Chandigarh

DF-I

CC/440/2016

Czarina Jindal - Complainant(s)

Versus

The Manager Max Bupa Health Insurance Ltd. - Opp.Party(s)

In person

03 Jan 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

==========

Consumer Complaint  No	:	CC/440/2016
Date  of  Institution	:	15/06/2016
Date   of   Decision	:	03/01/2017

 

 

 

 

 

Czarina Jindal w/o Sh. Varinder Jindal, resident of House No.C-802, Royal Mansion, Peer Muchhala Road, Zirakpur, District Mohali.

…………. Complainant.

Vs

 

(1)  The Manager, Max Bupa Health Insurance Limited, SCO 55-56-57, Sector 8-C, Chandigarh.

 

(2)  The Chief Executive Officer, Max Bupa Health Insurance Co. Limited, B-1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, Delhi – 44.

 

….......... Opposite Parties

 

 

BEFORE:   MRS.SURJEET KAUR                  PRESIDING MEMBER

                SH. SURESH KUMAR SARDANA   MEMBER

 

 

For Complainant	:	Sh. Naresh Kumar Verma, Advocate
For OP	:	Sh. Gaurav Bhardwaj, Advocate.

 

PER SURESH KUMAR SARDANA, MEMBER

 

 

          Succinctly put, the Complainant took Heartbeat Health Insurance Policy from the Opposite Parties for a sum assured of Rs.25.00 Lakhs, by paying the requisite premium. The policy was effective from 09.01.2015 to 08.01.2016. During the currency of the policy, during May, 2015, the Complainant fell ill and was diagnosed with the problem of Meningiomas. Prior thereto the Complainant was not aware of this type of ailment. The doctors advised her to go for surgery and she was got admitted in AIIMS on 10.07.2015 for operation. The operation was conducted on 24.07.2015 and finally, she was discharged from AIIMS on 28.07.2015. The Complainant as per the policy submitted all the bills/documents in original on 20.10.2015 for reimbursement of the medical claim for Rs.91,599/-. However, the Opposite Parties did nothing and during the interregnum the policy was also got renewed by the Complainant from 09.01.2016 to 08.01.2017 by paying the premium of Rs.14,059/-. After sometime, the Opposite Parties refunded the aforesaid premium for the period 2016-17, through NEFT, on 23.02.2016. On enquiry, the Complainant was informed that her entire claim was rejected on the ground of Non-Disclosure Clause and PED Clause 4 (a) of the Policy. Hence, alleging the aforesaid act & conduct of the Opposite Parties as deficiency in service and unfair trade practice, the Complainant has filed the present Complaint.

 

2.      Notice of the complaint was sent to Opposite Parties seeking their version of the case.

 

3.      Opposite Parties in their joint reply, while admitting the factual aspects of the case, have pleaded that on investigation it was found that the Complainant was a known case of intracranial meningiomas since prior to policy inception and had underwent craniotomy for the same in the past, which was not disclosed by her at the time of taking the policy. Accordingly, the claim was rightly not paid due to non-disclosure clause and also under clause 4(a) of the policy terms and conditions, which contains the exclusion cause with respect to the pre-existing disease (PED). Moreover, the premium paid by the Complainant with respect to the renewed policy was refunded to her by NEFT on 22.02.2016. Denying all other allegations and stating that there is no deficiency in service on their part, Opposite Parties have prayed for dismissal of the complaint. 

 

4.      Parties were permitted to place their respective evidence on record in support of their contentions.

 

5.      We have heard the learned Counsel for the parties and have also perused the record, along with the written arguments filed on behalf of the Complainant.

 

6.      The stand of the Opposite Parties is that the claim of the Complainant has been rejected due to pre- existing disease as per Para 4(a) of the terms and conditions of the insurance policy. We have gone through the Proposal Form dated 9.1.2015 placed on record by the Complainant (Pg. No.7 to 14 of the paper book). At para 6 (2) of the Form, we find a question “within the last 7 years you have been to a hospital for an operation and/or an investigation i.e. scan, x-ray, biopsy or blood tests?”, which has been answered by the Complainant in negative. Thus, the Complainant cannot be said to have not disclosed about her illness at the time of taking the policy in question, as there was no hospitalization or operation during the last seven years and the Complainant was not taking any medicine for any type of disease. Furthermore, the Opposite Parties have miserably failed to prove that the Complainant had fallen sick during the last seven years. To our mind, rejecting the entire claim of the Complainant, by the Opposite Parties on the ground of Non-Disclosure Clause and PED Clause 4 (a) of the Policy, is not justified and surely and definitely amounts to deficiency in service and their indulgence in unfair trade practice.

 

7.      For the reasons recorded above, the present complaint of the Complainant deserves to succeed against the Opposite Parties, and the same is partly allowed. The Opposite Parties are directed:-

 

[a]  To pay the claim amount of Rs.91,599/- to the Complainant;

 

[b]  Pay Rs.10,000/- as compensation on account of deficiency in service and causing mental and physical harassment to the Complainant; 

 

[c] Pay Rs.7,500/- towards costs of litigation;

 

[d]  To renew the policy for the year 2016-2017 with effect from 09.01.2016 to 08.01.2017 by issuing proper insurance certificate after taking the due premium from the Complainant;

 

8.      The above said order shall be complied within 30 days of its receipt by the Opposite Parties; thereafter, they shall be liable for an interest @12% per annum on the amounts mentioned in sub-para [a] & [b] above from the date of institution of this Complaint, till it is paid, besides complying with the directions as in sub-paras [c] & [d] above.

 

9.      Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

03^rd January, 2017                                                                                   

Sd/-            

(SURJEET KAUR)

PRESIDING MEMBER

 

 

Sd/-

(SURESH KUMAR SARDANA)                                                                                                      MEMBER

 

“Dutt”