BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.140 of 2016
Date of Instt. 28.03.2016
Date of Decision: 01.11.2017
Amrit Pal Singh son of Pritpal Singh resident of 167, GTB Nagar, Jalandhar.
..........Complainant
Versus
1. Max Bupa Health Insurance Co. Ltd. 2nd Floor, Kunal Tower, Mall Road, Ludhiana through its Branch Head Hitesh Aggarwal.
2. Max Bupa Health Insurance Co. Ltd. B-i-7-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi-110044, through its Authorized Representative.
….… Opposite parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Sh. Parminder Sharma (Member)
Present: Sh. Karan Kalia, Adv Counsel for the complainant.
Sh. AK Gandhi, Adv Counsel for the OP No.1 and 2.
Order
Karnail Singh (President)
1. The instant complaint filed by the complainant, wherein alleged that the OPs are insurance company, which deals in general insurance and health insurance and hence covered under the Consumer Protection Act.
2. The complainant has taken health insurance policy for himself and his family for one year and took a policy bearing No.30272634201502 for the sum assured Rs.25,50,000/- from the OPs, from 19.11.2015 to 18.11.2016 after paying the requisite premium of Rs.13,606/- to the OP. The said policy planned opted namely family first silver 5 Lacs + 15 Lacs. On 07.11.2015, Parteek Singh (Student) son of the complainant i.e. one of the insured of the health insurance policy of the OP got a problem in his nose and was admitted to Sharda ENT Hospital, 401, Lajpat Nagar Market, Jalandhar due to suffering from severe pain in his nose and tumor developed inside the nose and he was advised to go through the surgery by the doctor namely Surinder Sharda and on 07.11.2015, surgery was done by the doctor and removed the tumor from inside the nose of the son of the complainant and after getting the treatment, he was discharged from the hospital on 08.11.2015. Even after discharge from the hospital, he had to take medicine as per advise of the doctor and approximately spent Rs.12,427/. Insurance policy cover, record of medical treatments and accordingly, the complainant submitted an insurance claim on 20.01.2016 in regard to ill-health of his son namely Parteek Singh and the insurance claim of the complainant was rejected by the OP No.2, vide letter dated 17.03.2016 on the ground that “as per verification done by us it was found that patient having neurological disorder and hyper activity since birth which is not disclosed to us”. The OPs have wrongly rejected the claim of the complainant by taking a false and frivolous ground. It is pertinent to mention here that the son of the complainant having no problem at the time of issuing the above said policy by the OPs. By disallowing legal and genuine claim of the complainant by the OP, it tantamounts to callous approach of the OP, which clearly reflects negligence on the part of the OP, which is totally illegal, vague, on the part of the OP and against the rules of natural justice. The act of the OP regarding the medical negligence and repudiating the genuine claim of the complainant by the OP amounts to deficiency in service on the part of the OP and due to above said acts of the OPs, the complainant had to face financial loss, harassment, pain and mental agony, which clearly deficiency of service on the part of the OPs and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to admit the claim of the complainant pertaining to the medical expenses borne by the complainant to a total sum of Rs.12,427/- and further, OPs be directed to pay a sum of Rs.30,000/- as medical negligence on their part as the son of the complainant suffered from severe pain in left leg and was unable to walk and further OPs be directed to pay a compensation for mental agony, harassment to the tune of Rs.20,000/-. The aforesaid amount be paid to the complainant alongwith interest @ 18% and further OPs be directed to pay litigation expenses of Rs.11,000/-.
3. Notice of the complaint was given to the OPs, who filed a written reply, whereby contested the complaint by taking preliminary objections that all the allegations and averments as made against the OP in the complaint are false, frivolous and vexatious. Each and every allegation made against the OP shall be deemed to be specifically denied unless and until the same is specifically admitted herein and further submitted that the complainant has suppressed the material facts from the Forum because the complainant did not disclose any 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 OP issued health insurance policy opted by the complainant and further submitted that the complainant did not inform the OP immediately about the change in his state of health as mandated by the Clause 1 of the terms and conditions of the policy. Thus, the complainant has acted in breach of the Clause 1 of the terms and conditions of the policy and further submitted that an investigation was conducted by the person authorized by the OP to ascertain the facts. During investigation, it was revealed that patient “insured person” was having complaint of watering nose since the year 2011 i.e. since before policy inception. During the course of the investigation, it was also revealed that the insured person was suffering from neurological disorder since birth and he was also hyperactive since birth. The mother of the insured person had herself provided written statement to this effect, at the time of the verification of the claim. On merits, it is admitted that the complainant obtained an insurance policy for himself as well as his family members but the other allegations as made in the complaint are categorically denied and lastly prayed that the complaint of the complainant is without merits and the same may be dismissed.
4. In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavit of the complainant Ex.CW1/A alongwith some documents Ex.C1 to Ex.C7 and closed the evidence.
5. Similarly, counsel for the OP No.1 and 2 tendered into evidence affidavit Ex.OP1 alongwith some documents Ex.OP2 to Ex.OP9 and closed the evidence.
6. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
7. From the face of the pleadings of both the parties, it reveals that the factum in regard to purchase an insurance policy by the complainant for himself as well as his family members is not denied by the OPs and it is also not in dispute that the complainant submitted an insurance medical claim on 20.01.2016 and the said claim of the complainant was repudiated by the OPs, vide repudiation letter Ex.OP-7 and copy of the same has also brought on the file by the OP as Ex.OP-9, the claim of the complainant as per repudiation letter is Ex.OP-9 was repudiated on the ground that the insured i.e. the son of the complainant was found having neurological disorder and hyper activity since birth, which is not disclosed to the insurance company and in order to prove that the said pre existing disease is required to disclose by the complainant at the time of inception of the insurance policy as well as at the time of filling the proposal form. For reference, the OP has brought on the file proposal form Ex.OP-3 and further produced on the file investigation report Ex.OP-5, who invested the matter and collected medical evidence i.e. where from the insured Parteek Singh got a treatment i.e. Dr. Sood and prescription of the Dr. Sood is available on the file Ex.OP-8 and further a questionnaire was prepared by the Investigation Officer at the time of investigation and copy of the same is Ex.OP-6 and wherein statement of the mother of the insured Parteek Singh, was recorded and mother of the insured, namely Kamal Walia stated that as per medical history, his son is suffering from neurological disorder since birth, the statement of Kamal Walia is Ex.OP-7 and OP is relying upon the statement of mother of the insured as well as treatment of Dr. Sood and on the basis of proposal form tried to establish that the insured Parteek Singh was having pre existing disease and due to that reason, the claim of the complainant has been rejected because the complainant has to disclose any pre existing disease to himself as well as to his family.
8. We have considered the all aspect as put forth by the learned counsel for the OPs and find that the son of the complainant namely, Parteek Singh got treatment from Sharda Hospital, for that purpose, the discharge slip is available on the file Ex.C3, wherein reported that the patient was admitted on 07.11.2015 and discharged on 08.11.2015 and bills for payment of the treatment and medicine are available on the file Ex.C-4 to Ex.C-6 and repudiation letter Ex.C-7. Now question only remains whether the father of the Parteek Singh had concealed the pre existing disease to the insured Parteek Singh or not, this is the mute question in this case and entire issue involving in this case is revolving around aforesaid point and accordingly, we considered that the OP has brought on the file proposal form and in the proposal form, no doubt, the disease to the insured Parteek Singh is not disclosed but we think that the burden is upon the OP to establish that on the day of inception of insurance policy, the said disease to the insured, is to be proved by the OP, no doubt, the OP has brought on the file the treatment given by Dr. Sood and Photostat copy of the said treatment is Ex.OP-8, as per document Ex.OP-8, the treatment was given to the insured Parteek Singh in the year 2011 and proposal form filled up in the year 2013. So, it means that the said disease, which is not a minor disease, admittedly concealed by the complainant at the time of getting an insurance policy. Apart from the treatment document of that disease, the mother of the insured namely Kamal Walia wife of Amrit Pal Singh also suffered a statement under her signature, which is Ex.OP-7 that his son is suffering from neurological disorder since birth, so we cannot ignore the statement of the mother of the insured Parteek Singh. So, from all angles, the plea taken by the OP is established that the insured has to disclose all the facts in the proposal form but in this case, the complainant has admittedly concealed the disease of his son, which is pre existing and under these circumstances, we find that the claim of the complainant has been rightly repudiated by the OP and there is no substance in the argument of the learned counsel for the complainant and therefore, the complaint of the complainant is without merit and the same is dismissed with no order of cost. Parties will bear their own cost. Complaint could not be decided within stipulated time frame due to rush of work.
9. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Parminder Sharma Karnail Singh
01.11.2017 Member President
