District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 473/2021
Date of Institution:21.09.2021
Date of Order:12.04.2023.
Chander Prakash Gandhi Alias Chander Prakash (Now deceased) S/o Shri Dina Nath, R.o House No.43, Ward No. 12, Near MC Tailor, Jawahar Nagar Camp Palwal, Haryana – 121102.
(Through LRs namely)
i. Smt. Usha Rani W/o Lt. Chander Prakash Gandhi
ii. Sunny Gandhi S/o Lt. Chander Prakash Gandhi
Both R/o Ward No. 12, Near MC Tailor, Jawahar Nagar, Camp Palwal, Haryana – 121102.
iii. Ms. Varsha Seth D/o Lt. Chander Prakash Gandhi r/o House No. 1284, Sector-9, Faridabad.
…….Complainants……..
Versus
1. M/s. Max Bupa Health Insurance co. ltd., Local Office at: SCO-11, ist and Iind floor, Commercial Complex, Sector-16 Above Canara Bank, Faridabad.
2. M/s. max Bupa Health Insurance Co. Ltd., Issuing office at:- 2nd floor, Shop No. 18 & 28, The Center Stage Mall, Plot No.1 Block-L, Sector-18, Noida, Uttar Pradesh – 201301.
3. M/s. Max Bupa Health Insurance Co. Ltd., Regd, Office at: Block B1.1-2, Mohan Co-operative Industrial estate, Mathura Road, New Delhi – 110 044.
…Opposite parties
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Sachinder Bhatia, counsel for the complainant.(complainant died).
Sh. Mahesh Ahluwalia, counsel for LRs of Complainant.
Sh. Rakesh Dabaas, counsel for opposite parties Nos.1 to 3.
ORDER:
The facts in brief of the complaint are that opposite parties Nos. 1 & 2 being the branch office of the opposite parties issued the Family Health Policy in favour of the complainant vide policy No. 31454431202000 valid from 01.12.2020 to 30.11.2021 for a sum of Rs.5,00,000/- on the payment of Rs.42,374/- as premium of the said policy in favour of the complainant. Prior to this policy, the complainant was having health policy from National Insurance company since 2005 to 2020 and last policy issued from National Insurance co. Ltd. Valid from 01.12.2019 to 30.11.2020 and at the time of renewal of the said policy, the complainant had disclosed the opposite parties about previous medical policies and the opposite parties ported the policy of the complainant from national Insurance Co. Ltd. To Max Bupa Health Insurance Co. Ltd. Thereafter, the opposite parties issued the policy under family health policy in favour of the complainant. On 09.03.2021 during the risk covering period of policy, the complainant admitted in SSB Central Hospital with the complaint of Anorexia, weight loss since one month, exertional dysponea, stress incontinence discharged on 10.03.2021 and the hospital charged Rs.32000/- from the complainant and same had been paid in cash and thereafter reimbursed from the opposite parties and paid to the complainant. Further, form 08.04.2021 i.e. during risk covering period of policy, the complainant diagnosis with CLL (B Cell) and therefore, on 17.4.2021, the complainant was taken to Asian Institute of Medical Sciences, Sector-21A, Faridabad. The attending doctor admitted the complainant in hospital vide patient IPD No. AFBIP2110161 on 17.04.2021 for proper treatment. The complainant had undergone clinical and laboratory tests where the complainant was diagnosed as case of chronic kidney disease SD on MHD with Left Ventricular Apex Clot. The complainant was admitted under medical supervision and treatment of Dr. Reetesh Sharma and Dr. B.K.Upadhyay. The complainant was managed with IV fluids, antibiuotics, PPI nebuliztion and other supportive treatment. The condition of complainant improved and was discharged on 22.04.2021 with advice of follow up. Initially the opposite parties denied the cashless facility on 18.04.2021 and therefore, the complainant had to bear the entire cost of treatment. The complainant paid an amount of Rs.1,78,733/- to Asian Hospital, Faridabad towards final bill dated 22.4.2021 for indoor treatment. After discharge from hospital, the complainant submitted claim form for the aforementioned indoor treatment alongwith discharge summary, final bill, clinical investigation reports and other necessary documents to the opposite parties for reimbursement of Rs.1,78,733/-. Thereafter, the complainant applied for reimbursement of the final bill form the opposite parties and further raised vague and unnecessary queries and demanded documents by the opposite parties vide its letters dated 29.5.2021, 12.06.2021 and 19.06.2021 stated that due to non disclosure of the H/O hypertension since 15 years had been noted and exclusion had been applied for the same, secondly provide break up of the final bill and provide the documents mismatched the name of the complainant and in this respect, the opposite party sent the emails to the complainant and in reply thereto the complainant sent the clarification to the opposite party on 04.06.2021 through mail. It was worthwhile to mention that in reply of aforementioned letters of the opposite parties issued the letters for query in respect to both claims of the complainant i.e. for the period of 09.03.2021 to 10.03.2021 and for second claim for the period of 17.04.2021 to 22.04.2021 and the opposite passed the first claim and paid the medical expenses to the complainant but it was strange that the opposite parties denied the second claim to the complainant. The complainant was expecting the claimed amount of Rs.1,78,733/- but was shocked and astonished to receive email dated 23.06.2021 from opposite party No.1 under which the claim was repudiated on false and baseless ground stated that the claim had been denied for settlement based on the terms and conditions of the policy with them. The complainant had not received any claim repudiation letter except the aforementioned email. From the contents of email conveying claim repudiation, it was gathered that the opposite parties repudiated the clam/treating/considering the claim had been denied for settlement based on terms and conditions. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) refund an amount of Rs.1,78,733/- alongwith interest @ 18% p.a. from the date of deposit till realization to complainant.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 51,000 /-as litigation expenses.
2. Opposite parties put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that the complainant opted for the policy “Family floater” bearing NO. 31454431202000 with a sum insured of Rs.5,00,000/- from the period 01.12.2020 to 30.11.2021. The complainant opted for portability wherein the insurance policy bearing No. 361100501910012153 of National Insurance Company Limited of the complainant was ported into the aforesaid policy. The complainant submitted the claim for reimbursement of medical expenses for an amount of Rs.1,78,733/- with respect to the treatment of chronic kidney disease at Asian Institute of Medical Institute. The complainant was admitted in the hospital form the period 17.04.2021 to 22.04.2021. On the receipt of the aforesaid claim, the opposite party generated claim bearing No. 655988 and review the claim and documents of the complainant. On the scrutiny of the documents, the opposite parties found that issued a letter dated 29.05.2021/01.06.2021/12.06.2021 & 19.06.2021 with respect to the submission of the mandatory documents and the details of the same were reproduced herein below:
a) Non-disclosure of H/o Hypertension since 15 years had been noted in the claim documents. Accordingly, exclusion had been applied for the same.
b) Request you to provide your consent on the same for further processing of the claim.
c) Kindly provide breakup of final bill.
d) Kindly provide claim documents in name of Chander Prakash as in provided documents name mismatched (Chander Gandhi).
Despite the aforesaid letters issued by the opposite parties, the complainant did not submit the documents . The complainant made a following statement in the no claim declaration form submitted with portability documents:
“……I am medically fit and fine and I did not take any claim in my previous policy…..” However, it came in the knowledge of the opposite parties that complainant had failed to disclose the pre-existing medical conditions/illness and this could be further substantiated by discharge summary of the complainant:
“……..Known case of hypertension and ischemic disease….” In view of the aforesaid facts and circumstances, the opposite parties denied the claim of the complainant, while clearly stating that in case he proves the mandatory documents, his claim would be re-evaluated, it was to be noted that as per the IRDAI regulations on claim settlement a claim had to be settled or rejected within a stipulated time, since the complainant failed to produce the required documents, the claim of the complainant had to be rejected. Opposite parties denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties–M/s. Max Bupa health Insurance Co. Ltd.. with the prayer to: a) refund an amount of Rs.1,78,733/- alongwith interest @ 18% p.a. from the date of deposit till realization to complainant. b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 51,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex. CW1/A – affidavit of Chander Prakash Gandhi Alias Chander Prakash, Ex.C-1 – insurance policy with schedule valid from 01.12.2020 to 30.11.2021, Ex.C-2 – insurance policy valid from 01.12.2015 to 30.11.2016, Ex.C-3 – insurance policy valid from 01.12.2016 to 30.11.2017, Ex.C-4 – insurance policy valid from 01.12.2017 to 30.11.2018, Ex.C-5 – insurance policy valid from 01.12.2018 to 30.11.2019, Ex.C-6 – insurance policy from 01.12.2019 to 30.11.2020, Ex.C-7 – Discharge summary, Ex.C-8 – Final Bill of supply summary (Cash), Ex.C-9 - OPD sheet, Ex.C-10 – Discharge summary, Ex.C-11 – Draft Bill summary, Ex.C-12 – Cashless Denial letter, Ex.C-13 to 15– letter regarding missing information letter in respect of claim No. 655988, Ex.C-16 – Final Bill Summary, Ex.C-17 – Final Bill Details, Ex.C-18 & 19 - emails,, Ex. C-20 & 21 – emails regarding Member Reimbursement Statement.
On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties Ex.RW1/A – Affidavit of Shri Bhuwan Bhashker, Senior Manager, Legal, M/s. Niva Bupa Health Insurance Company Limited, 2nd floor, Plot NO. D-5, Logix Infotech Park, Sector-59, Noida, Uttar Pradesh, Ex.R-1 – Proposal form, Ex.R-2 - Policy schedule valid from 01.12.2020 to 30.11.2021, Ex.R-3 – Final report, Ex.R-4 to R-7 – letters regarding missing information letter in respect of claim Number 655988,,, Ex.R-8 – Discharge summary, Ex.R-9 - letter dated 03.12.2021 regarding member reimbursement statement for claim no.655988, Ex.R-10 – letter regarding endorsement related to policy No. 31454431202000, Ex.R-11 Request for Cashless Hospitalization for Health insurance policy Part-C, ExR-12 – Cashless Denial letter dated 18.04.2021.
6. In this case, the complaint was filed with the prayer of refund an amount of Rs.1,78,733/- alongwith interest @ 18% p.a. from the date of deposit till realization to complainant.
The complainant obtained the Family Health Policy bearing policy No. 31454431202000 valid from 01.12.2020 to 30.11.2021 from opposite parties Nos. 1 & 2 for the insured sum of Rs.5,00,000/-. The patient Chander Prakash was admitted in Asian Hospital on 17.4.2021 and discharged from the hospital on 22.4.2021. The complainant paid an amount of Rs.1,78,733/- to the Asian Hospital, Faridabad towards final bill dated 22.4.2021 for indoor treatment vide Ex.C-16. Earlier the complainant was admitted in SSB Central Hospital On 09.03.2021 with the complaint of Anorexia, weight loss since one month, exertional dysponea, stress incontinence discharged on 10.03.2021 and the hospital charged Rs.32000/- from the complainant same has been paid in cash and thereafter reimbursed from the opposite parties and paid to the complainant .Now the claim of the complainant was repudiated by the opposite party vide letter dated 18.04.2021.
7. As per letter dated 18.4.2021 vide Ex.R-12, the claim of the complainant was denied on the ground of following documents to be provided by the hospital in support of the claim:
a) Detailed Discharge Summary and all bills from the hospital.
b) Cash Memos from the hospitals/chemists supported by proper prescription.
c) Diagnostic Test Reports and Receipts supported by note from the attending Medical Practitioner/Surgeon recommending such Diagnostic supported by note from the attending Medical Practitioner/Surgeon recommending such diagnostic test.
d. Surgeon’s certificate stating nature of operation performed and Surgeon’s bill and receipt.
e. Certificates from attending Medical Practitioner/Surgeon giving patient’s condition and advice on discharge.
f. KYC document:
- Copy of photo ID, Address proof and recent photo of patient (for Valid proof of documents kindly refer KYC documents list) KYC documents list includes PAN Card/Driving License/Voter ID, Card/Aadhar card.
- Past illness records (with duration of symptoms) if any.
- First and subsequent consultation paper alongwith admission note.
- Complete medical history alongwith supporting investigation reports.
- In case of accident, MLC/FIR copy (if applicable.
- Claim consent letter.
The complainant had already submitted these documents and led in his evidence Ex.C1 to C-21. On the other hand, counsel for opposite parties has also tendered in his evidence Ex.R1 to Ex.R-12.
8. When the insured is above 63 years then the Insurance Company was at liberty to get the complainant medically examined prior to issuance of the policy in question. Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing the policy in question whether a person is fit to be insured or not. It was the duty of the opposite party to get the complainant immediately examined before issuing the policy as per IRDA guidelines.
During the course of arguments, Counsel for the complainant has placed on record Supreme Court on mediclaim policy: Insurer can’t reject claim by citing existing medical condition decided on 29.12.2021 vide Annx. X stating that:
“Once the policy has been issued after assessing the medical condition of the insured, the insurer cannot repudiate the claim by citing an existing medical condition, already disclosed by the insured in the proposal form. Supreme Court said.
An insurer cannot reject a claim by citing an existing medical condition that was disclosed by the insured in the proposal form, once the policy has been issued by the Supreme Court has said.”
9. After going through the evidence led by the parties, the Commission is of the opinion that once opposite parties have already paid the claim of the same patient they cannot denied the second claim of the complainant without any reasonable reason. Hence, the complaint is allowed.
10.. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite parties are also directed to pay Rs.5500/- as compensation for causing mental agony & harassment alognwith Rs.5500/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. File be consigned to the record room.
Announced on: 12.04.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
