Chandigarh

DF-II

CC/65/2016

Anil Kumar Manaktala - Complainant(s)

Versus

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

Aksh Chetal Adv.

17 Jan 2017

ORDER

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

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Consumer Complaint  No	:	65 of 2016
Date  of  Institution	:	28.1.2016
Date   of   Decision	:	17.1.2017

 

 

 

 

 

Anil Kumar Manaktala s/o late Sh. Chuni Lal, R/o #3036, Phase 7, Sector 61 SAS Nagar, Mohali.  

                …..Complainant

Versus

 

1.  Max Bupa Health Insurance Company Ltd. SCO 36-38, Sector 8-C Madhya Marg, Chandigarh 1600009 through its Branch Manager.
2. Max Bupa Health Insurance Company Ltd. B-1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi 110044 through its Chief Executive Officer. 

 

….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

         SH. RAVINDER SINGH             MEMBER

 

 

For complainant(s)      :     Sh. Akash Chatel, Adv. and complainant                in person.

 

For OPs                 :     Sh. Gaurav Bhardwaj, Adv.

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          As per the case, the complainant subscribed for ‘Heartbeat Health Silver Plan’ Insurance Policy for cover amount of INR3.00 lacs covering himself and his wife against the premium amount of Rs.32701/- paid to the OPs. According to the complainant the complainant expressly informed the agent about his 7 years medical history and the agent assured the complainant that as he had not suffered any major disease in the last 3 years so he is eligible for the cover of the above policy. It is averred that the medical examiner of the OP also conducted the medical examination of the complainant and his wife and  as per their report the complainant and her wife were assessed for normal health. It is alleged that the said medical examiner got signed some blank forms stating that all the columns to be filed by him on the basis of medical examination reports, as the reports were awaited

      It is averred that the complainant received the original policy document in May, 2014 wherein cover note was in the name of the complainant but the documents comprised in were in the name of some other person namely Pornima Manohar Gaji and the policy no. was also different.  The complainant took the issue with the OP  who assured the receipt of correct health cards reflecting the name of the complainant & his wife.  On 19^th October, 2014 the complainant suffered a mild brain stroke and was under medical treatment first at PGI and then at Fortis Hospital Gurgaon. After getting discharge the complainant filed his claim of Rs.52,781/- on 20.11.2014 but the OPs lingered on the matter on one pretext or the other.  Thereafter the OPs again sent policy papers to the complainant after filing of the claim which were received by the complainant in January, 2015, the policy documents were stamped as ‘Duplicate’ but the information in that said policy was absolutely different from the first policy documents received by the complainant showing that the complainant will be eligible for the claim subject to 24 months of waiting period and after the commencement of the third policy year as long as the complainant has to be insured continuously under the policy without any break. It is also showing that the complainant’s wife was suffering from disorder of Lipoprotein Metabolism and other lipidaemias mentioned as pre-existing condition though she is absolutely fine. The complainant again on 30.1.2015 received policy documents for the third time from the OPs, which shows complete negligence in service as they sent three times the policy documents with the different variation in the facts.   It is alleged that the OPs also arbitrarily refused the genuine claim of the complainant.. Alleging the said act of OPs as deficiency in service, this compliant has been filed.

 

2. The Opposite parties in their joint reply stated that the complainant did not disclose the factum of his medical history in the policy proposal form. Therefore, assuming that the proposer is a healthy person and risks involved in insuring him are within the acceptable limits, the OPs issued health insurance policy in question, opted by the complainant. Averred that at the time of issuance of the policy the complainant was provided the entire policy documents including terms and conditions thereof. Admitted that the complainant was hospitalized for treatment on 2.11.2014 and claimed that he was discharged on 4.11.2014 and lodged his claim with delay i.e. on 26.11.2014 for reimbursement of expenses incurred by him during hospitalization. It is further averred that when an investigation was conducted by the OPs it revealed that the complainant was K/C/O HTN since 10-15 years and was also K/C/O CA Penis 8-9 years and the complainant  deliberately concealed the above medical history at the time of inception of the policy; even the complainant did not disclose his true medical history at the time of submitting signed medical examination report. It is asserted that as the complainant had suppressed material information regarding his medical condition and therefore, his claim was rejected as per policy terms and conditions. Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.
3.     The Complainant also filed rejoinder thereby reiterating the averments as made in complaint and contradicting that of the Opposite Parties made in their reply.
4.     Parties led evidence in support of their contentions.
5.     We have heard the ld. Counsel for the parties and have also perused the record.
6.     The matter in dispute is in regards to the repudiation of claim lodged by the complainant under the policy availed by him from the OPs. it is evident from the record that before issuance of the policy in question the OPs preferred to get the medical examination conducted and accordingly the complainant was thoroughly examined by the medical practitioner as recommended by the OPs and had also undergone the prescribed tests.
7.     It is gathered that the OPs initially issued wrong policy document to the complainant, which was in the name of some other subscriber and when issue was raised they took couple of months to issue proper policy in the name of the complainant. When some deficiency regarding the health status of the wife of the complainant (co-insurer)  was found as wrong in the second policy document and was objected to, then again the OPs issued the ‘duplicate’ policy document correcting the mistake pointed out by the complainant. The above act of the OPs reveals their lackadaisical attitude while issuing the policy, which shows that the insurance companies are interested in the payments of premium only and are not bothered to provide due service and prefer to disallow the claim in a casual manner by taking recourse of pre-existing disease.   

         Record reveals that only after thorough medical verification the complainant was issued the policy in question covering the complainant and his wife. In such a scenario the OPs cannot be allowed to back track from their commitment in regards to indemnify the claim under the policy on the alleged ground that the complainant failed to disclose the factum that he was  suffering from pre-existing disease i.e. K/C/O hypertension since 10-15 years and K/C/o carcinoma penis; since 8-9 years which has not been proved by any substantial evidence by the OPs. Thus, the rejection of the claim on the ground  of pre-existing disease amounts to deficiency on the part of the OPs who failed to perform their  duty diligently. It is observed, that the OPs not only rendered deficient service towards the complainant in rejecting his genuine claim but also acted in gross deficient manner while issuing the policy in question, which was subscribed by the complainant.

8.     The Division Bench of Hon’ble Punjab & Haryana High Court in case titled IFFCO TOKIO General Insurance Company Ltd. Vs. Permanent Lok Adalat (Public Utility Services), Gurgaon and others – 2012(1) RCR (Civil) 901 has held as under:-

“Insurance Act, 1938 – Mediclaim – Exclusion clause – Pre existing disease – Claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the Policy – Single judge allowed the claim on the ground that it was for Insurance Company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease – No interference called for in the order of Single Judge – Held, the pre-existing condition existed in the year 2002 which was five year prior to acquiring Insurance Policy – Claim cannot be denied.”

 

9.     Thus, it has fairly been made clear in the above judgment that it is the duty of the insurance companies to see whether the  proposed insured is suffering from pre-existing disease or not and not to issue policy where person is not entitled to claim on account of treatment of existing disease. Thus, in view of the principle of law laid down in the above case, it is held that the OPs are indeed indulged in unfair trade practice and illegally rejected the claim of the complainant.

 

10.     In view of the above discussion, we are of the opinion that the complaint deserves to be allowed.  Accordingly, the complaint is allowed and the Opposite Parties are jointly & severally directed as under:-

        

a]  To reimburse the claim amount of Rs. 52781/-

 

b]  To pay Rs.10,000/- as compensation for deficiency in rendering service and indulgence in unfair trade practice.

C]  To pay Rs.5,000/- towards litigation expenses.

 

         The above said order shall be complied with by the Opposite Parties within 30 days of its receipt, failing which they shall be liable to pay interest @12% p.a. on the above awarded amounts at (a) from the date of claim till payment and at (b) from the date of filing the complaint till it is paid, besides paying litigation expenses.

 

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

Announced

17.1.2017  

                                                                                       Sd/-

 (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

(PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER