BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.78 of 2016

Date of Instt. 15.02.2016

Date of Decision: 20.06.2017

Gaurav Sharma S/o Som Dutt Sharma R/o H. No.70, Aman Vihar, Behind Verka Milk Plant, Jalandhar. ..........Complainant

Versus

1. M/s Max Bupa Health Insurance Ltd, Plot No.88, Second Floor, Kunal Tower Bharat Nagar Chowk, Mall Road, Ludhiana through its Manager/Authorized Person.

2. M/s Max Bupa Health Insurance Ltd, B-1/1-2, Mohan co- operative Industrial, Mathura Road, New Delhi-110044 through its Managing Director/Principal Officer.

3. Somesh Chandra, Chief Operations Officer & Chief Quality Officer, M/s Max Bupa Health Insurance Co. Ltd, B-1/1-2, Mohan co-operative Industrial, Mathura Road, New Delhi- 110044.

4. Vijay Sharma, Authorized Agent R/o H. No.344, Lajpat Rai Nagar, Ward 53, Jalandhar.

.........Opposite parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh, (President)

Sh. Parminder Sharma (Member)

Present: Sh. Amit Kumar, Adv. Counsel for the complainant.

Sh. AK Gandhi, Adv. Counsel for OP No.1 to 3.

OP No.4 exparte.

Order

Karnail Singh (President)

1. This complaint filed by complainant, wherein stated that he took health insurance policy from the OPs vide policy No.30431363201500 and under this policy, the name of insured Persons No.1. Som dutt Sharma 2. Sarita Sharma, the parents of complainant. The Medical policy was taken at Jalandhar from the OP No.4, who is authorized agent of the OP No.1 to 3.

2. At the time of insurance of policy the OPs understood all the needs of the complainant and the OPs assured him that the company having no any problem to issue the concerned policy as everything was cleared on the part of the complainant. As per instructions, rules and regulations of Insurance Companies, the medical examinations of insured persons were performed and after issuance of Medical Certificate and after completion of other formalities, the concerned policy was duly issued in favour of the complainant. The complainant provided all information to the OPs at the time of obtaining present policy and nothing was concealed on the part of the complainant. Everything was elaborated to the OPs and after going through, understanding and satisfying the norms and regulations of the company, the present policy was issued. The complainant has paid the whole premium and initial amount as demanded by the OPs and nothing is due towards the complainant.

3. That in the month of July, 2015 the mother of complainant namely Sarita Sharma became ill and got admitted to Nasa Brain & Spine Centre, Kapurthala Road, Jalandhar and the treatment of mother of complainant was done and during treatment on 11.09.2015, the mother of complainant unfortunately died. The expenses of treatment to the tune of 13,67,770/- was claimed from the OPs vide claim No.155083 by the complainant. But the said claim request was rejected by the OPs on 31.12.2015 without any reasonable cause, reason and clarification. The rejection of the claim is arbitrarily, illegal and against law. The complainant provided all bills at the time of submission claim with the OPs. Thereafter, the complainant sent an email on 01.01.2016 to Sr Executive Grievance Redressal of company for issuance of claim No.155083, but in reply of said email, Grievance Redressal send emails to the complainant on 02.01.2016 and 12.01.2016 and did not pass the claim of complainant and has been intimated in the reply that the claim has been rejected as intimated earlier dated 31.12.2015. No proper reason was assigned in this reply also for rejection of claim. Apart from this, the correspondence were made between the parties through emails. That in between correspondence one letter dated 11.01.2016, was received by the complainant by which the policy of complainant was cancelled unilaterally by the OP No.3, without giving any reasonable cause and it was never told to the complainant by the representative of the company at the time of issuance of policy. The complainant and insured persons never acted dishonestly or fraudulently in relation to policy and the complainant disclosed all material facts to the OPs, at the time of issuance of policy and the complainant never misrepresented the OPs in relation to policy. So, as per clause 3 of Policy Terms and Conditions, the OPs cannot cancel the present policy and notice issued to the OP No.3 dated 11.01.2016 is totally arbitrarily, baseless, illegal and against the law. That the grounds for rejection were itself manufactured by the officials of OPs, who came to hospital to verify the contents of claim.

4. That the mother of complainant never suffered from any Hypertension or Spinal pain as described by the OPs in rejection order dated 31.12.2015. The mother of complainant suffered from viral encephalitis, viral myocarditis, septic shock critical illness myopathy and it is specifically mentioned in her medical report, issued by the concerned Hospital and these reports have already been submitted to the OPs alongwith claim. The OPs rejected the claim on useless grounds without giving any reason and proof and just to avoid payment of claim amount, the OPs are taking these false and baseless causes and reasons. The complainant is legally eligible for obtaining the claim amount from the OPs and it was legal and moral duty of OPs to issue the claim to the complainant. Thereafter, the OPs were got served with the Legal Notice dated 21.01.2016, through registered post. Despite service of the legal notice, the OPs have willfully failed to make payment of the claim amount and as such necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and direction may be given to OP to pay claim amount to the tune of Rs.13,67,770/- to the complainant alongwith interest and also directed to pay Rs.1,00,000/- as compensation for suffering inconvenience, harassment, mental tension, cruelty and also direction be given to pay litigation expenses to the tune of Rs.25,000/-

5. Notice of the complaint was given to the opposite parties but despite service OP No.4 did not come present and ultimately OP No.4 was proceeded against exparte. Whereas OP No.1 to 3 filed reply and contested the complaint by taking preliminary objections that the complainant has not filed any document which supports his averments that it has been authorized by the policy holder to file the present Consumer complaint before this Forum. It is further submitted that the present complaint is not maintainable as the complainant has no locus standi. It is further averred that all the allegations and averments made against the OP in the complaint are false, frivolous and vexatious and further submitted that the entire policy booklet which included the welcome letter, insurance certificate, premium receipt, policy terms and conditions, proposal form filled by complainant etc. was provided to the complainant each time, when the policy was issued and further submitted that the complainant was hospitalized on 24.07.2015 and was discharged on 11.09.2015. However, the OP was intimated on 10.10.2015 i.e. after a delay of around one month without assigning any reason whatsoever for the same. It is submitted that the policy provides that intimation should be given immediately and the complainant has failed to provide the information immediately or within reasonable time. And delay in intimation is fatal to establish the genuniness of the claim of the complainant and the complaint deserves to be dismissed and further submitted that an investigation was conducted by the person authorized by the OP to ascertain the facts and during the course of the investigation, it was revealed that the insured person was suffering from hypertension since 12-15 years. It was also revealed that the insured person also had a history of back pain and received treatment for the same since 8-10 years. Insured person also consulted in multiple hospitals for aforesaid health problems. It is further submitted that when the investigator requested previous consultation papers then the same were not provided to him by the complainant, but in his self declaration, he has himself stated these facts. It is further submitted that the history sheet of hospital also authenticates it and further insured did not disclose her long lasting history of taking regular treatment for the spine and also not disclosed duration of disease while taking policy. The investigation report collected during the course of the investigation is annexed with the written reply. It is further submitted that the complainant has accepted the terms and conditions of the policy proposal form, which obligated him to make full and frank disclosure of all facts material to the assumption of risk in relation to him, that would influence the decision of the OP, regarding issuance of policy or its terms rather the complainant deliberately did not disclose medical condition in policy proposal form and further submitted that the OP has rightly declined the request of cashless treatment. The present case is a clear cut case of concealment of material facts and misrepresentation. It is further submitted that the complainant is estopped by his own acts and conducts from filing the present complaint. It is within the knowledge of the deceased that he was suffering from Hypertension since 12 to 13 years and was suffering from spinal pain since 8 to 10 years. The same was not disclosed by the deceased at the time of inception of the insurance policy. So, the present complaint is liable to be dismissed. On merits, it is admitted that the complainant has taken a health insurance policy from OP but the remaining allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merit and same may be dismissed.

6. In order to prove the case of the complainant, complainant himself tendered into evidence his affidavit Ex.CA alongwith documents Ex. C-1 to Ex.C-226 and closed the evidence.

7. In order to rebut the evidence of the complainant, counsel for OP No.1 to 3 tendered into evidence affidavit Ex.OP1-3/A alongwith documents Ex.OPW1/1 to Ex.OPW1/8 and closed the evidence.

8. We bestowed our thoughtful consideration to the submissions made by learned counsel for the respective parties and also gone through the case file very minutely.

9. In nutshell, the case of the complainant in regard to purchase of insurance policy Ex.C1 from OP No.3 through OP No.4 is admitted fact and the period of the policy is from 29.05.2015 to 28.05.2016, the total insured amount is Rs.25 lacs and the said policy was purchased by complainant Gaurav Sharma as well as in the name of his parents i.e. Mr. Som Dutt Sharma and Mrs. Sarita Sharma. These facts have been very much mentioned in the policy documents and during the persistence of that policy, the mother of the complainant died and prior to that she remained admitted in Nasa Brain and Spine Centre, Kapurthala Road, Jalandhar. Bills of treatment are available on the file Ex.C2, Ex.C3 and Ex.C21 to Ex.C226 and total amount incurred upon her treatment was Rs.13,67,770/- as per bill Ex.C3 and after the death of Mrs. Sarita Sharma, the son of the deceased namely complainant submitted a claim petition to the insurance company but the same was repudiated vide letter Ex.C4 dated 31.12.2015, on the simple ground that as per verification, done by investigator, it was found that the patient had been having history of Hypertension since 12-13 years and history of spinal pain 8-10 years, which is not disclosed at the time of policy inception, hence the claim is rejected, as per clause of Non Disclosure of material facts of policy, not so even thereafter the OP cancel the insurance policy of the complainant vide letter dated 11.01.2016, the same is Ex.C14 and accordingly necessity arose to the complainant to file the instant complaint.

10. Now question hinges in the air, whether non disclosure of Hypertension disease to the OP is one of the solid reason for rejecting the claim. The answer of this query comes out from the judgments of Hon'ble State Commission cited 2008(2) C.P.J 213 Life Insurance Corporation of India Vs. Sushma Sharma, wherein it is categorically observed that the Hypertension, no doubt is a disease but it is not a material disease rather in those day of fast life, majority of the people suffer from Hypertension. If these diseases had been so material then the insured deceased Mrs. Sarita Sharma would not have been survived for 12-13 years. In support of our above version, we further like to refer an other pronouncement of Hon'ble State Commission cited 2009(1) C.P.J 461 Life Insurance Corporation of India Vs. Satwinder Kaur. So, in the light of above judgments, it has been established that the Hypertension is not a disease and moreover, the death of the insured deceased Mrs. Sarita Sharma was not due to Hypertension. If so then, the disease of Hypertension, does not come in the way to discard the claim of the insured complainant.

11. Apart from above, there is an other aspect in this case, whereby the complainant has established on the file that the deceased Mrs. Sarita Sharma did not conceal any previous disease. For that purpose, we should have a look on the document i.e. insurance policy document Ex.C1 and same document has been brought on the file by the OP i.e. OPW1/2 and in the said insurance policy at Page No.3 infront the name of Mrs. Sarita Sharma, the column is pre existing condition and the same is filled with Hypertension disease. Not so there is an other document in the insurance policy i.e. proposal form, wherein the disease of BP (Blood Pressure) has been mentioned since 2009 and the said document is also available in the insurance policy, produced by the OP i.e. Ex.OPW1/2 at Page No.34 and further the OP has also brought on the file an other document Ex.OPW1/8, which is also a proposal form and in this form, the disease of the deceased Mrs. Sarita Sharma is mentioned BP since 2009. So, it means that Sarita Sharma has not concealed any disease rather she explained that she is a patient of BP and accordingly the same was mentioned in the insurance policy as well as in the proposal form. So for the concern of back pain is related, regarding that the OP has not examined any Doctor who can say that the Spinal pain is so serious. So, it means that the Spinal Pain is also not a serious disease. Therefore, we came to conclusion that the claim of the complainant had been wrongly and illegally repudiated by the OPs No.1 to 3 and accordingly, the said repudiation letter Ex.C4 dated 31.12.2015 is set aside being void, illegal having no force in the law and hold that the complainant is entitled for relief claimed.

12. In the light of above detailed discussion, the complaint of the complainant is partly accepted and accordingly OP No.1 to 3 are directed to pay a medical bill claim amounting to Rs.13,67,770/- with interest @ 9% per annum from the date of repudiation of the claim i.e. 31.12.2015 till realization and further OP No.1 to 3 are directed to pay a compensation to the complainant for inconvenience, harassment and loss of time to the tune of Rs.20,000/- and also pay litigation expenses of Rs.3000/-. The entire compliance of the order be made within 30 days from the date of receiving copy of order. Complaint could not be decided within stipulated time frame due to rush of work.

13. 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

20.06.2017 Member President