Chandigarh

DF-II

CC/850/2016

Satinder Kaur Walia - Complainant(s)

Versus

Max Bupa Health Insurance Company Limited - Opp.Party(s)

Rahul Prashar Adv. & Harsh Goyal Adv.

03 Oct 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	850 of 2016
Date  of  Institution	:	05.10.2016
Date   of   Decision	:	03.10.2017

 

 

 

 

1]  Satinder Kaur Walia wife of Mr.Daljit Singh Walia,

2]  Daljit Singh Walia son of Sh.Gurdarshan Singh Walia,

Both residents of H.No.814, RCS Enclave, Sector 49-A, Chandigarh.      

             …..Complainants

Versus

1]  Max Bupa Health Insurance Company Limited,  B-1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi 110044 through its Chief Executive Officer.

2]  Max Bupa Health Insurance Company Limited through its Manager, SCO No.55-56-57, Sector 8-C, Top Floor, Chandigarh

3]  Mohanjit Kaur, Agent Code CHB-0124743, resident of H.No.R-48, Residential Area, Mohali, Distt. Mohali.

                          ….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

                                SH.RAVINDER SINGH              MEMBER 

 

Argued by: Sh.Rahul Prashar, Adv. for complainant.

           Sh.Nitin Thetai, Adv. for OPs No.1 & 2.

 OP No.3 exparte.

  

 

PER RAVINDER SINGH, MEMBER

 

 

          The case of the complainants briefly is that they obtained one Insurance Policy bearing No.30395377 from OPs commencing from 11.2.2015 to 10.2.2016 for an amount of Rs.10.00 lacs and opted for the plan health companion and paid an amount of Rs.17,863/- as premium.  It is averred that as per the said policy, the complainants are entitled for cashless treatment at the empaneled hospitals of the OPs.  It is also averred that the complainant No.1 has suffered Menometrorrhagia and was diagnosed a simple Endo Metrial Hyperplasia without Atypio and was admitted at Max Health Care Super Specialty Hospital, Mohali on 5.2.2016 and was discharged after the treatment on 6.2.2016 (Ann.C-2).  It is submitted that the complainants submitted the claim form along with original bills to the Opposite Parties for reimbursement of the amount paid to the Hospital amounting to Rs.1,02,706/- (Ann.C-3 colly), but the same was repudiated by the Opposite Parties vide communication dated 12.5.2016 on the ground that as per the documents submitted and investigation done by them, it was found that insured has history of D and C in 2011 and 2014 and per the policy terms and conditions, this falls under material non-disclosure which is not disclosed during the policy inception (Ann.C-4).  However, the complainant No.2 sent an e-mail dated 12.5.2016 to the OPs clarifying that the treatment which took place on 2011 and 2014 were in fact, for preventing unwanted pregnancy and therefore, it cannot be taken as a material non-disclosure and further with regard to the same at the time of obtaining the insurance policy, they were not asked for the same (Ann.C-5). Alleging the said repudiation of claim as illegal, deficiency in service and unfair trade practice on the part of OPs, hence this complaint has been filed.

 

2]       The OPs No.1 & 2 have filed reply and while admitting the factual matrix of the case, the policy was issued to the complainants on the basis of portability application and proposal form for insurance dated 23.1.2015 signed by complainant No.2-Daljit Singh Walia and in the said application, the complainant No.2, in reply to Questions relating to Medical History of Complainants Q.No.(5), 1 to 4 answered in negative.  It is submitted that as per the documents submitted and investigations done by the OPs, it was found that the life insured/complainant No.1 had history of D&C in 2011 and 2014 and as per policy terms & conditions, this falls under material non-disclosure which is not disclosed in policy inception and hence, the claim has rightly been repudiated by the OPs.  Pleading no deficiency in service and denying rest of allegations, the OPs No.1 & 2 have prayed for dismissal of the complaint.

         Opposite Party No.3 did not turn up despite service of notice sent through regd. post on 20.10.2016, hence it was proceeded exparte vide order dated 2.12.2016.

 

3]       The complainant also filed rejoinder reiterating the contentions as raised in the complaint.

 

4]       Parties led evidence in support of their contentions.

 

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

 

6]       The claim of the complainant No.1 has been repudiated by the OPs No.1 & 2 merely on the ground that she had not disclosed about D & C treatment taken by her in the year 2011 & 2014 while obtaining the policy in question.

 

7]       The D & C treatment i.e. Dilation (or dilatation) and curettage (D&C) refers to the dilation (widening/opening) of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping (curettage). It is a therapeutic gynecological procedure as well as the most often used method of first trimester miscarriage or abortion.

 

8]       The D & C treatment is not any disease or sickness, but was done only for preventing unwanted pregnancy.  The reasons put forth by the OPs No.1 & 2 to defend their decision of repudiation of medical claim of the complainant No.1, on the face of it, is based on surmises, without any cogent medical or any other administrative hurdle.

 

9]       The complainant No.1 was hale and hearty at the time of obtaining the insurance policy on 11.2.2015 and there is undoubtedly nothing adverse to her present claim.  The OPs No.1 & 2 has erred in not considering the genuine claim of the complainant in right perspective, which amounts to unfair trade practices. 

 

10]      Keeping into consideration the peculiar facts & circumstances, the complaint is allowed with directions to the Opposite Parties No.1 & 2 to pay an amount of Rs.1,02,706/- to the complainant No.1, which she has incurred on her medical treatment at Max Health Care Super Specialty Hospital, Mohali from 5.2.2016 to 6.2.2016,  within a period of 30 days from the date of receipt of certified copy of this order.

         In case the OPs No.1 & 2 failed to comply with the order within the stipulated period, then they shall also be liable to pay compensatory cost of Rs.10,000/-.

 

11]      However, the complaint qua OP No.3 stands dismissed.    

 

         Certified copy of this order be communicated to the parties, free of charge. After compliance, file be consigned to record room.

Announced

3^rd October, 2017                                                           Sd/-

                                                                                               

                                                                   (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER