BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

 Complaint No.187 of 2024

      Date of Instt. 22.05.2024

                Date of Decision: 06.08.2024

Romesh Singh Rajpoot son of Shangara Singh Rajpoot, Resident of Near Telephone Exchange, Apra, Distt. Jalandhar, Punjab-144416

..........Complainant

Versus

Niva Bupa Health Insurance Company through its authorized person, Registered Office:-C-98, First Floor, Lajpat Nagar, Part 1, New Delhi-110024.    

….….. Opposite Party

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                            (Member)

                   Sh. Jaswant Singh Dhillon       (Member)   

Present:       Smt. Harleen Kaur, Adv. & Ms. Anchita, Adv. Counsels                            for Complainant.

                   OP exparte.

Order

Dr. Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein it is alleged that the complainant obtained Apollo Munich Health Insurance Policy No.110600/11121/AA00739764 from its inception date of 15.01.2018 which was continues by the complainant without any gap. The company Apollo Munich was taken over by HDFC ERGO General Insurance Co. Ltd. on 08.01.20210, but the policy continued under the new company until 16.02.2024 with HDFC ERGO and subsequently being allured by the tempting benefits of the OP, chose to get ported to Niva Bupa Health Insurance on 14.02.2024 by the complainant and the portability accepted by Niva Bupa Health Insurance. The total amount of renewal premium of Rs.76,151/- was paid to Niva Bupa Health Insurance via cheque NO.000046 dated 10.02.2024 through its authorized agent/representative. The complainant complained of severe pain in the chest and uneasiness, pursuant to which he decided to get his heart check up done and upon the checkup the ECG reports showed that they were no normal so for further checkup the complainant consulted Medanta-The Medicity Hospital in Gurugram, he got admitted in the hospital on 20.03.2024, where he was diagnosed with 90% blockage in his Coronary Artery and he had to undergone an angioplasty and he underwent Coronary Artery Bypass Graftng on 21.03.2024 during surgery, steel wires have been placed to unite the sternum. Thereafter the complainant was discharged from hospital on 26.03.2024. The preauthorization request for cashless claim was made by the complainant for a claim of Rs.4,40,000/- for medical and surgical expenses to be incurred. However, the same was declined by the OP on 20.03.2024. The complainant also filed a claim for reimbursement of Rs.5,05,929/- alongwith all the requested documents to the OP and the same was also repudiated vide letter dated 30.04.2024. The act and conduct of the OP has been arbitrary and causing a lot of mental tension and harassment to the complainant and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse total amount of claim in the sum of Rs.5,05,929/- with interest @ 12% per annum from the date of lodging of mediclaim till the date of actual payment to the complainant. Further, OPs be directed to pay a compensation of Rs.1,00,000/- for causing mental tension and harassment to the complainant and Rs.35,000/- as litigation expenses.         

2.                Notice of the complaint was given to the OP, but despite service the OP did not appear and ultimately, OP was proceeded against exparte.

3.                In order to prove his respective version, the counsel for the complainant has produced on the file his respective evidence.

4.                We have heard the learned counsel for the respective parties and have also gone through the case file as well as written arguments submitted by counsel for the complainant very minutely.

5.                The complainant has proved that he had obtained Apollo Munich Health Insurance Policy in the year 2018 with the inception date 15.01.2018, which continued till 14.02.2024 when the complainant got ported the policy to Niva Bupa Health Insurance with the OP on 14.02.2024. It has also been proved that the company Apollo Munich was taken over by HDFC ERGO on 08.01.2020, but the old policy with Apollo Munich continued. The complainant has proved the insurance policies since 15.01.2018 till 16.02.2024 Ex.C-1 to Ex.C-3. The complainant has proved that under this policy, the complainant and his wife were covered. The complainant has also proved on record that after porting the policy into the OP, the complainant was held entitled for all the benefits and facilities for which he was entitled in the earlier policy which was taken in the year 2018. The complainant has proved Ex.C-4, the cheque of Rs.76,151/- paid to the OP as a premium. It has also been proved that the policy was renewed from time to time. Policy is still continuing. The policy schedule has been proved by the complainant as Ex.C-5 which shows that the sum insured limit carried over from previous insurance policy for the complainant and his wife were Rs.10,00,000/- each. Ex.C-3, the letter written by the OPs show that the policy was ported from 15.01.2018 and the benefits to be accrued to the complainant have been mentioned in this letter.

6.                The complainant has alleged that when he felt severe pain in his chest and felt uneasiness, he decided to get his heart checked up and after check up and going through the ECG reports, he came to know that the ECG reports were not normal, so he went to the hospital Medanta-The Medicity Hospital in Gurugram. He was diagnosed with 90% blockage in his Coronary Artery and he had to undergo an angioplasty. He was admitted in the hospital on 20.03.2024 and was discharged on 26.03.2024 from the hospital. The complainant has proved the discharge document Ex.C-7 and the certificate of the doctor Ex.C-6. Perusal of the Ex.C-6 shows that the Dr. Tushar Dhruv of Medanta Medicity has given the certificate about the admission of the complainant in their hospital and his discharge from the hospital. In the certificate, the doctor has also given the procedure adopted by them for the surgery of the heart of the complainant. The complainant has also proved that the request was made for cashless payment, but the same was denied vide Ex.C-8 on the ground that the possibility of chronicity of the illness cannot be ruled out at this moment so in depth verification required. The complainant was suggested to file for reimbursement. When the reimbursement was filed the same was repudiated by the OP vide Ex.C-9. The reason for repudiating the claim was as ‘patient is suffering from chest pain on exertion radiating to bilateral upper limbs since 3 months, which is prior to policy start date. This was not disclosed to us at policy issuance stage. We regret the claim is not payable under non disclosure, policy clause 6.1.2.2 and 6.1.14’. Perusal of the document i.e. discharge certificate Ex.C-7 shows that the complainant was having hypertensive and diabetic, but he was presented with complaints of chest pain on and off since 2-3 months. It has nowhere been mentioned that he was suffering from any chest problem earlier also or he was having any heart problem, no document is on the record to show that his disease is old one and pre-existing. He was having feeling of pain of and on and not regularly as per the certificate of the doctor.

7.                It has been held by the Hon’ble State Consumer Disputes Redressal Commission, U.T., Chandigarh, in a case titled as ‘Manish Goyal Vs. Max Bupa Health Insurance Co. Ltd., in Appal No.234 of 2017, decided on 22.03.2018 that ‘as per settled law & IRDAI requirement all people above the age 45 years should be thoroughly got medically checked before issuance of insurance policy’. It has been alleged by the complainant that before porting the policy, he was thoroughly medically checked up by the panels of the doctors of the OP, but since he was not having any problem, therefore, no pre-existing disease was found. More so, the policy with date of initiation i.e. 15.01.2018 was ported as per portability guidelines meaning thereby the policy was not started as alleged on the date of porting of policy but the same was continued since 15.01.2018 and the premium was duly received by the complainant including OPs.

8.                It has been held by the Hon’ble State Commission, Delhi, in a case titled as ‘Pardeep Kumar Garg Vs. National Insurance Co. Ltd.’ in an Appeal No.A-482/2005, decided on 01.08.2008 that ‘claim of insured should not and cannot be repudiated by taking a clue or remote reference to any so called disease from the discharge summary of the insured’.

9.                So, far as the ailment of diabetic is concerned. It has been decided by the Hon’ble National Commission in various judgments that Hypertension and Diabetes are not a disease, it is a general wear and tear of the life which occurred due to the pressure of the present life style and even otherwise the disease of Hypertension and Diabetes can be cured by taking medicine. It has been held by the Hon'ble National Commission in a case titled as ‘Neelam Chopra Vs. LIC (2018)’ that ‘common life style disease cannot be a ground to repudiate insurance claims.  It has further been held that ‘the non-disclosure of information regarding common life style disease such as diabetes will not disentitle the insured from claiming the policy amount’. Similar view was taken by the Hon'ble National Commission in a case titled as ‘Reliance Life Insurance Co. Ltd. Vs. Tarun Kumar Sudhir Halder (2019)’ that ‘diabetes is a life style disease in India and the entire of insurance claim cannot be rejected only based on its non-disclosure.’

10.              On the other hand, the OP has not come to contest the case. So, the version of the complainant remained un-rebutted and un- challenged, even then the same is required to glance very deeply. The allegation of the complainant is supported by his own affidavit Ex.CA and supported documents Ex.C-1 to Ex.C-9.

11.               In view of the above detailed discussion, the repudiation letter Ex.C-9 is held to wrong and illegal and the same is hereby set-aside. Thus, the complaint of the complainant is partly allowed and OP is directed to pay claim amount of Rs.5,05,929/- with interest @ 9% per annum from the date of lodging of mediclaim till its realization. Further, OP is directed to pay a compensation of Rs.25,000/- for causing mental tension and harassment to the complainant and Rs.15,000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

12.               Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated          Jaswant Singh Dhillon    Jyotsna               Dr. Harveen Bhardwaj     

06.08.2024         Member                          Member                President