Punjab

Ludhiana

CC/21/16

Anil Kumar Bhalla - Complainant(s)

Versus

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

Kim Bhalla

27 Jun 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 16 dated 08.01.2021.                                                Date of decision: 27.06.2024. 

 

Anil Kumar Bhalla through his Legal Heirs

1. Renu Bhalla W/o. Late Sh. Anil Kumar Bhalla, R/o. H. No.9545, Joshi Nagar, Haibowal Kalan, Ludhiana.
2. Kin Bhalla S/o. Late Sh. Anil Kumar Bhalla, R/o. H. No.9545, Joshi Nagar, Haibowal Kalan, Ludhiana. 

                                                                                      ..…Complainant

                                                Versus

M/s. Max Bupa Health Insurance Co. Ltd., Unit No.3, Plot No.88, Second Floor, Kunal Tower, Mall Road, Opposite AXIS Bank Ltd., Ludhiana, Punjab.                                                                                    …..Opposite party 

Complaint Under Section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Kin Bhalla, legal heir of the complainant in                                           person.

For OP                           :         Sh. Varun Gupta, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that the complainant Anil Kumar Bhalla (now deceased) purchased Heartbeat Silver Plan Health Insurance policy for two adults from the OP firstly in the year 2015 i.e. from 18.03.2015 to 17.03.2016 vide policy No.30409203201500, which was got renewed from time to time from 18.03.2016 to 17.03.2017, 18.03.2017 to 17.03.2018, 18.03.2018 to 17.03.2019. Before issuing the policy in the year 2015, proper medical of the complainant was conducted by authorized doctor of the OP and after receipt of reports, the policy was given to the complainant on payment of yearly premium of Rs.20,628/-. The OP issued policy No.30409203201803 having validity from 18.03.2018 to 17.03.2019. The complainant stated that suddenly on 07.01.2019, he fell seriously ill and was admitted in Dayanand Medical College & Hospital, Ludhiana. Intimation was given to the OP who initiated pre authorization and sanctioned initial amount for cashless treatment. The complainant was given treatment in the said hospital and was discharged on 12.01.2019. A cashless claim of Rs.71,331/- was raised on the same day but the OP cancelled the previous sanctioned authorization invoking clause 8.4. The complainant had to pay the entire bill from his own pocket. The complainant further stated that the OP denied his claim of Rs.71,331/- despite the fact that he had paid a premium of Rs.1,20,000/- to the OP since 2015 till 2019. However, at the time of rejection of the claim, the OP assured the complainant to reconsider his request later and as such, the complainant in February 2019 submitted all the bills, receipts of medicines with the OP but the OP rejected his claim without giving any proper and reasonable grounds. Rather the OP retained the medicine bills of the complainant and only returned him the hospital bill and reports. The complainant approached the OP to know the reason of denial of his claim but to no effect. As such, the OP is guilty of rendering deficiency in service and unfair trade practice despite receipt of huge premium from the complainant which has caused mental pain, agony and harassment to the complainant. In the end, the complainant has prayed for issuing directions to the OPs to pay claim of Rs.71,331/- along with compensation of Rs.2,00,000/- and litigation expenses of Rs.11,000/-.

2.                Upon notice, the OP appeared and filed written statement and assailed the complaint by taking preliminary objections on the ground of maintainability; lack of jurisdiction and cause of action; suppression of material facts and also took the plea of estopple. The OP stated that the complaint is devoid of any material particulars and same has been filed to harass and gain undue advantage and unjustified monies from them.  The complainant is not entitled for any claim and his claim of the complainant was repudiated on the ground that the disease of the complainant falls within the purview of permanent exclusion.

                   In the column Brief Facts, the OP stated that it received a duly filled and signed proposal form from the complainant for issuance of insurance policy for himself and his spouse and believing the information and details of the proposer including his medical history in the form, the OP issuance policy No.30409203201500 for sum assured of Rs.3,00,000/-. The policy documents were delivered to the complainant. The OP further stated that it received pre-authorization from DMC & Hospital, Ludhiana for which the OP raised additional information about the health of complainant and upon receiving the same, the OP found that the disease of the complainant is related with auto-immune disorder which falls under Permanent Exclusion of the terms 8.4 conditions of the policy. The claim of the complainant was rejected as per purview of Permanent Exclusion Clause, on the following grounds:-

          “8.4 Autoimmune Disorders

Screening, Counseling, treatment of complications related to auto immune diseases. Hence the claim is not payable. Further Permanent exclusions means that listed category of treatments, which are never covered in health insurance policy for whole life. They are excluded permanently from the ambit of the health insurance scope.”

 

According to the OP, the claim was rightly rejected.

                   On merits, the OP reiterated the crux of averments made in the preliminary objections. The OP has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                The complainant filed rejoinder to the written statement reiterating the facts mentioned in the complaint and controverted those mentioned in the written statement.

4.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 is the copy of premium receipt dated 19.03.2015 and policy terms and conditions, Ex. C2 is the copy of insurance certificate w.e.f. 18.03.2018 to 17.03.2019, Ex. C3 is the copy of In-Patient Final Bill dated 12.01.2019, Ex. C4 is the copy of discharge summary, Ex. C5 is the copy of repudiation letter dated 22.12.2020 and closed the evidence.

5.                On the other hand, the counsel for the OP tendered affidavit  Ex. RA of Sh. Bhuwan Bhashker, Authorized Signatory of the OP along with documents Ex. R1 is the copy of  policy documents etc from page 1 to 251 and closed the evidence.

6.                During the pendency of the complaint, the complainant Sh. Anil Kumar Bhalla died. An application dated 20.02.2023 for impleading his legal heirs was moved. The counsel for the OP suffered statement having no objection if the said application is allowed. As such, said application was allowed vide order dated 27.03.2023 by impleading legal heirs Smt. Renu Bhalla, being wife and Sh. Kin Bhalla, being son.

7.                We have heard the arguments of the counsel for the parties and also gone through the complaint, rejoinder, affidavit and annexed documents and written statement along with affidavit and documents produced on record by both the parties.

8.                On the basis of proposal form dated 11.03.2015 Ex. R1 (Page 1), the OPs issued policy bearing No. 30409203201500 namely Heartbeat Siler 03 Lacs 2 Adults Plan having a sum insured of Rs.3,00,000/- for complainant and his wife, having validity from 18.03.2015 to 17.03.2016 by paying premium of Rs.20,628/- vide receipt Ex. C1. The complainant continued to get renewing the insurance policies from the OPs i.e. from 18.03.2016 to 17.03.2017, 18.03.2017 to 17.03.2018 and from 18.03.2018 to 17.03.2019 (Ex. C2) on an annual premium of Rs.34,423/-. On 07.1.2019 the complainant fell ill and was admitted at Dayanand Medical College & Hospital, Ludhiana and he was discharged on 12.01.2019 vide discharge summary Ex. C4. Intimation was given to the OP vide Intimation Verification Form Ex. R1 (Page 235). The cashless authorization submitted by the hospital authorities (Ex. R1 page 222 and page 238) was initially approved by the OP but later on the OP denied the cashless treatment to the complainant by invoking clause 8.4 of the terms and conditions of the policy Ex. R1 page 220) on the ground that “In accordance with clause 8.4, Expenses for Screening, counseling, treatment or complications related to autoimmune disease will not be covered”. The complainant paid a sum of Rs.71,331/- to the hospital and later on, lodged a claim of Rs.71,331/- with the OP vide claim form Ex. R1 (page 111 to 114) along with relevant documents. The OP got investigated the claim of the complainant and investigation report Ex. R1 (Page 213 to 215) was prepared, in which the investigator recorded the following findings and recommendations:-

“Findings: As per IVR-Patient told me that he had pain in the abdomen from the past 15-20 days for that he consulted with the Dr. Dinesh but he did not get any relief after that when the condition get worse he admitted in the DMC hospital.

Recommendations: Claim seems to be genuine”

 

Later on, the OP repudiated the claim of the complainant vide letter dated 22.12.2020 Ex. C5, the operative part of which is reproduced as under:-

                   “Disallowance reason

As per the documents received & investigation done by us it has been observed that the present ailment is autoimmune in nature and not covered under policy clause no.8.4, hence claim is denied.”

9.                The main basis of repudiation of the claim by the OP is that the complainant was suffering from autoimmune disease. The OP repudiated the claim of the complainant by invoking exclusion clause 8.4 of the terms and conditions of the policy on the basis of findings of the treating doctor given in discharge summary Ex. C4 “Patient was suspected to be having Autoimmune disease. Patient was worked up for it. Patient’s liver biopsy was done.”

                   The OP has not produced any terms and conditions of the policy containing exclusion clause 8.4. Further the complainant has been getting insurance policy since the year 2015 and clause 8.4 should be in the terms and conditions supplied to the complainant with the policy in the year 2015. But in the present case, no such exclusion clause 8.4 has any existence in the policy terms and conditions supplied to the complainant by the OP. The onus to prove the exclusion clause is on the insurance policy. Further it is material to see whether this clause was in existence at the time of inception of the policy or not. Repeated queries were put to the counsel for the OP to produce the some document on record to show that the Auto Immune disease was also excluded in the first policy. No such document has been placed by the OP. Meaning thereby that this clause was introduced during the subsistence of subsequent policies without any notice to the complainant. As per settled law, if there is any change in the terms and conditions of the policy, then notice of the same should be given to the insured. In this regard, reference can be made to judgment passed in Civil Appeal No.6778 of 2013 in Jacob Punnen & Another Vs United India Insurance Co. Ltd. decided on 09.12.2021 whereby the Hon’ble Supreme Court of India in para No.34 of its judgment has made the following observations:-

“34. Such a failure assumes importance even from the perspective of consumer protection law. The Consumer Protection Act, 1986 states the definition of ‘deficiency’ in service under Section 2(g) as “[A]ny fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be maintained by or under any law for the time being in force or has been undertaken to be performed by a person in pursuance of a contract or otherwise in relation to any service”. In order to demonstrate deficiency, it is not necessary that the same emanates only from a law or a contract. The term “or otherwise” clearly provides for circumstances where a certain level of service is expected from a provider. As stated above in the judgment, the principle of uberrima fides involves prior intimation of change in terms in insurance contracts. The deficiency of service assumes even more significance in the present case, as it pertains to senior citizens.”

10.              Seeing from the another angle, the treating doctor in the discharge summary has expressed his suspicion by mentioning the patient being suspected to be having autoimmune disease. The OP has also placed on record the complete discharge summary as Ex. R1 (Page 245)  and tried to pick holes in the discharge summary in order to deny the claim of the complainant. The discharge summary contains the treatment record in chronicle order by the treating doctors and there is nothing to suggest that the complainant was not hospitalized. Even the investigator appointed by the OP found the claim to be genuine and recommended for its settlement. Moreover, no expert of the medical team was examined nor any affidavit of medical team was tendered by the OP to support their contentions. In the absence of any expert medical opinion or affidavit of the team member, the claim of the complainant with regard to his ailment and admission seems to be genuine and not false or fraudulent. Therefore, the OP has wrongly invoked the exclusion clause 8.4 of the terms and conditions of the policy. As such, in the given circumstances, it will be just and appropriate if the OP is directed to settle and reimburse the claim of the complainant within 30 days from the date of receipt of copy of order and to pay composite costs of Rs.10,000/-. 

11.              As a result of above discussion, the complaint is partly allowed with direction to the OP to settle and reimburse the claim of the complainant Sh. Anil Kumar Bhalla, now deceased with regard to his hospitalization at Dayanand Medical College and Hospital, Ludhiana from 07.01.2019 to 12.01.2019 within 30 days from the date of receipt of copy of order failing which the legal heirs of the complainant shall be held entitled to interest @8% per annum on the settled amount from the date of order till its actual payment.  The OP shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the legal heirs of the complainant within 30 days from the date of receipt of copy of order. The legal heirs of the complainant shall be entitled to above said amounts in equal share.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

12.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:27.06.2024.

Gobind Ram.