Order-17.
Date-05/09/2016.
This is an application u/s.12 of the C.P. Act, 1986.
The case of the complainant, in short, is that on 06-02-2014, complainant was issued with a Max Bupa Health Insurance Policy with policy No.30296033201400 by the OPs. The OPs are the service providers and the complainant is their consumer. In the month of October, 2014, the complainant felt a pain in her abdomen and was diagnosed as having stones in gallbladder and the doctor advised her for an immediate operation. Accordingly, on 19-10-2014 she was admitted in Sri Aurobinda Seva Kendra Hospital and the operation was carried out on 20-10-2014 and she was released on 22-10-2014. Thereafter, complainant submitted her claim form with all supportive documents to the OPs on 12-11-2014. On 22-12-2014 the complainant was surprised to find that the claim was repudiated on the ground that the OP’s team of doctors on the basis of the documents observed that the patient had a history of abdominal pain since one year which is prior to policy inception date with Max Bupa. It is also stated that the disease was pre-existed and that was not disclosed by the complainant at the time of taking the policy. It is alleged by the complainant that she never suffered from any pain before October, 2014. That was an emergency pain and was attended by her doctor immediately. It is also alleged that the OPs by their negligence and reluctant attitude have repudiated the claim of the complainant. Hence, this case.
OPs in filing written version have stated that the instant complaint is not maintainable in its present form and in law and the instant complaint has been filed with oblique motive in order to extract money from the OPs without any legitimate basis. One of the terms of the policy as stated in the written version as specified in the said insurance policy so that the insurance company shall not be liable to pay for pre-existing disease until 48 months from the date of inception. Clause 4A of the policy reads “benefits will not be available for pre-existing disease until 48 months of continuous coverage have elapsed since the inception of the first policy with us”. In the month of November, 2014, the OP received a claim from the complainant for reimbursement and it was noted after reviewing the claim that the patient had symptoms of calculous cholecystitis for one year that is since before the commencement of the policy which she failed and neglected to disclose while taking the policy. Hence, the claim of the complainant was rejected for non-disclosure of past medical history and or pre-existing disease. The OPs have prayed for dismissal of the claim.
Points for Decision
- Whether the OPs have rightfully repudiated the claim of the complainant?
- Whether the complainants suffered from any pre-existing disease less than 48 months?
- Whether the complainant is entitled to get the relief as prayed for?
Decision with Reasons
We have travelled over the documents on record namely insurance certificate, terms and condition of the policy, payment details, discharge summary and certificate of Sri Auribindo Seva Kendra and other medical reports on record. From the documents on record we find that the complainant Mrs. Sujata Sengupta firstly visited Dr. Dipankar Roy, a General Physician on 10-10-2014 and she was advised USG upper abdomen (‘cholecystitis’) and after perusal of USG dated 14-10-2014 she was advised to consult surgeon. In USG report she was found with stones in gallbladder and the doctors advised her for an immediate operation. Accordingly, on 19-10-2014 she was admitted in Sri Aurobinda Seva Kendra Hospital and the operation was performed on 20-10-2014 and she was discharged from the hospital on 22-10-2014. We find that USG was performed on 12-10-2014 and her abdominal pain started or manifested shortly before that on 10-10-2014. She went to Dr. Dipankar Roy on 10-10-2014. So, from the medical papers we find that the abdominal pain of the complainant cropped up on 10-10-2014 and not before that. The whole episode as it appears from the medical papers started onwards 10-10-2014. So, it is very difficult to hold that the complainant had pre-existing disease of abdominal pain and she did not disclose the same at the time of availing of the policy. Moreover, we find that the complainant was issued the policy on 06-02-2014 completing all medical check up and getting assured by the OPs that there was no pre-existing disease and after medical check up complainant was issued with a Max Bupa Health Insurance Policy. We think that there has been deficiency in service committed by the OPs and OPs have not been justified in repudiating the claim to the complainant. We think that the complainant is entitled to get the relief.
In result, the case succeeds.
Hence,
Ordered
That the complaint be and the same is allowed on contest with a cost of Rs.10,000/-.
OPs are jointly and severally directed to pay the claim amount of Rs.53,178/- as reimbursement of the medical bills within one month from the date of this order. OPs are also directed to pay an amount of Rs.20,000/- for undue harassment caused to the complainant within the said stipulated period.
Failure to comply with the order will entitle the complainant to put the order into execution u/s.25 read with Section 27 of the C.P. Act and in that case OPs will be liable to pay penal damages at the rate ofRs.3,000/- per month to be paid to this Forum with full and final satisfaction of the decree.
