BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.37 of 2021

Date of Instt. 27.01.2021

Date of Decision:11.12.2024

Sarvesh Bhandari age 55 Years S/o Sh. Milkhi Ram Bhandari resident of House No.293, Adarsh ​​Nagar, Jalandhar.

..........Complainants

Versus

1.       Max Bupa Health Insurance Company Limited, Booth no.30, New Grain Market, Hoshiarpur Road, Phagwara Road, Jalandhar City.

2.       Max Bupa Health Insurance Company Limited, B-1/1-2, Mohan Cooperative, Industrial Estate, Mathura Road, New Delhi-110044.

….….. Opposite Parties

          Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                                      (Member)

                   Sh. Jaswant Singh Dhillon       (Member)             

Present:       Sh. Surat Chander, Adv. Counsel for Complainant.

                   Sh. A. K. Gandhi, Adv. Counsel for OPs.

Order

          Dr. Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein it is alleged that the complainant had purchased "Group Health Policy" of the OPs on 26.11.2019. In terms of the said policy, the OP undertook to provide complete health cover to Complainant Sarvesh Bhandari and his family members. Notably Sarvesh Bhandari and his family members were fully hale and hearty at the time of purchasing the said policy and were not suffering from any disease. The complainant paid the premium of Rs.13,733/- against the medical policy of the OPs bearing no.00269100201900, which was effective from the date 26.11.2019 to 25.11.2020. As per the terms and conditions of the said policy, OPs assured them to provide them complete health cover/medical benefits to them upto Rs.3,00,000/-. Even after the purchase of the aforesaid policy, on 05.12.2019, the complainant in routine also got his medically tested from one of the reputed Test Laboratory of the Jalandhar i.e. Sardana Lab and his all medical reports were found to be normal and it is quite evident from the SEROLOGY Report that the Complainant was not having previous history of Blood Sugar/Diabetic. On 21.01.2020 due to some sudden medical problem/ill-health complainant got admitted in Tagore Hospital and Heart Care Centre Jalandhar with chief complaint of discomfort in the chest area. The complainant was admitted in the above said hospital on dated 21.01 2020 and later on discharge on dated 26.01.2020. The complainant had paid an amount of Rs.1,32,335/- in total upon his treatment which includes hospital bills, medical bills and other expenses. The complainant duly intimated regarding the treatment to the OPs and also forwarded the hospital documents, medical bills and other requisite documents to the OP for reimbursement of the same and Claim Form was filed by him. All the queries were promptly answered by the insured as well as the complainant and the requisite documents were also provided by them. They were assured by the OP that their claim is being processed and once all the formalities are over, it would be reimbursed. Thereafter, OP started harassing the complainant for one reason or other and started making lame excuses to somehow dilly dally the matter. Thereafter, the complainant received email dated 24.09.2020 from the OPs whereby it illegally repudiated the claim on the basis of totally false concocted and baseless ground of there being any discrepancy in the information about some pre-existing disease and the complainant was suffering from the blood Sugar problem and hypertension for the last 4 Years. The said reason of the repudiation of the claim is absolutely incorrect & wrong in as much as complainant was not having any such pre existing disease at the time of purchasing the policy and such disease was diagnosed for the first time only when he was admitted in the hospital on dated 21.01.2020. The repudiation of the claim is without any justification and is totally illegal, arbitraty and untenable in law, which caused mental tension and harassment to the complainant and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the claim amount of Rs.1,32,355 to the complainant and Rs.1,00,000/- as compensation for causing mental tension and harassment to the complainant.

2.                Notice of the complaint was given to the OPs, who filed reply and contested the complaint by taking preliminary objections that the present complaint is false, vexatious and has been filed with a malafide intention to harass the OPs by misusing the process of law and to avail undue advantages. It is an attempt to waste the precious time of this Commission as no cause of action has been arose against the answering OPs and in favour of the complainant, hence this complaint is liable to be dismissed. It is further averred that the complaint is not maintainable against the OPs and the same is liable to be dismissed. The OPs have rightly repudiated the claim of the complainant as per clause 4(a) of the insurance policy in question. As per the investigation it came into the light that the complainant was suffering from Diabetes Mellitus and Hypertension since 4 years i.e. prior to inception of the insurance policy in question and the same were not disclosed at the time of the execution of the insurance contract by the complainant. It is further averred that the complainant has not come to the Court with clean hands. On merits, it is admitted that the complainant had insured himself and his family under Group Health Policy from Max Bupa Health Insurance Company Ltd. It is also admitted that the premium was paid by the complainant and the policy was in existence from 26.11.2019 to 25.11.2020. The factum with regard to lodging the claim by the complainant is also admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

3.                Rejoinder not filed by the complainant. 

4.                In order to prove their respective version, the counsel for both the parties has produced on the file their respective version.

5.                We have heard the Ld. Counsel for the respective parties and have also gone through the case file very minutely.

6.                It is not disputed that the complainant had insured himself and his family under Group Health Policy from Max Bupa Health Insurance Company Ltd. with sum insured of Rs.3,00,000/-. It is also not disputed that the policy was in existence from 26.11.2019 to 25.11.2020 as per Ex.C-1. The complainant has alleged that on 21.01.2020 due to some sudden medical problem/ill health complainant got admitted in Tagore Hospital and Heart Care Centre Jalandhar with chief complaint of discomfort in the chest area and was discharged on 26.01.2020. It has been alleged that all the medical expenses of Rs.1,32,335/- were borne by the complainant for his treatment and when he lodged the claim with the OP alongwith the documents, the same was repudiated, vide email Ex.C33 on the ground of pre-existing disease. The complainant has proved on record the hospital bills, medical bills and other expenses Ex.C4 to Ex.C32.

7.                The contention of the OPs is that the complainant was suffering from Diabetes Mellitus and Hypertension since 4 years i.e. prior to inception of the insurance policy in question and the same were not disclosed at the time of the execution of the insurance contract by the complainant. It has been alleged that as per medical record ailment diagnosed by the hospital arise due to the diabetes as well as hypertension and were its related complication. The treatment was given to the complainant pertaining to the ailments i.e. CAD, Severe LV Dysfunction, CCF, Active on CKD, B/L Pleural Effusion, Congestive Hepatomegaly, Anaemia etc. which arose out of the diabetes as well as hypertension and were its related complication.

8.                So, far as the ailment of diabetes and hypertension is concerned. It has been decided by the Hon’ble National Commission in various judgments that Hypertension and Diabetes are not a disease, it is a general wear and tear of the life which occurred due to the pressure of the present life style and even otherwise the disease of Hypertension and Diabetes can be cured by taking medicine. It has been held by the Hon'ble National Commission in a case titled as ‘Neelam Chopra Vs. LIC (2018)’ that ‘common life style disease cannot be a ground to repudiate insurance claims.  It has further been held that ‘the non-disclosure of information regarding common life style disease such as diabetes will not disentitle the insured from claiming the policy amount’. Similar view was taken by the Hon'ble National Commission in a case titled as ‘Reliance Life Insurance Co. Ltd. Vs. Tarun Kumar Sudhir Halder (2019)’ that ‘diabetes is a life style disease in India and the entire of insurance claim cannot be rejected only based on its non-disclosure.’

9.                In view of the above detailed discussion, the repudiation letter Ex.C-33 is held to be wrong and illegal and same is hereby set-aside. Thus, the complaint of the complainant is partly allowed and OPs are directed to pay claim of Rs.1,32,335/- to the complainant. Further, OPs are directed to pay a compensation of Rs.15,000/- for causing mental tension and harassment to the complainant and Rs.8000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.    

10.              Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated          Jaswant Singh Dhillon    Jyotsna               Dr. Harveen Bhardwaj     

11.12.2024         Member                          Member                President