Chandigarh

DF-I

CC/455/2023

VINOD KUMAR NANCHAHAL - Complainant(s)

Versus

NIVA BUPA HEALTH INSURANCE COMPANY LIMITED - Opp.Party(s)

DEVINDER KUMAR

05 Mar 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/455/2023
Date of Institution	:	19/09/2023
Date of Decision	:	05/03/2024

 

Vinod Kumar Nanchahal son of Sh. Kuldeepak Lal Nanchahal, aged about 71 years, r/o H.No.251-B, Sunny Enclave, Urban Vatika, Zirakpur, SAS Nagar, Mohali, 140603.

… Complainant

V E R S U S

1. Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Company Limited), SCO No.84-85, Sector Floor, Sector 8-C, Madhya Marg, Chandigarh through its Branch Manager.

2. Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Company Limited) Registered Office: C-98, Lajpat Nagar-I, New Delhi 110024 through Managing Director.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

       

ARGUED BY	:	Sh. Devinder Kumar, Advocate for complainant
	:	Sh. Gaurav Bhardwaj, Advocate for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Vinod Kumar Nanchahal, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that, in the month of January 2021, agent of OP-1 had approached the complainant and explained about the features of health insurance policy and upon assurances given by the said agent, complainant had agreed to purchase a health insurance policy from the OPs.  At the time of purchase of the subject policy, complainant was 64 years old and he was told by OP-1 that before obtaining the medical health policy, he is required to undergo medical examination regarding which one email (Annexure C-1) was also sent to the complainant by the OPs asking him to come for his medical examination on 24.1.2021.   After getting the medical examination of the complainant on the said date and on obtaining the medical examination report and test report etc. (Annexure C-2 colly.), OPs issued health insurance policy under the plan “Health Companion Variant 1” valid w.e.f. 4.2.2021 to 3.2.2022 (Annexure C-3) to the complainant and later on the said policy was annually renewed w.e.f. 4.2.2022 to 3.2.2023 (Annexure C-4) and 4.2.2023 to 3.2.2024 (Annexure C-5) (hereinafter referred to as “subject policy”).  From the year 2021 to March 2023 complainant, had not raised any claim with the OPs and he continued getting the policy renewed annually on payment of premium to the OPs.  In the month of February 2023, complainant faced pain and accordingly he visited the Max Hospital, Mohali (hereinafter referred to as “treating hospital”) where he was advised for tests and after conducting tests Symptomatic Cholecystectomy + Liver Cirrhosis was diagnosed (i.e. stone in gall bladder) was diagnosed and accordingly the doctor advised for surgery to the complainant and copy of medical slip is Annexure C-6.  Prior to conducting surgery, the treating hospital had submitted the required documents with the OPs for cashless facility for treatment of the complainant and the OPs had approved cashless facility to the tune of ₹1,30,840/- vide letter (Annexure C-7). Thereafter, on obtaining approval from the OPs, treating hospital had conducted surgery on 3.3.3023 and discharged the complainant on 4.3.2023 by raising bill of ₹1,59,751/-. Copies of discharge summary and bill are Annexure C-8 and C-9.  However, vide letter dated 4.3.2023 (Annexure C-10) OPs had rejected the cashless facility already approved in favour of the complainant on the ground that the patient had history of CLD since 2017 which is prior to the policy start date and as the said fact had not been disclosed by the insured, OPs are unable to extend the cashless facility to the complainant and due to the aforesaid act of the OPs, complainant was compelled to pay an amount of ₹1,95,539/- to the treating hospital which is clear from the payment receipts (Annexure C-11).  Prior to the surgery, complainant had already paid a sum of ₹34,014/- and after surgery he has further paid an amount of ₹1,774/- as post hospitalisation expenses as is also clear from the bills (Annexure C-12 colly. & C-13) and in this manner has paid total amount of ₹1,95,539/-.  Not only this, instead of paying the genuine claim of the complainant, vide email dated 6.3.2023 (Annexure C-14) OPs have further sent a notice for cancellation of the subject policy. Since complainant was not having history of CLD since 2017, which was even not diagnosed at the time of his medical examination got conducted by OPs, and he had disclosed to the OPs about his health issues before obtaining the subject policy, OPs have wrongly rejected/repudiated the claim of the complainant and cancelled the subject policy. In this manner, aforesaid act of OPs amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result. Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action and concealment of material facts.  On merits, admitted that the subject policy was obtained by the complainant from the OPs, but, alleged that as the complainant has suppressed material facts qua his pre-existing disease before purchasing the subject policy, as he was suffering from CLD since 2017 which is prior to the policy start date, the claim was rightly rejected/repudiated by the OPs on account of non-disclosure and concealment of material facts by the complainant and the subject policy was rightly cancelled by the OPs.  Not only this, by concealing the facts about his pre-existing disease, which was prior to obtaining the subject policy, complainant has violated the terms and conditions of the subject policy and the consumer complaint of the complainant, being false and frivolous is liable to be dismissed. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. Despite grant of sufficient opportunity, rejoinder was not filed by the complainant to rebut the stand of the OP.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had obtained the health insurance policy (Annexure C-1) which was valid w.e.f. 4.2.2021 to 3.2.2022 and got the same annually renewed w.e.f 4.2.2022 to 3.2.2023 and 4.2.2023 to 3.2.2024, as is also evident from copies of the policy certificates (Annexure C-4 and C-5) and in the month of February complainant had undergone surgery at the treating hospital where he was admitted on 3.3.2023 and discharged on 4.3.2023, as is also evident from the discharge summary (Annexure C-8) and he had spent total amount of ₹1.95,539/-, as is also evident from the copies of receipts/bills (Annexure C-11 to C-13) and firstly the OPs have approved the cashless claim vide their letter (Annexure C-7) and later on rejected the said approval vide letter (Annexure C-10) and have further cancelled the subject policy vide email (Annexure C-14), the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in rejecting/repudiating the claim and cancelling the policy and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs have rightly rejected/repudiated the claim and cancelled the subject policy on the ground of non-disclosure of material facts and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, medical record, having been relied upon by the OPs, and claim rejection/repudiation letter as well as policy cancellation letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Annexure C-5 is copy of subject policy which was renewed on annual basis and the same is valid w.e.f. 4.2.2023 to 3.2.2024. As per terms & conditions of subject policy, in case of non-disclosure of material facts by the insured, claim can be repudiated and policy can be cancelled by the insurer.
   4. In the case in hand, as per the case of the complainant, he was not suffering from any disease including liver disease, except that he was operated upon for hernia four years back regarding which the said fact had also been disclosed by the complainant even at the time of his medical examination, which was got conducted by the OPs before issuing the subject policy, and further when the complainant was treated upon by the treating hospital for Symptomatic Cholecystectomy + Liver Cirrhosis was diagnosed (i.e. stone in gall bladder), which otherwise has no nexus with the chronic liver disease (CLD), OPs have wrongly rejected/ repudiated the claim of the complainant and have cancelled the subject policy.
   5. On the other hand, defence of the OPs is that since the complainant was suffering from CLD four years prior to his surgery, conducted on 3.3.2023, which indicates that even before obtaining the subject policy, complainant was suffering from the said disease and as the complainant had suppressed material facts qua pre-existing disease from the OPs, the cashless facility was rightly rejected/repudiated and the policy was accordingly cancelled.
   6. However, the defence of the OPs that the complainant was suffering from CLD four years prior to obtaining the subject policy stands falsified from the medical reports issued by the medical officer by whom the complainant was medically examined at the instance of the OPs before issuance of the subject policy and no such disease was even diagnosed by the medical team headed by Dr. S.L. Singla, of which now the OPs have been resisting the claim of the complainant.
   7. Annexure C-1 is the letter sent by the OPs to the complainant to come for his medical examination  on 24.1.2021 and accordingly the complainant appeared before the medical team of the OPs and had disclosed all the facts including his surgery of hernia four years back, as is also evident from the medical examination report (Annexure C-2) and the medical examination of the complainant was confirmed by the said team as per confirmation of medical examination (available at page 16 of Annexure C-2) making further clear that after getting the complainant medically examined from the medical team and in pursuance to the medical record (Annexure C-2), OPs had issued the subject policy to the complainant.
   8. Even the discharge summary (Annexure R-6), having been relied upon by the OPs, clearly indicates that the complainant was admitted in the treating hospital on 3.2.2023 and was discharged on 4.3.2023 where he was diagnosed with Symptomatic Cholelithiasis + ?Liver Cirrhosis and Laparoscopic Cholecystectomy Liver Biopsy was done under GA on 03/03/2023. The relevant portion of discharge summary is reproduced below for ready reference :-

“Diagnosis:

Symptomatic Cholelithiasis + ?Liver Cirrhosis

Procedure Done:

Laparoscopic Cholecystectomy Liver Biopsy done under GA on 03/03/2023

Presenting Complaints:

EPIGASTRIC DISCOMFORT AND DYSPEPSIA FOR ONE MONTH.

History of Present Illness:

PATIENT PRESENTED WITH EPIGASTIRC DISCOMFORT AND DYSPEPSIA FOR THE LAST ONE MONTH WHICH WAS PROGRESSIVE IN NATURE AND DID NOT RESOLVE WITH MEDICATION. NO C/O ASSOCIATED FEVER/VOMITINGS/JAUNDICE.

USG SUGGESTIVE OF MULTIPLE GALL BLADDER CALCULI 7.5 MM. HETEROGENOUS LIVER PARENCHYMA.

CECT ABDOMEN: HEPATOMEGALY WITH IRREGULAR OUTLINE WITH HETEROGENPUS ATTENUATION WITH VOLUME REDISTRIBUTION WITH LEFT LOBE AND CAUDATE LOBE HYPERTROPHY.

TINY HYPODENSE NODULES IN THE RIGHT LOBE OF LIVER. POSSIBLE TINY REGENERATIVE CIRRHOTIC NODULES.

FEW TORTUOS ESOPHAGEAL VARICES.

FEW TORTOUS VESSELS IN MESENTRY IN EPIGASTRIC REGION

MULTIPLE SMALL HYPODENSITIES SEEN IN LUMEN OF GALL BLADDER-LIKELY CHOLELITHIASIS.

Past Medical History

H/O CLD SINCE 2017

H/O BPH FOR 1 YEAR

H/O HYPOTHYROIDISM FOR 6 MONTHS

H/O HYPERTENSION FOR 2 MONTHS

PATIENT UNDERWENT B/L INGUINAL HERNIOPLASTY IN NOV 2022.”

 

9. Thus, one thing is clear from the discharge summary that the complainant had undergone surgery/ procedure for “Laparoscopic Cholecystectomy + Liver Biopsy done under GA” on 03.03.2023 at the treating hospital i.e. the present ailment  and there is only reference of history of CLD (chronic liver disease) since 2017 by the medical officer in the discharge summary and merely on the basis of reference made in the discharge summary under the heading of past medical history of CLD since 2017, OPs have rejected/repudiated the cashless claim of the complainant, which otherwise has no nexus with the treatment for gall bladder of which the necessary surgery was performed by the treating hospital upon the complainant. 
10. Moreover, when the medical team who had medically examined the complainant at the instance of the OPs have not found any such disease i.e. CLD before issuance of the subject policy to the complainant, the possibility cannot be ruled out that the complainant had suffered from the liver disease only during the subsistence of the subject policy and not prior to that and, therefore, there is no question of suppression or non-disclosure of the same by the complainant at the time of obtaining the subject policy.
11. The Hon’ble National Commission in case titled as Neelam Chopra Vs. Life Insurance Corporation of India & Ors., IV (2018) CPJ 321 (NC), while dealing with the question of suppression/non-disclosure of material facts, has held as under :-

     12. In the present case, clearly the cause of death is cardio respiratory arrest and this disease was not existing when the proposal form was filled. Clearly, there is no suppression of material information in respect of this disease, which is the main cause of death. The other disease of LL Hansen, which was prevailing for five weeks on the date of admission on 1.8.2003 was also not existing when the proposal was filed by the DLA. The fact of DLA having been treated in the year 2002 for LL Hansen is not supported from any direct evidence though PGI Chandigarh in its certificate has mentioned that disease was treated in 2002. Moreover, this disease does not have any correlation with the cause of death in the present case. Hon’ble Supreme Court in Sulbha Prakash Motegaonkar and Ors. v. Life Insurance Corporation of India, Civil Appeal No.8245 of 2015, decided on 5.10.2015 (SC) has held the following:

        “We have heard learned Counsel for the parties.

                It is not the case of the Insurance Company that the ailment that the deceased was suffering from was a life threatening disease which could or did cause the death of the insured. In fact, the clear case is that the deceased died due to ischaemic heart disease and also because of myocardial infarction. The concealment of lumbar spondylitis with PID with sciatica persuaded the respondent not to grant the insurance claim.

                We are of the opinion that National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischaemic heart disease and myocardial infarction had nothing to do with this lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified.”

12. In view of the foregoing discussion and the ratio of law laid down above, it is clear that the OPs/insurer have not been able to connect the previous diseases/ailments with the present diseases/ailments, for which the insured/complainant had taken treatment from the treating hospital.  Hence, it is unsafe to hold that the OPs/insurers were justified in rejecting/repudiating the claim of the complainant as well cancelling the subject policy and the present consumer complaint deserves to succeed. 
13. Now coming to the quantum of amount, since the complainants has proved the receipts/bills (Annexure C-11 to C-13) totaling to ₹1,95,539/- towards the expenses spent on his hospitalisation/treatment, it is safe to hold that OPs/insurers are liable to pay the said amount to the complainant alongwith interest and compensation etc.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. To restore the subject policy in the name of the complainant, as per its terms & conditions, with upto date benefits on payment of requisite charges, if any;
2. to pay ₹1,95,539/- to the complainant alongwith interest @ 9% per annum from the date of rejection/repudiation of the claim i.e. 4.3.2023 onwards.
3. to pay ₹15,000/- to the complainant as compensation for causing mental agony and harassment;
4. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(ii) & (iii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of remaining directions.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

05/03/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Suresh Kumar Sardana] Member