The complainant had earlier filed her complaint as to same cause of action bearing NO. 17/2018 titled “Alpana Sinha Vs. Max Bupa Health Insurance company Limited” before the Hon’ble Fora but since no claim was lodged by the complainant with the insurance company thus the said complaint had been dismissed being pre-mature by the Hon’ble For a vide order dated 27.02.2019, whereby that “the complainant to lodge the claim with the opposite parties – insurance company within 15 days from the date of receipt of said claim. However, if the claim of the complainant is repudiate then he is at liberty to file fresh complaint before this Forum.”
Thereafter, in view of the directives of the Forum as per the said order the complainant had lodged her claim with the opposite party company and then, on the basis of documents and investigations, it was revealed that claim was being sought for CLD (Chronic Liver Disease) which was existing since February 2014, prior to policy inception since the patient had taken treatment for CLD in GB Pant Hospital, New Delhi and it was evident from its discharge summary dated 11.02.2015 that the patient was complaining for jaundice since one year so the duration of said complaint was falling prior to policy inception and the same was not disclosed to the insurance company at the time of obtaining insurance policy thus the said claim had been rejected on account of misrepresentation by the insurance company as per the terms & conditions of the insurance policy so issued under “Letter of intimation” dated 23.04.2019 by following the guidelines of the insurance company, which decision cannot be termed unconscionable at all.
The answering opposite party relies upon the following document submitted by the complainant themselves alongwith the claim for reimbursement which showcases the aforementioned non disclosure on the basis of which the claim was rejected:
a. The discharge summary from G.B.Pant Hospital with date of admission 15.01.2015 notes the following:-
H/o LVP 5 years back treated as TB with ATT 3 months and stopped. K/C/O Psorais, jaundice progressive.
b. Documents submitted alongwith claims (at page 202) states that the insured patient was suffering from intermittent abdominal distension since 2007 and has been in distress since then.
C Emergency notes from AIIMS dated 14.01.2015 clearly notes that the insured patient was suffering from jaundice since 1 year (which is prior) to policy issuance.
Therefore, relying on the aforementioned documents and on the basis of the investigation conducted, the claim of the complainant was rejected on the basis of non disclosure. Opposite party 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 party–Max Bupa Health Insurance Company Ltd. with the prayer to: a) release the payment of Rs.5,00,000/- alongwith interest @ 18% p.a. from the date of its due till realization of whole amount immediately. b) pay Rs.2,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 55,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.C1/1 – affidavit of Alpana Sinha,, Annexure C-1 - policy, Annx.C2 – discharge summary,, Annx.C-3 – affidavit, Annx.C-4 – prescription from Kaya Maya Ayuredic Hospital, Annx. C-5 – prescription from S.K.Medical Centre, Annexure C-6 – prescription from Patanjali Ayurveda Hospital, Annexure C-7 – Requisition/Instructions/Consent Form for MRI., Annx.C-8 - prescription, Annx.C-9 – Deth certificate,, Annx.C-10 – interim bill, Annx.C-11 – postal receipt, Annx.C-12 – legal notice, Annexure C-13 – withdraw order dated 28.03.2016, Annexure C-14 – order dated 25.08.2017, Annx.C-15 – order dated 27.02.2019 passed by DCDRF, Faridabad, Annx.C-16 – letter dated 23.04.2019., Annx. C-17 – invoice,, Annx.C-18 – driving licence, Annx. C-20 – Ration card, Annx.C-21 – adhaar card,
On the other hand counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party Ex.RW1/A, Ex.R1 – letter of authorization, Ex.R-2 – form, Ex.R-3 – policy, Ex.R-4 & 5– emails, Ex.R-6 - Claim form, Ex.R-7 – investigation report, Ex.R-8 - letter dated 11.10.2019.
6. As per Annexure C-1, Shri Vijay Kumar Sinha obtained a medical claim insurance policy bearing No. 30298059201400 covering the risk from 14.2.2014 to 13.02.2015 for a sum of Rs.5,00,000/- issued by the opposite party. As per Annexure C-2 on 07.12.2014 the above named son of the complainant became sick, as he was suffering from Chronic Liver disease, hence he got admitted in Indraprastha Apollo Hospital, Delhi on the same date, on the basis of above said insurance policy, where he was given treatment by the concerned doctors/medical officers. When the abovesaid hospital authority contacted the opposite party, then they stated that in their records, the name of insurance policy holder had been written as ‘Vinay Kumar Sinha’ instead of Vijay Kumar Sinha and due to the said reason, the opposite party flatly refused to release the payment of any amount. Whereas the above named son of the complainant remained admitted as an indoor patient in the above said hospital as indoor patient from 7th December 2014 to 13th December2014 and during that period, the complainant spent Rs.1,02,945/- on account of treatment of her son. As per affidavit dated 09.12.2014 vide Annx.C-3 that Vijay Kumar Sinha and Vinay Kumar Sinha are one and same person. Opposite party has repudiated the claim of the complainant vide letter dated 25.04.2019 Annexure C-16 on the ground that “As per submitted documents and investigation/evaluation done by us, it revealed that patient seeking claim for CLD, which is existing since Feb. 2014, prior to policy inception. Since, patient taken treatment for CLD in GB Pant Hospital, discharged summary dated 11.02.2015 evident that , patient complaining for jaundice since one year, the duration of complaint is falling prior to policy inception and the same was not disclosed to us at the time of taking policy. Therefore, the claim is being rejected in misrepresentation under policy T&C, clause NO.12.20. Treatments done on 07.12.2018 falls outside member coverage period from 14.2.2014 to 13.2.2015.
7. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite party is directed to process the claim of the complainant as per the T&C of the insurance policy and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite party is also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alognwith Rs.2200/- 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: 11.05.2023 (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.
