CONSUMER DISPUTES REDRESSAL COMMISSION-VII

DISTRICT: SOUTH-WEST

GOVERNMENT OF NCT OF DELHI

FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN

CASE NO.CC/324/17

          Date of Institution:-   07.07.2017

          Order Reserved on:- 20.10.2023

                      Date of Decision:-     04.03.2024

IN THE MATTER OF:

Gurcharan Singh Khalsa

Flat No.8119, Sector-D, Pocket-8,

Vasant Kunj, Delhi - 110070

.….. Complainant

VERSUS

Max Bupa Health Insurance Co. Ltd.

B-1/1-2, Mohan Co-operative Industrial Estate,

Mathura Road, New Delhi – 110044.

  .…..Opposite Party

    ORDER

Suresh Kumar Gupta, President

1. The complainant has filed the complaint under section 12 (1) of Consumer Protection Act, 1986 (hereinafter referred to as Act) with the allegations that he has purchased a policy bearing no.30424067201500 on 29.04.2015 for a sum of Rs.5 lakh from the OP by paying a premium of Rs.31907/- which was valid from 29.04.2015 till 28.04.2016. The waiting period for pre-existing diseases was waived off in view of his pre-medical reports. On 01.08.2015, he was hospitalized at Fortis Flt. Lt. Rajan Dhall Hospital, Vasant Kunj. A pre authorization request for cashless treatment was given to TPA. On 03.08.2015, the cashless authorisation was denied by quoting clause 3 (c) of the terms and conditions of the policy. The doctors have initially suspected the possibility of gastric ulcer but it was clarified after investigation that ailment is Cirrhosis so clause 3 is not applicable. He was discharged from the hospital on 04.08.2015 and a bill of Rs.1,12,128/- was paid by him to the hospital. The ailment is not covered under the exclusion clause. The claim denial communication was received on 06.10.2015 by him. He raised his grievance vide letter dated 23.10.2015 to chief operation officer and chief quality officer of the OP but same was not considered and reply dated 08.12.2015 was received from them. He has received the treatment for Cirrhosis from the hospital which has further raised post-hospitalisation expenses of Rs.35,532/-. The charges were duly paid by him. He has also made a compliant dated 28.12.2015 to the insurance ombudsman but to no avail. Hence, this complaint.

2. The OP has filed the written statement with the averments that pre-authorisation claim was rejected in consonance with clause 3 (C)(3) of the policy documents. The allegations are in ill founded. The complainant was diagnosed with Cirrhosis Erosive Gastritis with GI bleed. The patient has a past history of pulmonary Koch received ATTA for 9 months and off and on low BP for the last 5-6 years. The parties are bound by the terms and conditions of insurance policy. The claim was rejected as his case falls under exclusion clause.

3. The complainant has filed the rejoinder wherein he has denied the averments of the written statement and reiterating the stand taken in the complaint.

4. The parties were directed to lead the evidence.
5. The complainant filed his own affidavit in evidence wherein he has corroborated the version of the complainant and placed reliance on documents Ex.CW-1/A to CW-1/G.

6. The OP has filed the affidavit of Chandiraka Bhattacharya, Senior Manager-Legal in evidence wherein he has corroborated the version of written statement and placed reliance on the documents Ex. RW-1/1 to RW-1/7.

7. We have heard the Ld. Counsel for the parties and perused the entire material on record.

8. The perusal of the material on record shows that issuance of policy in question is not in dispute.

9. On 01.08.2015, the complainant was admitted to Fortis Flt. Lt. Rajan Dhall Hospital, Vasant Kunj where he was diagnosed with Cirrhosis, Erosive Gastritis with GI Bleed. The patient was having past history of Pulm Koch diseased ATT x 9 months (5-6 years back), off and on low BP with history of disprine intake off and on. On 04.08.2015, he was discharged from the hospital. The cashless facility was denied to the complainant as his case falls under exclusion clause 3 (C) of the insurance policy. The complainant had to pay a sum of Rs.1,12,128/- to the hospital. He has also incurred an expenses of Rs.35,532/- during post hospitalization treatment.

10. The complainant was diagnosed with Cirrhosis and Erosive Gastritis with GI-Bleed. There is nothing on the record from the side of the OP that complainant was aware of Cirrhosis and Erosive Gastritis with GI-Bleed before taking the policy from OP.
11. The query reply given by the hospital to the OP shows that patient came in the emergency for the first time and there is not history of past consultation. The question of pre-existing disease does not arise as complainant was not aware that he is suffering from any disease.

12. The exclusion clause 3 (C) (3) of the policy shows that waiting period for disease like gastric and duo denal ulcer is 24 months.

13. The discharge summary shows that complainant was also diagnosed with Cirrhosis (idiopathic) along with Erosive Gastritis with GI-Bleed. The complainant was not exclusively diagnosed with Erosive Gastritis. The complainant was given treatment for Cirrhosis as well as for Erosive Gastritis with GI-Bleed. There is no document that complainant was earlier admitted to hospital with the same disease. The plea of concealment would have been valid if the insured conceals the factum of his having been hospitalised for such disease as mentioned in clause 3 (C) (3) of the policy. The Annexure-R3 filed by the OP does not show that complainant was suffering from any such disease at the time of taking the policy meaning thereby that there was no such pre-existing disease at the time of taking the policy.

14. The OP should have taken the entire diagnosis of the complainant in consideration before invoking the exclusion clause. The complainant has undergone the treatment for Cirrhosis with Erosive Gastritis with GI-Bleed.

15. To our mind, the case of the complainant does not fall under exclusion clause and his claim has been wrongly rejected by the OP.
16. The complainant has claimed post-hospitalization treatment expenses. There was no admission so complainant cannot claim bills for incurring expenses on medicines as well as tests/investigations.

17. In view of our aforesaid discussion, the complaint of the complainant is allowed to the effect that complainant is entitled for a sum of Rs.1,12,128/- along with interest @7% p.a. from the date of rejection of the claim till its realization. The complainant is forced to go for litigation. He has undergone mental harassment. The complainant is entitled for compensation on this score. A compensation of Rs.20,000/- is granted to the complainant for mental harassment and litigation  expenses. The OP shall comply with the order within 45 days from the date of receipt of order failing which complainant is also 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 04.03.2024.