Order-16.

Date-21/11/2017.

       Mrs. Sangita Paul, Member.

This is an application u/s.12 of the C.P. Act, 1986.

Complainant’s case in short is that complainant purchased a health insurance policy from Max Bupa Health Insurance Co. Ltd. on 19/06/2013 and sum insured is Rs.7,50,000/-. Complainant suffered a severe back pain and visited the Medica Super Specialty Hospital on 31/05/2013. According to doctor’s advice he was admitted to Medica Super Specialty Hospital and underwent an operation on 04/06/2013. Complainant was diagnosed Thoracic 12 fracture compression. Complainant lodged a claim for reimbursement of Rs.3,21,298/- for hospitalization to O.P. i.e. Max Bupa Health Insurance Co. Ltd. on 13/06/2013. O.P. company vide their letter dated 07/08/2013 repudiated the claim under exclusion clause of suppression of material facts. A certificate was issued by Dr. L. N. Tripathy of Medica Super Specialty Hospital on 08/06/2013. In that certificate the concerned doctor stated that although there was history of low back ache due to fall, the present problem, admission and surgery (Vertibroplasty) is not related to it. Complaint filed against repudiation of claim before Insurance Ombudsmen but Ombudsmen has upheld the repudiation done by Max Bupa Health Insurance Co. Ltd. Complainant states that the Ombudsman failed to realize the gravity of his problem. Thus O.P. is negligent and deficient in providing service by repudiating complainant’s legitimate claim, O.P. failed to feel the importance of the certificate issued by Dr. L.N. Tripathy and by repudiating the complainant’s genuine claim O.P. also falls under unfair trade practice. As a result complainant suffered monetary loss, mental agony and harassment for such illegal repudiation by O.P. Hence, the complainant prays for directing the O.P. to pay Rs.3,21,298/- towards reimbursement of the expenses of his medical treatment, compensation of Rs.2,00,000/- for his harassment and mental agony together with litigation cost of rs.20,000/-.

O.P. Max Bupa Health Insurance Co. Ltd. appeared and contested the case by filing W.V. contending inter alia that the instant complaint is misconceived and based on misconception of the insurance policy. The complaint is filed in oblique motive in order to extract money from the O.P. without any legitimate basis. No deficiency of service is committed by O.P. O.P. also stated in their W.V. that Complainant was suffering from lower back pain since 2005 but the same ailment was not disclosed to the insurance company at the time taking the policy. After rejection of preauthorization claim complainant procured a false certificate from the treating doctor and raised a claim of reimbursement amounting to rs.3,21,298/-. Complainant was admitted to Medica Super Specialty Hospital, where he underwent 12 fracture compression. From the record it is evident that he was suffering from lower back pain in 2005 and 2010. The insured complainant did not disclose the above mentioned pre-existing back pain in the proposal form. He did not disclose that he continually had been suffering from back ache since 2005. Non-disclosure of such ailment has led to violation of Clause-1 of the terms and conditions and Clausde-5 of the proposal form. Subsequently the claim for reimbursement is rightly repudiated.

In the light of above facts and circumstances there was no negligence or deficiency of service on the part of the O.P. and thereby no question of claim arises. O.P. also stated that the instant complaint is bad in law because the instantcomplaint has been filed after the limitation period. Complaint has been filed only to extract money unlawfully.

It is denied that complainant had suffered severe back pain and cramps only on 31/05/2013. It is also stated that complainant had a past medical history of low back ache since 2005 and the same was not disclosed by the complainant at the time of taking the policy The back ache of complainant subsisted for quite sometime even before inception of policy. This pain was not sudden as contended by complainant. From the submission of complainant it is evident that complainant was suffering from severe back ache i.e. Osteoporosis, Chronic pain is related to Osteoporosis. So the claim was rightly repudiated. Insurance policy is based on utmost good faith but complainant preferred to stay silent. So all the allegations levelled against O.Ps. are denied and disputed.

Decision with Reasons

We have perused all the documents like complaint petition, Written Version, Evidence-in-Chief, photocopies of discharge summery and other documents.

            From the documents it is revealed that complainant had a mediclaim policy named Heartbeat Gold 7.5 Lacs 1 Adult Policy bearing No.30108365201200 for the period from 20/06/2012 to 19/06/2013. The policy is still continuing. Complainant had a severe back pain and visited to Medica Super Specialty Hospital and underwent an operation on 04/06/2013 and was discharged on 05/06/2013 and incurred an expense of Rs.3,21,298/-. Complainant lodged a claim for reimbursement of the aforesaid amount for hospitalization to the O.P. on 13/06/2013. Max Bupa Health Insurance Co. Ltd. vide letter dated 07/08/2013 repudiated the claim under exclusion Clause of suppression of material facts. Complainant was suffering from back ache in 2005 and also in 2010. It was not the precondition of thoracic 12 fracture compression. These are completely two different ailments. There was no continuity between the ailments of 2005 and 2010. O.P. could not produce a single evidence where it was recorded that complainant had been suffering since 2005 due to same ailment. All these are separate incidents and O.P. mingle up the incidents of 2005 and 2010 with the present ailment for not to reimburse the claim. No doctor of the Medica Super Specialty Hospital admitted that complainant was suffering from 2005 and he came to the hospital for the same cause in 2013. Moreover, Dr. L.N. Tripathy, Consultant Neuro Surgeon, Director, Medica Institute of Neurological diseases and Vice Chairman, Medica Super Specialty Hospital opined that the patient was considered by the doctor on 31/05/2013 causing spinal fracture  of D 12 A. Vertebroplasty was done in order to rectify the fractured spine. Although there was a history  of low back ache previous to this fall, the present problem, admission and surgery (Vertebroplasty) are not related to it. The report was published on 08/05/2013. It is an authentic medical report. The report was not collected from outside. It is declared by the Vice Chairman of Medica Super Specialty Hospital. No counter opinion has been produced on behalf of the O.P. to contradict or controvert such certificate of Dr. Tripathy. But O.P. Insurance Company challenges its veracity. The doctors of the hospital writes the report which was observed in the neurological tests. After the test he underwent the operation. Complainant had earlier ailment in 2005 and 2010. It is in no way related to the present operation. The spinal fracture is due to fall, not for aggravated low back pain.

            O.P. states that complainant is not entitled to get the reimbursement as complainant has suppressed material facts. But no question of suppression of material facts arises. Fact remains that complainant is entitled to get reimbursement for his surgery. O.P. has no justification in repudiating the claim of Rs.3,21,298/-.

            In result, the case succeeds.

Hence,

Ordered

The complaint be and the same is allowed on contest against the O.P. with cost of Rs.10,000/-.

O.P. is directed to pay Rs.3,21,298/- towards claim of reimbursement of medical treatment to the complainant within a period of one month from the date of this order.

O.P. is further directed to pay Rs.10,000/- towards compensation for causing harassment and mental agony to the complainant within the aforesaid 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.