CONSUMER DISPUTES REDRESSAL COMMISSION-VII
DISTRICT: SOUTH-WEST
GOVERNMENT OF NCT OF DELHI
FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN
SECTOR-20, DWARKA, NEW DELHI-110077
CASE NO.CC/547/15
Date of Institution:- 12.10.2015
Order Reserved on:- 11.12.2023
Date of Decision:- 07.03.2024
IN THE MATTER OF:
Shri Puneet Kapoor
S/o Shri Ashok Kumar Kapoor
R/o WZ-273, First Floor,
Gali No.15, Shiv Nagar,
New Delhi - 110058
.….. Complainant
VERSUS
M/s Max Bupa Health Insurance Co. Ltd.
B-1/1-2, Mohan Cooperative Industrial Estate,
Mathura Road, New Delhi – 110044
Through its Director
.…..Opposite Party
ORDER
Suresh Kumar Gupta, President
- The complainant has filed the complaint under section 12 of Consumer Protection Act, 1986 (hereinafter referred to as Act) with the allegations that he has availed mediclaim policy no.30323251201400 from 26.04.2014-25.04.2015 issued by the OP. On 14.02.2015, he was admitted to Tyagi Nursing Home and discharged on 15.02.2015. He was diagnosed with DM and HTN and thereafter he was admitted to Central Hospital, Ganesh Nagar, Tilak Nagar, New Delhi on 15.02.2015 and discharged on 16.02.2015. Dr. Satish Purwaha of Central Hospital has inadvertently written in the consultation papers that he was suffering from K/C/O-DM and HTN from last five years. The said doctor has rectified the mistake and issued the certificate that there was no past record of DM and HTN. The medical claim was duly reimbursed by the OP. He applied for the renewal of policy from 26.04.2015-24.04.2016 and policy no.30323251201501 was issued. A letter dated 17.02.2015 was received from OP that he has not disclosed pre-existing disease DM and HTN by taking the policy and thereafter cancelled the policy despite the clarification given by him. A legal notice dated 07.09.2015 was issued to the OP to renew of the policy but in vain. Hence, this complaint.
- The OP has filed the reply with the averments that Sh. Sumit Bajaj, Chief Manager, Legal is authorised representative of the OP. The complainant is guilty of the suppression of the fact. The issue raised by the complainant needs evidence including expert evidence so Civil Court is competent to decide such cases. The complainant did not disclose medical history or additional information as required under clause 6 or 7 of the coverage selection. The consultation paper of Central Hospital shows that complainant is a case of K/C/O-HTN and DM for the last five years and concealed this fact from the very inception of the policy. The complainant has filed two claims. The claim of Tyagi Hospital was reimbursed. The bill of Rs.25004/- raised by Central Hospital was partly reimbursed and a sum of Rs.17123/- was reimbursed. The investigation was conducted by OP and it was revealed during investigation that there was non-disclosure of pre-existing disease of DM and HTN by the complainant. The complainant was duly informed vide letter dated 17.08.2015 that OP would be compelled to cancel the policy if exclusion clauses are not acceptable to him. The complainant did not agree and accordingly policy was cancelled. The complainant was requested to provide affidavit attested from the Magistrate for the reasons of the doctor to rectify the mistake and all past medical documents relating to DM and HTN for reconsideration of the case. The said documents were not supplied. The policy has been cancelled due to pre-existing disease. There is no deficiency of service on the part of the OP.
- The complainant has filed the replication where he has denied the averments of written statement and reiterated the stand taken in the complainant.
- The complainant has filed his own affidavit in evidence where he has corroborated the version of complaint.
- The OP has filed the affidavit of Sh. Sumeet Bajaj, Chief Manager-Legal in evidence where he has corroborated the version of written statement and placed reliance on the documents Ex.OPW-1/1 to OPW-1/6.
- No one appeared on 11.12.2023 so the case was reserved for orders.
- We have perused the entire material placed on record.
- It is clear from the material on record that issuance of policy no. 30323251201400 is not in dispute. The OP has not disputed the admission of complainant in the Tyagi Hospital as well as in the Central Hospital.
- The OP has not disputed the issuance of policy bearing no. 30323251201501 and thereafter its cancellation vide email dated 17.08.2015 on the grounds of concealment of pre-existing disease DM and HTN for the last five years under the clause 5 (i) 3 of terms and conditions of the policy.
- The case of the complainant is that he was not suffering from K/C/O-DM and HTN for the last five years as he was diagnosed with dyslipidemia with hepatitis and he was diagnosed for the first time with the case of DM and hypertension by Tyagi Hospital. Dr. Satish Purwaha of Central Hospital, Tilak Nagar has clarified vide certificate dated 13.07.2015 that it was mistakenly written in the consultation papers as a case of K/C/O-DM-HTN for the last five years.
- The main thrust for the cancellation of policy is the non-disclosure of the existence of diabetes for the last five years and HTN for the period not disclosed. There is concealment/misrepresentation of the facts by the complainant. The policy can be continued if complainant agrees to the exclusion clause of the pre-existing diseases failing which policy will be cancelled as apparent from the emails dated 22.08.2015 which is annexure-OPF attached with the reply. The complainant did not agree to the exclusion clause as a result policy was cancelled.
- The perusal of the entire material on record shows that admission of the complainant in the Tyagi hospital and Central Hospital is not disputed by the OP. The claim of Tyagi hospital was fully reimbursed whereas claim of Central Hospital was partly reimbursed.
- The complainant has taken a certificate dated 13.07.2015 annexed with the complaint wherein Dr. Satish Purwaha has clarified that it was inadvertently written in the consultation papers that it was a case of K/C/O-DM and HTN.
- The papers of medical claim submitted by the complainant were with the OP. The fresh policy bearing no. 30323251201501 was issued by the OP. The certificate dated 13.07.2015 qua rectification was issued by Dr. Satish Purwaha of Central Hospital. The question of concealment or misrepresentation on the part of complainant does not arise as he was not allegedly suffering from DM and HTN. The OP has not taken into consideration the certificate dated 13.07.2015. The OP could have got investigated this certificate from the concerned hospital and doctor which was not done for the reasons best known to OP. The complainant should not suffer for the mistake on the part of the hospital which was later on rectified by the hospital. The OP has only considered the discharge summary dated 16.02.2015 issued by the Central Hospital which is annexed with the complainant without adverting to the certificate dated 13.07.2015. The OP should not have passed the claim of the bill raised by Central Hospital in case there was concealment of pre-existing disease.
- In view of all this fact, we are of the view that OP has cancelled the policy without considering the entire material on record which led to the deficiency of service.
- Hence, in view of our discussion, the complaint of the complainant is allowed to the effect that OP shall renew the Mediclaim policy bearing No.30323251201400. The complainant has undergone mental agony so he is entitled for compensation on this score also. The OP shall also pay Rs.10,000/- towards compensation on account of mental agony and harassment. The OP shall comply with the order within 45 days from the date of receipt of order failing which complainant is entitled for interest @7% p.a. on compensation from the date of order till its realization.
- A copy of this order is to be sent to all the parties as per rule.
- File be consigned to record room.
- Announced in the open court on 07.03.2024.
