Chandigarh

StateCommission

A/231/2019

Max Bupa Health Insurance Company Ltd. - Complainant(s)

Versus

Rajbir Singh - Opp.Party(s)

Gaurav Bhardwaj, Karandeep Singh Cheema Adv.

15 Oct 2019

ORDER

        STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

 

Appeal No.	:	231 of 2019
Date of Institution	:	11.10.2019
Date of Decision	:	15.10.2019

 

1.  Max Bupa Health Insurance Company Limited, SCO No.55-56-57, 2^nd Floor, Sector 8-C, Madhya Marg, Chandigarh through its Branch Manager.

2.  Max Bupa Health Insurance Company Limited, Corporate Office: Block B1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi – 110 044 through Managing Director.

 …….Appellants/Opposite Parties.

Versus

 

Rajbir Singh S/o Sh. Harkirat Singh R/o House No.1714/3, Near Kwality Sales Corporation, Shimlapuri, Ludhiana – Punjab.

 

...Respondent/Complainant.

 

Appeal under Section 15 of the Consumer Protection Act, 1986

 

BEFORE: JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT.

                MR. RAJESH K. ARYA, MEMBER.

       

Argued by:

 

Sh. Gaurav Bhardwaj, Advocate for the appellants.

 

PER  RAJESH  K.  ARYA, MEMBER

                   In this appeal, the opposite parties have assailed order dated 13.08.2019 passed by District Consumer Disputes Redressal Forum-I, U.T., Chandigarh (in short ‘the Forum’ only), vide which, the complaint of the respondent/complainant bearing RBT CC No.374 of 2019 was partly allowed directing the appellants/opposite parties to withdraw notice of cancellation of policy, revive the same for the period it was valid and pay claim amount of Rs.2,74,889/- to the complainant alongwith interest @9% p.a. w.e.f. 26.04.2019 besides awarding Rs.35,000/- & Rs.15,000/- towards compensation for mental agony and harassment & costs of litigation. The order was to be complied within a period of 30 days from the date of receipt of its certified copy, failing which, the awarded amounts were to entail penal interest. There is also a delay of 16 days in filing the appeal, for which an application for condonation of delay has also been filed alongwith the appeal.

2.             Briefly stated the facts are that the policy, in question, was purchased initially on 04.08.2016 in which, the parents of the complainant were insured under a health insurance policy for the period from 17.08.2016 to 16.08.2017, which was renewed for further one year i.e. from 17.08.2017 to 16.08.2018 by paying premium of Rs.57,300/-. The complainant spent an amount of Rs.2,74,889/- for treatment of his father Sh. Harkirat Singh for tongue cancer. However, when claim, duly verified by Medical Superintendent, PGI, Chandigarh, was submitted, the same was repudiated by the opposite parties on the ground that the father of the complainant was suffering from pre-existing illness i.e. history of Non-Alcoholic Steatohepatitis (NASH) for 6 years back, which fact was concealed by the complainant.

3.             Counsel for the appellants raised an argument that the nexus of cancer and liver disease is not important since the insured knowingly made selective disclosures in the MER and Proposal Form and in a case of non-disclosure, the nexus point has to be eschewed out of consideration. He has also argued that since the insured did not provide details of his existing adverse medical problems at the time of submitting the proposal form as well as the medical examination form, the claim was rightly repudiated by the appellants.

4.             In our considered opinion, the argument raised is not sustainable in the eyes of law. The Forum has given exhaustive finding in its order. It is on record that the appellants ignored the observation of the doctor, which says that the patient was apparently alright six months back i.e. up-to March/April 2018 and then he noticed a growth in the (L) lateral border of tongue. He noticed some itching problem in the tongue which was diagnosed as Cancer at PGI, Chandigarh. In our opinion and as rightly observed by the Forum, the problem of liver had no nexus with alcohol intake. Another circumstance mentioned that the father of the complainant was chronic alcoholic was also negative as the liver problem was non-alcoholic and not related to alcoholism. The Forum has also rightly held that from the record, it has also not been made out that who provided the information before PGI that the father of the complainant being chronic alcoholic as no substantive evidence was brought on record qua the said plea. Further, there is nothing on record to establish that he was alcoholic and further, in our considered opinion, Non Alcoholic Steatohepatitis had no connection with alcohol intake.  

5.             Not only above, the Forum has also rightly observed that it has not proved on record that cancer had any connection with the disease of Non Alcoholic Steatohepatitis or liver cirrhosis alongwith alcohol intake. It rightly held in Para 12, inter-alia, as under:-

“…..Though as per record it is not established on the date of purchase of the policy by the complainant in the year 2016, Sh. Harkirat Singh had pre-existing disease of Non Alcoholic Steatohepatitis or say liver cirrhosis or hypertension. The claim was not to be repudiated merely on assumptions and presumptions.  There had to be a concrete evidence to this effect before it was repudiated as hefty amount of more than Rs.1.50 lakhs had already been received by the OPs and they had also the chance to get the complainant or the person insured medically examined from their authorised medical officer for the detection of any pre-existing disease having been suffered by Sh. Harkirat Singh. This record leads to the irresistible conclusion, no information with regard to the pre-existing disease was suppressed by the complainant while initially taking the policy in the year 2016 and onwards.  Even in March or April, 2018, second renewal of the policy was in existence though the disease for which Sh. Harkirat Singh was treated was detected in October 2018.  Prior to that, research work/investigations were going on in various hospitals.  We find there was no concealment of pre-existing disease.  As such the claim was wrongly repudiated.  This tantamounts to deficiency in service on the part of the OPs and the present consumer complaint deserves to succeed.”

6.             Thus, in view of above discussion, we are of the considered opinion that the appeal filed by the appellants/opposite parties is liable to be dismissed at the preliminary stage as the appellants have miserably failed to make out any case to set aside the impugned order passed by the Forum.

7.             For the reasons recorded above the appeal is dismissed in limine with no order as to costs. The impugned order dated 13.08.2019 passed by District Forum-I, U.T., Chandigarh is upheld. Consequently, the miscellaneous applications bearing No.733 of 2019 for condonation of delay in filing the appeal and No.734 of 2019 seeking stay of the impugned order also stand dismissed having become infructuous.

8.             Certified copies of this order, be sent to the parties, free of charge.

9.             The file be consigned to Record Room, after completion.

Pronounced.

15.10.2019.

[RAJ SHEKHAR ATTRI]

PRESIDENT

 

 

(RAJESH  K. ARYA)

MEMBER

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