Chandigarh

DF-II

CC/493/2015

Rakesh Walia - Complainant(s)

Versus

M/s Max Bupa Health Insurance co.Ltd. - Opp.Party(s)

Sh. Yogender Mohan Adv.

23 Mar 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	493 of2015
Date  of  Institution	:	4.9.2015
Date   of   Decision	:	23.3.2016

 

 

 

 

 

Rakesh Walia S/o Shri Gurdas Ram Walia r/o House No.597, Sector 10, Urban Estate, Panchkula (Haryana).

                …..Complainant

Versus

 

1. M/s Max Bupa Health Insurance Co. Ltd. SCO No.55, Top floor, Sector 8, Chandigarh through its Branch Manager.
2. The Managing Director, Max Bupa Health Insurance Co. Ltd., Block B1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi 110 044.
3. The Managing Director Max Bupa Health Insurance Co., Ltd. Regd. Office Max House-1 Jha Marg, Okhla, New Delhi 110 0220.

….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         SH.JASWINDER SINGH SIDHU       MEMBER

         MRS.PRITI MALHOTRA             MEMBER

 

 

For complainant(s)      :     Sh. Yogesh Mohan, Adv.

 

For Opposite Party(s)   :     Sh. Gaurav Bhardwaj, Adv.

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          As per the case, the complainant on the allurement of the agent of the Opposite Parties purchased a ‘Health Insurance Policy’ for himself and his wife from the OPs and paid a cheque of Rs.17,399/- for the same. It is averred that after getting medical examination of the complainant and his wife and after getting satisfactory certificate from the concerned doctor the Opposite Parties issued Policy No.30257502201401  on 23.9.2013 under Heart Beat Silver 02 lacs plan commencing from the period 21.9.2013 to 20.9.2014 with sum insured for Rs.2.00 lacs. Thereafter the complainant renewed the policy by issuing a cheque of Rs.18,767/-. On 9.2.2015 the wife of the complainant fell ill and she was taken to hospital at New Delhi. After examination the doctors gave an estimate of Rs.2,35,697 for the treatment of wife of the complainant.  The said expenditure detail was immediately mailed to the OPs by the hospital authorities as the Fortis Hospital is attached with Opposite Parties for the purpose  of treatment and the same is covered under the policy. The OPs sent a message to the complainant that your pre authorized request number 65773 has been totally approved for Rs.1,20,000/-..  The treatment of wife of the complainant was done in the fortis hospital and at the time of discharge the complainant requested the OPs to pay the bill amount but they advised him to pay from his own pocket and assured the complainant to reimburse the same in due course. Accordingly the complainant cleared the hospital bill. It is alleged that  when the complainant submitted bills for Rs.2,54,035 with the OPs they rejected his claim vide letter dated 30.3.2015 on the ground of non-discloser of preexisting condition, which is arbitrary and illegal as before issuing the policy a proper medical checkup of the complainant and his wife was done by the Opposite Parties. However, the Opposite Parties did not supply copy of first medical check up conducted by an authorized doctor of the company.  It is further averred that had there been any preexisting conditions of disease the Opposite Parties would not have issued the policy and renew the same further.   When the grievance of the complainant was not redressed he sent a legal notice dated 9.4.2015 to the Opposite Parties but to no avail. Alleging the said act of OPs as deficiency in service, this compliant has been filed.

 

 

2.     Opposite Parties in their joint reply while admitting the factual matrix of the case stated that at the time of getting the insurance complainant proposed/represented that they both are totally healthy having no pre-existing  ailment/disease/disorder and on the basis of the information supplied by the complainant in the proposal form, the policy was issued to them. It has been denied that any medical examination of complainant or his wife was conducted. The policy was issued only on the basis of representation and information supplied in proposal form in good faith. It is asserted that the documents submitted by the complainant and the investigation report, clearly highlight the fact of the non-disclosure of pre-existing disease in existence prior to policy inception, as such the claim of the complainant was rightly rejected by the OPs. Claimed that the complainant concealed the factum at the time of taking the policy that his wife was suffering from pre-existing disease, which amount to serious non-disclosure of material facts and violation of terms and conditions of the policy. Had the complainant and his wife disclosed the material factum regarding the previous ailment to the Opposite Parties the Opposite Parties would not have issued them the policy,  therefore the OPs rightly rejected the claim of the  complainant in view of clause 4 (a) of the terms and conditions of the policy. It has been averred that this Forum has no jurisdiction to entertain and decide the complaint as the treatment was done at   Delhi and the complainant is resident of Mohali. Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.
3.     The Complainant also filed rejoinder thereby reiterating the averments as made in complaint and controverting that of the Opposite Parties made in the reply.
4.     Parties led evidence in support of their contentions.
5.     We have heard the ld. Counsel for the parties and have also perused the record carefully.
6.     The fact that the complainant is holder of health insurance policy availed from the OPs for the period from 21.9.2013 to 20.9.2014  which also covers his wife is well established on record.  It is further proved that the said policy was renewed by the OPs for the period from 21.9.2014 to 20.9.2015 against the receipt of premium to Rs.18,767/- Paid by the complainant. It is also undisputed that the wife of the complainant duly covered under the policy had undergone treatment from 9.2.2015 to 13.2.2015 at  Fortis hospital. It is claimed by the complainant that an amount of Rs.2,54,035 was incurred for the said treatment. The complainant after clearing the dues of the hospital lodged claim with Opposite Parties for the reimbursement of the same. However the OPs rejected the claim of the complainant vide letter dated 30.3.2015 Annexure C-3. 

    It is claimed by counsel of the complainant that not only before issuing the policy in question for the first time the complainant as well as his wife were thoroughly medically examined by the authorized doctor of the OPs but also were medically examined at the time of renewal of the policy for the period from 21.9.2014 to 20.9.2015. It is further claimed that an estimate of expenditure of Rs.2,35,697/- for the treatment of the wife of the complainant given by the hospital was immediately emailed to the OPs for its pre-authorization  as the said hospital was attached with the OPs for the purpose of treatment and it is covered under the policy. Further claimed that after thorough examination of bills of expenditure the OPs gave message to the complainant confirming that the pre authorisation request has been approved for Rs. 1,20,000/-. The relevant message claimed by the complainant is reproduced as under:-

“we are pleased to inform you that your pre-auth request  number 65773 has been totally approved for
Rs. 12000 so far, as requested. Thank you. Max Bupa, Time 19:21, 10.2.2015.”

 

7.     It is further claimed on behalf of the complainant that after the treatment and getting discharge from the hospital the complainant approached the OPs for the reimbursement but they illegally repudiated the claim vide letter dated 30.3.2015 citing the following reason:-

“As per submitted/document/investigation done by us discloser of preexisting condition is evident. Symptom falls prior to policy inception. Hence denied under clause 4a.”

 

8.     The counsel for the complainant argued that the above repudiation is not justified the complainant is entitled for the claim being fully covered under it.
9.     On the contrary the OPs claimed that the complainant is guilty of non disclosure of certain facts which were duty bound to disclose at the time of getting insurance policy from the Opposite Parties. Further claimed that since contract of insurance is a contract of mutual faith and insured is under obligation for disclosure of statement within his knowledge and in case of non-disclosure the repudiation is justified. Further claimed that the complainant failed to disclose the fact that his wife was suffering from pre-existing disease and only from the documents submitted by the complainant and the report of investigation it was found that his wife was suffering from pre-existing disease.  
10.     The OPs took objection regarding jurisdiction of this Forum on the ground that the alleged treatment has been taken at Delhi and the complainant is resident of mohali hence this Forum cannot entertain and decide the case. This objection of the Opposite Parties has no merit in view of the factum that the insurance certificates(Annexures C-1&2) were issued to the complainant by the branch office of OPs at Chandigarh.  
11.     Now it is to be seen whether complainant is entitled for the expenditure incurred for the treatment of his wife (duly covered under the policy) which the OPs have repudiated on the ground of non-disclosure of facts about pre-existing disease. For this certainly we require proposal form duly filled in by the complainant at the time of proposing of the policy in question for first time. Strangely it is found that no proposal form has been placed on the record by the OPs to verify allegation of the non-disclosure  of the pre-existing disease.  The ‘Annexure B’ claimed to have been a proposal form by the OPs in their written statement. In fact this is not a proposal form in actual and if for the argument sake it is presumed that it is a proposal form, a perusal of all the columns there under would reveal that all disclosures about the medical history of the wife of the complainant have been mentioned. So it cannot be said that anything has been concealed from the OPs while obtaining the policy in question.  So the allegation of the concealment of any pre-existing disease proves baseless and the OPs are held negligent in rendering service to the complainant.  
12.     In addition to the above the (IRDA) has given clear cut instructions to the insurance companies to get medical examination conducted of the proposed in case of  medi-claim policy if the age of person proposing for the policy is 45 years old or more.  But in the present complaint the OPs categorically stated in the written version that they had not got conducted the medical examination of the complainant and his wife at the time of issuing the policy and issued the policy on the disclosures made by the complainant in the proposal form, which materially is a defiance of the instructions issued by the IRDA and now they cannot take shelter under the non disclosure of pre-existing disease to justify their repudiation.
13.     The Opposite Parties have also not contradicted the contention of the complainant that the pre-authorization request was accepted vide message sent by the OPs for an amount of Rs.1,20,000/-. So it can safely be said that the Opposite Parties earlier accepted pre-authorization request and after treatment when the complainant lodged his claim for the reimbursement they illegally repudiated the claim citing clause 4A of the policy terms and conditions about pre-existing disease. We are of the considered opinion that pre-authorisation acceptance is only made after thorough verification and thus thereafter the claim cannot be denied.
14.     The expenditure incurred to the tune of Rs.2,54,035/-  on the basis of bill raised by the hospital concerned, is not disputed by the   OPs.
15.     In view of the above, it is quite clear that the OPs are deficient in rendering service to the complainant   by not paying his genuine claim for expenditure incurred for the treatment although having duly covered under the policy.
16.     Since as per policy the complainant and his wife are insured for the sum of Rs.2.00 lacs only so are entitled to be indemnified to  that extent only and are left to bear the burden of the rest of the amount.
17.          For the reasons discussed above, we are of the opinion that the complaint deserves to be allowed.  Accordingly, the complaint is allowed and the Opposite Parties are jointly & severally directed as under:-

        

a]  To pay the insured amount of Rs.2.00 to the complainant towards the expenditure incurred by him towards the treatment of his wife in the hospital.

 

b]  To pay Rs.15,000/- as compensation for causing mental agony and physical harassment to the complainant.

C]  To pay Rs.5,000/- towards litigation expenses.

 

         The above said order shall be complied with by the Opposite Parties within 45 days of its receipt, failing which they shall be liable to pay interest on the above awarded amount at (a) and (b) at the rate of 12% p.a. from the date of this order till it is paid, besides paying litigation expenses. 

 

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

23.3.2016

                                                                                       Sd/-

 (RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (JASWINDER SINGH SIDHU)

MEMBER

 

 

Sd/-

(PRITI MALHOTRA)

MEMBER