 proves and supports the payment of Rs.1581/- as a premium given to the OP. The insurance policy has been proved as Ex.C-3. The OP has also admitted that the subject policy was issued to the complainant on the basis of information received during the telephonic conversation. The complainant has alleged that on 24.09.2017 he suffered acute problems in abdomen and was rushed to DMC Hospital, Ludhiana for treatment and he was provided medical assistance there. Various tests including ECG etc. were carried out and he was admitted in the hospital on 24.09.2017 and was discharged on 27.09.2017 on the request of the complainant. The reports have been proved by the complainant as Ex.C-4 to Ex.C-6. The claim was filed, but the same was repudiated by the OPs on the ground that ‘as per medical records the diseases suffered by the complainant were not covered under the critical illness benefit of the policy so no benefit of insurance claim is payable to the complainant.’
7. All the facts of illness and admission of the complainant and treatment of the complainant have been proved. Now the point in controversy is as to whether the diseases suffered by the complainant come within the purview of critical illness or not.
8. The contention of the OPs is that as per the definition of First Heart Attack of Specified Severity and the Exclusion Clause in the Policy, the complainant is not entitled to the claim. The treatment undergone by the complainant does not fall into any of the criteria of first heart attack as relied upon by the OPs. The further contention of the OPs is that since the complainant’s disease does not fall within the purview of First Heart Attack of Specified Severity, therefore, there is no deficiency in service on the part of the OPs. The actions of the OPs are in good faith and strictly according to the terms and policy of the insurance.
9. After considering the arguments advanced by the complainant as well as the OPs and the case of the complainant, the point to be seen is what is the critical illness. Ex.C-5 is the ECG and as per the report of ECG Ex.C-6, there was an indication of Ac, LVF, Ischaemic cardiomyopathy. As per Ex.C-4, the Ischemic Cardiomyopathy, EF was found as 20%, Severe LV Dysfunction, Acute LVF, Mild MR, Mild AR, Mild PAH, LV Diastolic Dysfunction (Type-III) and as per the doctor, he was discharged on request on 27.09.2017 by DMC Hospital, Ludhiana. Ischemic Cardiomyopathy is a condition when heart muscle is weakened; as a result of a heart attack or coronary artery disease. In coronary artery disease, the arteries that supply blood to heart muscle become narrowed. Further Ischemic Cardiomyopathy is caused by a chronic lack of oxygen to the heart muscle because of coronary artery disease. Dilated cardiomyopathy is the most common type. The heart muscle stretches (dilates), becomes thinner and weaker, and doesn’t pump normally. This often leads to congestive heart failure. This disease/illness is dangerous to life and, as such, it certainly comes in the definition of Critical Illness. As per Ex.C-4, the complainant was having a complaint of abdominal fullness and decreased appetite since 2-3 days prior to admission. The treatment given by the doctor to the complainant was regarding the life threatening disease. The heart muscles of the complainant were weakened as a result of heart attack or coronary artery disease. The Hon’ble State Commission has declared the diseases of the complainant as critical illness/disease in a complaint filed by the present complainant against Bajaj Allianz General Insurance Co. regarding the same disease and the treatment got by him in the DMC Hospital, Ludhiana from 24.09.2017 to 27.09.2017. Therefore, the repudiation of claim on the ground of the disease being not critical illness, is deficiency in service committed by the OPs. The OPs have wrongly and unfairly repudiated the claim of the complainant vide Ex.C-7. Therefore, the repudiation letter is held to be wrong.
10. The contention of the complainant is that he was never served with the terms and conditions of the policy nor was explained about the exclusion clause of the policy rather it was told to the complainant that this policy covers the critical illness. The terms and conditions were never communicated to the complainant, whereas the contention of the OP is that the terms and conditions were explained and communicated to the complainant. It has been held by the Hon’ble Punjab & Haryana High Court in case titled as New India Insurance Co. Ltd. Vs. Usha Yadav & Ors. 2008 (3) RCR (Civil) 111, which is as under:-
“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.
The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.”
Thus, it was the duty of the OP to make the complainant aware of the terms and conditions of the policy by explaining in a manner which is easily understood by the complainant. The OP has not proved on record any document or any evidence to prove that the terms and conditions of the policy were explained to the complainant and after understanding and admitting the same to be correct, he had purchased the policy. It has also not been proved by the OP that the exclusion clause was also brought to the notice of the complainant and it has also not been proved that the complainant was explained about the critical illness, thus, it can easily be concluded that the complainant was not made aware of the terms and conditions.
11. The complainant has not filed the bills of the treatment taken by him from DMC Hospital, Ludhiana from 24.09.2017 to 27.09.2017 and has claimed the total amount of the sum assured i.e. Rs.5,00,000/-. This amount of the claim cannot be allowed to be given to the complainant as he has not filed on record any bills. Therefore, the amount claimed by the complainant cannot be granted.
12. In view of the above detailed discussion, the complaint of the complainant is partly allowed and the repudiation letter dated 29.11.2017 Ex.C-7 is set-aside being illegal and arbitrary. The OPs are directed to decide the claim of the complainant by taking into consideration the fact that the disease/illness for which he had taken the treatment from DMC Hospital, Ludhiana falls in the definition of ‘Critical Illness’ as defined in the Critical Insurance Policy purchased by the complainant from them and to pay the insurance claim to him accordingly. Further, OPs are directed to pay Rs.10,000/- as compensation on account of mental agony and harassment and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr.Harveen Bhardwaj
26.04.2022 Member Member President
