Chandigarh

DF-II

CC/739/2015

Anita Chopra (Ashok Kumar Chopra-Deceased) - Complainant(s)

Versus

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

Sh. A.K.Sharda Adv.

15 Sep 2016

ORDER

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

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Consumer Complaint  No	:	739 of 2015
Date  of  Institution	:	23.12.2015
Date   of   Decision	:	15.09.2016

 

 

 

 

 

Anita Chopra wife of late Sh.Ashok Kumar Chopra, resident of Flat No.A/34, Upple Marble Arc, Manimajra, Chandigarh (U.T.) (Natural legal heir and nominee in the Health Insurance Policy)   

 

             Complainant

Versus

 

1]  The Max Bupa Health Insurance Co. Ltd., (through Managing Director), B-I/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi 110044

 

2]  The Branch Manager, The Max Bupa Health Insurance Co. Ltd., SCO 55-56-57/2^nd Floor, Sector 8-C, Madhya Marg, Chandigarh.

   

 Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

MRS.PRITI MALHOTRA        MEMBER

           

 

Argued By: Sh.A.K.Sharda, Counsel for the complainant.

Sh.Gaurav Bhardwaj, Counsel for the OPs.

 

 

PER PRITI MALHOTRA, MEMBER

               

1]       At the outset, it is pertinent to mention that the present complaint originally was filed by Sh.Ashok Kumar Chopra (now deceased), who obtained Health Insurance Policy No.330277993201401 from Opposite Party No.1 effective from 09.12.2014 to 08.12.2015.  However, after the death of original complainant Sh.Ashok Kumar (hereinafter to be referred as ‘insured’), his wife Smt.Anita Chopra was substituted in his place being the legal heir as well as being the nominee named in the said policy. 

 

2]       As per the case, Sh.Ashok Kumar (now deceased), husband of the complainant, was a regular policy holder of the OPs, who also got Health Insurance Policy No.330277993201401 from Opposite Party NO.1 effective from 9.12.2014 to 08.12.2015 (Ann.C-1).  It is averred that insured Sh.Ashok Kumar was got admitted in Fortis Hospital, Mohali on 31.5.2015 for treatment of Coronary Artery Disease and after the discharge from Hospital, he submitted medical reimbursement claim with the Opposite Party Company for Rs.6,36,021/- alongwith all requisite documents on 8.6.2015 (Ann.C-2).  He also gave reminders to the OPs for releasing the claim amount (Ann.C-3 to C-6).  However, the Opposite Party Company vide letter dated 1.9.2015 disallowed the claim without assigning any valid reason and the sole reason given was non-submission of mandatory documents (Ann.C-7).  Thereafter the insured Sh.Ashok Kumar again sent letter dated 10.9.2015 (Ann.C-8) for release of his claim, followed by another letter dated 22.9.2015.  Thereupon, the insured received an e-mail dated 29.9.2015 from the office of Opposite Party No.1, assuring to resolve the claim within 7 working days, but when nothing was done by the OPs, a legal notice dated 13.10.2015 (Ann.C-10) was sent to the OPs, but to no avail. Hence, this complaint has been filed alleging the above act of the OPs as deficiency in service.

 

3]       The Opposite Parties jointly have filed reply and admitted the issuance of Health Insurance Policy in question in favour of Sh.Ashok Kumar (Insured), its validity from the period 09.12.2014 to 08.12.2015, treatment taken by the insured during currency of the policy, submission of claim as well as its rejection.  It is averred that after submission of claim, it was investigated by the Opposite Party and from the documents as well as from the investigation conducted by the Opposite Party, it was found that as per the ‘discharge summary’, issued by Fortis Hospital, the complainant was suffering from “Hypertension, DM-2, Melanoma rectum (Post Colostomy).  It is also submitted that during the course of investigation, it was further revealed that since Dec., 2014 insured had complaints of constipation, blood & mucus in stool; his colonoscopy showed recurrent Rectal Melanoma; the ICPs revealed history of Rectal Melanoma in 2013, which was rubbed & changed to 2014. It is also submitted that it also revealed that Tumor excision was done in 2013 but later on changed to 2014 in ICP.  It is further submitted that these facts were not disclosed in the proposal form at the time of taking policy, which amounts to non-disclosure of material facts, which is violation of terms & conditions of the policy.  The investigation report/ICP/documents collected during the course of investigation/medical examination report have been annexed as Ann.D (Colly) and discharge summary of Fortis Hospital is as Ann.E.  It is pleaded that keeping in mind the investigator’s opinion, the fact that the complainant lied and played fraud upon the insurance company and the fact that the complainant was found guilty of non-disclosure of material facts, the complainant’s claim was rejected, as per policy terms & conditions, vide letter Ann.F. Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.

 

4

 

 

 

 

]        Rejoinder has been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of Opposite Party.

 

5]       Parties led evidence in support of their contentions.

 

6]       We have heard the ld.Counsel for the parties and have also perused the record as well as written arguments.   

 

7]       It is well proved on record that the husband of the complainant Sh.Ashok Kumar (now deceased) got the health insurance Policy No.330277993201401 from Opposite Party No.1 effective from 09.12.2014 to 08.12.2015. Said policy was renewed from the previous Health Insurance Policy obtained from the Opposite Party No.1 bearing No.30277993201300 and this fact is proved vide letter dated 10.12.2014 issued by Opposite Party Company, placed on record by the Opposite Party at Page NO.37 of the paper-book.  It is also evident on record that the insured (Sh.Ashok Kumar) took treatment of Coronary Artery Disease from Fortis Hospital, Mohali on 31.5.2015 and an amount of Rs.6,36,021/- was incurred on the said treatment.  It is also not disputed that the insured being covered under the policy, lodged the claim on 8.6.2015 for the reimbursement of the expenses incurred on the treatment.  The record is further evident of the fact that the insured also served reminders on different dates on the OPs for the settlement of his claim.  In pursuance of the reminders for the claim settlement, the OPs issued one letter dated 01.09.2015 whereby the claim of the complainant was disallowed for the non-submission of document. The complainant vide present complaint has challenged the repudiation of the claim done by the OPs being illegal and alleged deficiency in service on the part of the OPs.

 

8]       The ld.Counsel for the OPs submitted that the claim of the complainant has rightly been repudiated for the reason that the complainant is guilty of suppression very and suggestion falsi and the complainant has no right whatsoever to maintain the present complaint before this Forum and is liable to be rejected on account of being fraudulent claim and is devoid of any merit.  The other objection, the OPs have raised is regarding the delay in intimation/filing of the claim by the insured as the insured took the treatment from 28.5.2015 o 31.5.2015 and the Opposite Party Company was intimated on 8.6.2015 i.e. after a delay of one week without assigning any reason.  In furtherance, it is submitted that the claim lodged by the complainant was when investigated, it reveals that the complainant was suffering from Hypertension, DM-2, Melanomarectum (Post Colostomy) since Dec., 2014 and the ICPs revealed history of Rectal Melanoma in 2013 and tumor excision was done in 2013 but later on changed to 2014 in ICP.  It is claimed by the OPs that the above facts were not disclosed in the proposal form at the time of taking policy and such non-disclosure of material facts amounts to violation of terms & condition of the policy and thus, the complainant is not entitled for any relief, as claimed in his complaint.

 

9]       The documents placed on record by the OPs does not support the averments made by it in the written statement.  The OPs have objected that the insured had not mentioned about his previous ailment in the proposal form while obtaining the policy in the year 2013 and also while renewing the same in the year 2014.  But no such proposal forms have been made the part of the record, for the reasons best known to the OPs.  Thus, the insured cannot be blamed for the non-disclosure of facts alleged by them.  The complainant has also proved on record that at the time of availing the policy for the first time in the year 2013, he had undergone medical examination got conducted at the instance of the OPs.  It is not denied by the complainant that the insured underwent treatment of “Melinoma” in Lilavati Hospital, Mumbai in March, 2015.  The complainant also claimed that the insured had also submitted his claim for reimbursement of the expenses incurred on the treatment of “Melinoma” in Leela Wati Hospital, Mumbai on 7.5.2015, which too was not sanctioned by Opposite Party NO.1.  It is observed that the OPs have not contradicted such submissions of the complainant and observed silence on the issue. Such observation of silence by OPs, draws an adverse inference against them, which clearly establish that they were in the knowledge of the ailment suffered by the complainant, which developed during the previous policy period and was not taken into account at the time of renewal of the policy in question. Thus again it is rightly held that the insured is not guilty of any non-disclosure of material information or facts about his health. 

 

10]      The perusal of the record also reveals that the OPs have taken contradictory & different views to justify the rejection of the claim in their written reply, whereas in actual they repudiated the claim of the complainant for non-submission of mandatory documents, as is evident vide letter dated 01.09.2015 (Ann.C-7).  There is no letter or correspondence whereby the insured was asked to submit any documents, mandatory for settlement of the claim.  Even in the present complaint also, no such requirement has been shown by the OPs for the purpose of settlement of the claim. However, the complainant has placed on record each & every document concerning the medical treatment availed by him in March, 2013, then in the year 2015 as well as the treatment availed by him at Fortis Hospital, Mohali on 31.5.2015 for Coronary Artery Disease.  The record further is sufficient to establish that all the documents have duly been supplied to Opposite Parties and also they were supplied with the certificate issued by Dr.P.Jagannath, Consultant Onco Surgeon of Lilavati Hospital, Mumbai, where the insured had availed the treatment on 3.3.2015.  The contents of the said certificate are reproduced as under:-

“This is to certify that Mr.Ashok Jiwan Dass Chopra, 66 years old male patient has been admitted in Lilavati Hospital & Research Centre, Mumbai on 03^rd March, 2015 at 01:31 PM under Dr.P.Jagannath, Consultant Onco Surgeon.  He is a known case of Melanoma of Rectum.  He was treated in the year 2014 with Excision of Tumour.

He is admitted now with symptoms of intestinal obstruction, for which he has undergone Diversion Colostomy on 04^th March, 2015”

 

11]      The complainant has placed on record the sufficient proof that all the documents including the certificate, referred above, had duly been supplied to the OPs. It clearly reveals that the insured suffered the ailment of Coronary Artery Disease only during the currency period of the policy in question and also the disease relating to “Melinoma” was suffered during the currency period of the previous insurance policy and the complainant was not suffering from any of the disease at the time of taking the policy for the first time in the year 2013.  Further, the OPs have failed to prove their stand, so the repudiation of the claim, is held to be illegal, unjustified, which amounts to deficiency in service on the part of the OPs.

 

12]      In view of the above discussion, we are of the opinion that deficiency in service on the part of the Opposite parties has been proved and thus, the complaint deserves to be allowed against the OPs. Accordingly, the complaint is allowed and the Opposite parties are jointly & severally directed as under:-

a]  To pay insured amount of Rs.5.00 lacs to the complainant, as the expenses incurred on the treatment of the insured are more than the insured amount, along with interest @9% p.a. from the date of repudiation i.e. 01.09.2015 (Ann.C-7) till it is paid;

 

b]  To pay an amount of Rs.25,000/- as compensation for causing mental agony and physical harassment, due to their deficient services;

 

c]  To pay Rs.10,000/- towards litigation expenses.

 

         The above said order shall be complied with by the Opposite Parties within 45 days of its receipt, failing which they shall be liable to pay interest @18% p.a. on the awarded amount as at sub-para [a] from the date of repudiation of the claim i.e. 01.09.2015 till it is paid and also on the compensation amount, as at sub-para [b] above from the date of filing this complaint till it is paid, besides paying litigation expenses.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

30^th Sept., 2016                                                                                                                                                             Sd/-

 (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-  

 (PRITI MALHOTRA)

MEMBER