Chandigarh

DF-I

CC/391/2020

Amarjeet Singh - Complainant(s)

Versus

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

Adv. Devinder Kumar

09 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/391/2020
Date of Institution	:	21.09.2020
Date of Decision	:	09.01.2023

 

Amarjeet Singh son of Sh. Surinder Singh aged about 51 years H.No. 2121, Sector 38-C, Chandigarh.

… Complainant

V E R S U S

[1]  Max Bupa Health Insurance Company Limited, SCO No.55-56-57, 2^nd Floor, Sector 8-C, Madhya Marg, Chandigarh through its Branch Manager.

 

[2]  Max Bupa Health Insurance Company Limited, Corporate office: B-1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi-110044, through Managing Director.

   … Opposite Parties

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR	MEMBER
	SURESH KUMAR SARDANA	MEMBER

                        

ARGUED BY	:	Sh. Devinder Kumar, Adv. for complainant.
	:	Sh. Gaurav Bhardwaj, Adv. for OPs.

Per Suresh Kumar Sardana, Member

1.      Briefly stated, the Complainant took a Health Policy (Annexure C-1) from the OPs covering his father and daughter valid from 25.11.2016 to 24.11.2017 by paying premium amount of Rs.42728/-. The OPs issued the Policy after conducting proper medical tests. The Policy was again renewed by the complainant by paying premium of Rs.53,377/-  which was valid from 25.11.2017 to 24.11.2018. On 25.08.2018, the father of the complainant was hospitalized due to dehydration problem in Santokh Hospital, Sector 38-C, Chandigarh. Due information was given to the OPs with request of cashless facility, which was initially approved by the OPs vide letter dated 25.08.2018 (Annexure C-3). However, later on, vide letter dated 26.08.2018 (Annexure C-4), the OPs denied to provide the cashless facility on the ground of non-disclosure of material facts of HTN since 10 years. On receipt of letter dated 26.08.2018, Santokh hospital sent an email to the OPs that due to mistake they mentioned HTN 10 years instead of 10 months. However, the OPs sent letter (Annexure C-6) intimating the complainant for applying exclusion clauses of pre-existing disease in the policy in question. It has been averred that the complaint’s father thereafter, remained hospitalized in Max Hospital, Mohali and PGI, Chandigarh and the complainant spent a sum of Rs.6,81,142/- on the treatment of his father and sent all the medical bills to the OPs for reimbursement, but the OPs lingered on the claim of the complainant on one pretext or the other. Even the complainant sent e-mail dated 3.10.2018 to the agent of OPs that the in the discharge summary dated 26.08.2018, it was inadvertently mentioned as hypertension 10 years instead of 10 months and also sent e-mail of Santokh Hospital affirming the said fact, but the OPs vide letter dated 11.12.2018 (Annexure C-12) repudiated the claim of the complainant. Alleging the aforesaid act of OPs deficiency in service and unfair trade practice on their part, this complaint has been filed
2.      The Opposite Parties in their reply while admitting the factual matrix of the case has pleaded that they received a claim for the treatment of the father of the complainant for severe hypotension at Santokh Hospital, Max Hospital and PGIMER. As per investigation of the company and hospital records, it was found that the insured person was a known case of hypertension for the last 10 years and was taking tablet telsma and also under cholecystectomy 15 years backs i.e. much before the issuance of policy. Since the said ailments were prior to policy inception and was continuing; as such, the same came in the category of pre-existing condition and non-disclosure of facts and hence, the claim was not payable. Thus, the complaint is liable to dismissed for concealment of material facts at the time of taking the policy in question. All other allegations made in the complaint has been denied being wrong. It is prayed that the complaint be dismissed.
3.      Rejoinder was filed and averments made in the consumer complaint were reiterated
4.      Contesting parties led evidence by way of affidavits and documents.
5.      We have heard the learned counsel for the contesting parties and gone through the record of the case.
6.      The issuance of the policy, subsequent renewal thereof and lodging of the claim by the Complainant in respect of the treatment of his father Sh.Surinder Singh at Santokh Hospital, Max Hospital and PGIMER has not been disputed at all.
7.      The Complainant being aggrieved by the rejection of his claim by the OPs under the aforesaid Policy has preferred the present consumer Complaint. Per contra, OPs held their nerve admitting that they received the claim for the treatment of Sh.Surinder Singh and on investigation it transpired that he was a known case of Hypertension for the last 10 years i.e. much before the issuance of the Policy. As there was non-disclosure on the part of the Complainant about the aforesaid pre-existing disease, the claim was rejected being not payable.
8.      Learned Counsel for the Complainant argued that the history of hypertension was wrongly mentioned by one of the hospitals as 10 years instead of 10 months, which mistake they corrected subsequently vide Annexure C-5. As against it, the Learned Counsel for the Opposite Parties vociferously contended that the PGIMER, Chandigarh in the Discharge Summary has clearly mentioned that the Complainant had Hypertension/Post Chole Cystectomy Status 20 years back. However, we are not impressed with this contention raised by the OPs for the reason that the same does not carry much significance in view of the fact that prior to issuance of the policy in question, Opposite Parties conducted proper medical test, which fact has nowhere been refuted by the Opposite Parties either in their pleadings or during the course of arguments. To our mind, if on the consideration of the medical report(s), the insurance company gets satisfied about the medical condition of the proposer and that there was no risk of pre-existing illness, and on such satisfaction it issues the policy, it cannot thereafter, contend that there was a pre-existing illness or sickness which has led to the claim made by the insured and for that reason repudiate the claim.
9.      To cap it all, once the health insurance policy is issued to the insured after assessing his/her medical condition, no insurer can repudiate a claim by citing a pre-existing medical condition that was disclosed by the insured in the proposal form. The contention raised by the OPs in repudiating the claim of the Complainant is therefore, totally unsustainable against the established law as laid down by the Hon’ble Supreme Court as well as Hon’ble National Consumer Disputes Redressal Commission in various judgments.
10.      At any rate, hypertension is not a material disease and is manageable by medication/ medication, change of life style etc. and as such, cannot be a ground for rejection of the genuine claims. In this backdrop, the OPs (Insurance Company) were not right in repudiating the policy in question. Though the Complainant in the prayer clause of the Complaint sought indemnification of Rs.6,81,142/- under the Policy, but a mere perusal of the claim statement reveals that the claim of the Complainant was of only Rs.6,31,135/-. The Complainant is thus held entitled to be indemnified in the sum of Rs.6,31,135/- under the policy.  Had, the OPs been vigilant in processing the claim of the Complainant in right earnest, complainant would not have been put to unnecessary harassment and mental tension, who otherwise had to knock at the door of this Commission for seeking redressal by spending money on litigation. In this backdrop, we are of the considered view that the ends of justice would be met if the complainant is awarded a sum of Rs.50,000/- on account of compensation for mental agony and physical harassment and Rs.25,000/- as litigation expenses.
11.      In the wake of above, it is established beyond all reasonable doubts that the complaint of the Complainant is genuine. The harassment suffered by the Complainant is also writ large. Thus, we have no other alternative, but to allow the present complaint against the OPs.
12.      For the reasons recorded above, the present complaint of the Complainant deserves to succeed against the OPs, and the same is partly allowed. The OPs are, jointly and severally, directed:-

[a]  To pay a sum of Rs.6,31,135/- to the Complainant being treatment charges along with interest @ 9% p.a. from the date of repudiation till its realization;

[b]  To pay Rs.50,000/- as compensation to the complainant for deficiency in service, unfair trade practice and for causing harassment caused to him.

[c]  To pay a sum of Rs.25,000/- to the complainant as litigation expenses. 

13.      The above said order shall be complied within 30 days of its receipt by the OPs; thereafter, they shall be liable for an interest @12% per annum on the amount mentioned in sub-para [a] above from the date of repudiation, till it is paid. The compensation amount as per sub-para [b] above, shall carry interest @12% per annum from the date of institution of this complaint, till it is paid, apart from compliance of directions contained in sub-para [c] above.
14.      Certified copies of this order are sent to the parties free of charge. The file be consigned.

Announced

09 January, 2023                       

                                                            Sd/-

(PAWANJIT SINGH)

PRESIDENT

 

 

Sd/-

(SURJEET KAUR)

       MEMBER

 

Sd/-

 

 (SURESH KUMAR SARDANA)

       MEMBER