Chandigarh

DF-II

CC/369/2016

Kumar Kant Chhabra - Complainant(s)

Versus

M/s Max Bupa Health Insurance Company Limited - Opp.Party(s)

Pradeep Sharma Adv.

13 Feb 2017

ORDER

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

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Consumer Complaint  No	:	369 of 2016
Date  of  Institution	:	25.05.2016
Date   of   Decision	:	13.02.2017

 

 

 

Kumar Kant Chhabra s/o Late Sh.Madan Mohan Chhabra, R/o H.No.429, Sector 16, Panchkula.

             …..Complainant

Versus

1]  M/s Max Bupa Health Insurance Company Limited, through its Chairman and Director Mr.Rajesh Sud and CEO Mr.Ashish Mehrotra, Corporate Office:-B-1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi 110044

2]  M/s Max Bupa Health Insurance Company Limited, through its Branch Manager, Branch Office: SCO No.55, 56 & 57, Sector 8-C, Madhya Marg, Chandigarh.

3]  Miss Jaya, Sales Officer, M/s Max Bupa Health Insurance Company Limited, Branch Office, SCO No.55, 56 & 57, Sector 8-C, Madhya Marg, Chandigarh.

….. Opposite Parties  

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

                                SH.RAVINDER SINGH             MEMBER 

        

 

For complainant(s)      : Sh.Pradeep Sharma, Advocate

 

For Opposite Party(s)   : Sh.Gaurav Bhardwaj, Adv. for OPs No.1 & 2.

                          OP-3 exparte.

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          As per the case, the complainant purchased Health Insurance Policy (Ann.C-1) from OP No.2 effective from 16.2.2015 to 15.2.2016 having sum insured of Rs.3.00 lakhs covering the complainant and his wife for cashless treatment. It is stated that the proposal form for the said policy was got signed from the complainant in blank, which later on was filled by OP No.3 (Ann.C-1).  It is averred that before issuance of the policy, the complainant and his wife had to undergo a pre-insurance medical test by OPs, in which they were found absolutely fine.

         It is stated that on 22.11.2015, the complainant started feeling intense pain in his arms and back, therefore got admitted in emergency at Alchemist Hospital, Sector 21, Panchkula, where it was observed that he was having high blood pressure and intense pain.  The complainant was discharged in late night (Ann.C-2) and was told that there might be some heart related problem, which should be checked. Thereafter, the complainant visited Dr.Anurag Sharma, who advised Quantitative Trop-I Blood Test, 2D-Color & Doppler Echocardiography and after going through the result of these tests, recommended Coronary Angiography as it was found that there was mild concentric Left Ventricular Hypertrophy only (Ann.C-3).  It is pleaded that while undergoing angiography, the doctor also placed Stent to prevent the damage to cardiac tissues due to Ischemia and blockage. It is lleged that the cashless request made to the Opposite Parties was denied (Ann.C-5), as such, the complainant had to make payment of the treatment expenses amounting to Rs.2,73,577/- to the hospital authorities. Thereafter, the complainant lodged claim with Opposite Parties for reimbursement of medical expenses, which they declined stating that ‘as per verification done, it was found that patient is having history of Borderline Mild Concentric LVH, which is prior to policy inception and same was not disclosed with us at the time when the policy was taken and hence the claim is rejected as per clause of non-disclosure of material facts of the policy. Alleging the said repudiation as illegal and deficiency in service, hence this complaint has been filed.

 

2]       The OPs No.1 & 2 have filed joint reply and while admitting the factual matrix of the case, stated that during the course of investigation done by them, it was revealed that the complainant’s health check-up reports dated 7.9.2013 confirmed him Borderline mild concentric LVH (Ann.G-colly). It is stated that the material facts revealed in the said health check-up reports were not disclosed by the complainant in the proposal form submitted at the time of inception of the policy. Had he disclosed about his medical condition, the OPs would not have issued the Health Insurance Policy to the complainant (Ann.H). Hence, the claim filed by the complainant was repudiated due to non-disclosure of material facts and the health insurance policy was terminated by the Opposite Party under Clause 5(i)(3) of the policy (Ann.I & J). Pleading no deficiency in service and denying rest of the allegations, the OPs have prayed for dismissal of the complaint.

         OP No.3 did not turn up despite service of notice through regd. post, hence it was proceeded exparte vide order dated 30.6.2016.

 

3]       Replication has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of the OPs in their 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 entire record as well as written arguments.

 

6]       From the perusal of medical record of the complainant comprising preventive health check-up undergone by him in the year 2013 as well the certificate issued by the doctor on whose advise the complainant undergone these tests, it is clear that although the complainant was found to be a case of Boderline Mild Concentric LVH, but the same is not a specific disease nor the root cause for blockage in Heart, as is duly certified by the doctor. It is duly certified by the Consultant Cardiologist of the complainant that the ailment suffered during the subsistence of the coverage period i.e. unstable angina is not due to Boderline Mild Concentric LVH. The said doctor has also certified that the complainant was not taking nor was advised any antihypertensive treatment in 2013, when was found as Borderline Mild Concentric LVH as it is common even in a healthy person. The certificate issued by Dr.Anurag Sharma, Consultant Cardiologist, Max Super Specialty Hospital, Mohali (Ann.C-16), reads as under:-

“Mr.Kumar Kant Chhabra, S/o late Sh.Madan Mohan Chhabra R/o H.NO.429, Sector 16, Panchkula took comprehensive cardiac package from Max Hospital in the year 2013, when only a Boderline Mild Concentric LVH was found and no prescription or any precaution was advised to him. Boderline Mild Concentric LVH is neither a specific disease nor the root cause for blockage in Heart and is common even in a healthy person.  Unstable angina is not due to borderline mild concentric LVH as this change in the echo report was not because of high Blood pressure.  Patient Mr.Kumar Kant Chhabra was not taking nor was advised antihypertensive treatment in 2013.”

 

         The abovesaid certificate issued by the doctor supported by his duly sworn affidavit undoubtly established that the complainant is not guilty of any suppression of material fact regarding his medical condition at the time of availing insurance policy in question as alleged by OPs No.1 & 2.

 

7]       The OPs have not placed on record any cogent evidence to contradict the genuineness of the claim or any expert opinion establishing that the treatment undergone by the complainant in the coverage period on 24.11.2015 (date of treatment), is the result of any previous ailment or the complainant was having any pre-existing disease.  The OPs have issued letters to the complainant asking him to provide the following vide Ann.C-7 & C-8:-

“1. Valid address proof of proposer, as the provided one is not clear to us.

         2.  All past treatment records of 2013.

3.  Confirm why 2013 records not share at the time of initial underwriting (Feb 2015)?

4.  Exact duration of Hypertension, certified by treating doctor”

 

8]       In our opinion, the above queries raised by OPs have duly been answered by the complainant vide Ann.C-9 and the record is evident of the fact that the complainant has no history of any past ailment and had not undergone any treatment.  Undergoing any preventive health check-up is not an impediment, in any way, to avail medical insurance policy and therefore, the complainant is in his full right to get his claim.

 

9]       In addition, it is admitted by the OPs that while availing the policy in question, the complainant was thoroughly medically examined and after undergoing all testes, he was not declared to be an unfit person to avail the policy.  Therefore, the rejection of the claim in the present complaint is totally a deficient act of the OPs No.1 & 2, which also shows their indulgence into unfair trade practice.

 

10]      In the light of above observations, the present complaint of the Complainant is allowed qua OPs No.1 & 2 and dismissed qua OP No.3. The Opposite parties No.1 & 2 are jointly & severally directed as under:-

 

[a]      To refund an amount of Rs.2,73,577/- to the complainant being the claim amount;

 

[b]      To pay Rs.20,000/- to the complainant as consolidated amount of compensation for causing mental agony and harassment for the deficiency in service of the OPs NO.1 & 2 and resorting to unfair trade practice.

[c]      To pay Rs.10,000/- towards litigation expenses to the complainant. 

 

         The above said order shall be complied within 45 days of its receipt by the Opposite Parties No.1 & 2; thereafter, they shall also be liable to pay interest @9% per annum on amount as at sub–para [a] & [b] above from the date of filing this complaint till realization, apart from complying with directions as at sub-para [c] above.

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

Announced

13^th February, 2017                                                                          Sd/-

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

 

Sd/-

(RAVINDER SINGH)

MEMBER