Haryana

Karnal

CC/166/2024

Sh. Khajanchi Lal - Complainant(s)

Versus

Niva Bupa Health Insurance Company Limited - Opp.Party(s)

Smt. Shakuntla Dagar

24 Oct 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.166 of 2024

                                                        Date of instt 22.03.2024

                                                        Date of Decision: 24.10.2024

 

Shri Khajanchi Lal son of Shri Deva Ram, aged about 60 years, resident house no.2171, ward no.2, Aggarwal Dharamshala Wali Gali, Nissing, Karnal now at present house no.505, Sector-7, Urban Estate, Karnal. Aadhar no.2790 9102 6128. Mobile no.9466594211.

 

                                                                        …….Complainant.

                                              Versus

 

1.  Niva Bupa Health Insurance Company Limited, SCO no.84-85, second floor, Sector 8C, Chandigarh through its authorized representative.
2. Niva Bupa Health Insurance Company Limited, registered office: C-98, 1^st floor, Lajpat Nagar, Part-1, New Delhi through its authorized signatory.

 

…..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

              Ms. Neeru Agarwal…….Member

      Ms. Sarvjeet Kaur…..Member

 

Argued by:  Ms. Shakuntla Dagar, counsel for the complainant.

                    Shri Sandeep Rana, counsel for the OPs.

                   

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant had purchased a health insurance policy since 2017 from the OPs, vide policy no.306834420201700, effective from 06.07.2017 to 05.07.2018. Thereafter, the policy was renewed regularly and the last policy bearing no.30785336202305 was effective from 06.07.2023 to 05.07.2024 for sum assured of Rs.10,00,000/- on payment of premium of Rs.39,911/-. The wife of the complainant Smt. Salochana Devi was also insured vide this policy. At the time of first time purchase of the policy, the OPs have also got done medical examination of the complainant. Moreover, complainant has also not claimed a single penny from the OPs under the health policy, except this claim for the first time. The complainant had issues of gastic dyspepsia 25 years ago but recovered following treatment and thereafter he had no medical problem in between. In the month of January 2023, complainant has developed Insomnia and Gastric Problem, he consulted local doctors with no relief. So, he approached the institute of Liver and Biliary Science, D-1, Vasant Kunj, New Delhi in April, 2023. There he was treated and his condition improved within a week of treatment. Now near about 31^st August or 1^st September, 2023, complainant has problem in his sleep and felt heart burn sensation so he again went to the abovesaid institute in Delhi on 04.09.2023, where he was admitted and various tests for his problems were conducted and he has to remain admitted in the hospital for 3 days and was discharged on 06.09.2023 in the late evening with advise and medicines. It is pertinent to mention here that the complainant has no diabetes or hypertension till 1 or 1¼ years ago when he has been diagnosed as diabetic and hypertensive, so since then he is taking medicines for the same. Before that the complainant has taken no medicines nor took any treatment for the last 24-25 years, except for some occasional cold or fevers that too rarely. Thus, it was not a case of any pre-existing ailment at all. The complainant has spent a sum of Rs.41,316/- on his treatment and hospitalization. The OPs were informed about the hospitalization of the complainant well in time but the cashless facility was denied by the OPs. After discharge from the hospital, complainant lodged the claim with the OPs for reimbursement of the abovesaid amount and submitted all the required documents. Thereafter, complainant requested the OPs several times for reimbursement of the abovesaid amount but OPs refused to pay the same and not only this the policy of the complainant and his wife was cancelled though it was the continuous 7^th policy of health insurance taken from the OPs on the ground of mis-representation or mis-description of non-disclosure of known case of Bipolar disorders vide notice of cancellation of policy no.30785336202305 dated 07.09.2023, which is absolutely wrong.

2.             It is further averred that complainant has problem of gastric dyspepsia 25 years ago and he took treatment and recovered fully. He never had any problem for long 25 years. So, it is clear that this was not a pre-existing disease or ailment at all. It was the wrongly mentioned that he has depression since 7-8 years i.e. prior to policy inception whereas the current problems have started from January, 2023 onwards. The treating doctor has specifically mentioned in foot note of revised discharge summary that the current issues are from last 7 months. However, in the initial discharge summary it was mentioned by mistake that the complainant is K/C/O i.e. known case of DM-2 (Diabetic ) and HTN  (Hypertensive) and is on medication for the same since the past 25 years which is absolutely wrong. Diabetic and hypertension of the complainant was also detected 1-1¼ months ago and since then the complainant is taking medicines for that. The complainant did not notice this mistake of hospital so he submitted the same with the OPs but when he noticed it after sometime then he approached the treating doctor and pointed it out.  Another revised discharge summary was issued correcting their mistake. The complainant also submitted the re-issued discharge summary but with no result. It is for the first time in these policies that the complainant has lodged a claim with the OPs. Left no other alternative, the complainant approached the Insurance Ombudsman at Chandigarh, vide complaint no.CHD-H-031-2324-1832, who also dismissed the complaint, vide award dated 07.02.2024 without taking into consideration the revised discharge summary issued by the Institute. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence, complainant filed the present complaint seeking direction to the OPs to cancel the notice dated 07.09.2023 regarding cancellation of the policy no.30785336202305 and denying his claim and to release/pay the claim amount of Rs.41,316/- illegally repudiated by the OPs alongwith interest @ 18% per annum from 07.09.2023 till its actual realization to the complainant, to regularize the health insurance policy of the complainant further without break, to pay Rs.2,00,000/- for deficiency in service and unfair trade practice, mental pain, agony and harassment and Rs.33000/- towards the litigation expenses.

3.                    On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that on the basis of declaration made in the proposal form, the company has issued a Reassure Family Floater Policy bearing no.32203696202200 and Health Recharge bearing no.30683420201700, commencing from 06.07.2017 to 05.07.2018 in the name of complainant himself and his spouse for a sum insured of Rs.5,00,000/-. The cashless request bearing no.715608 was filed by the complainant for the reimbursement/settlement of complainant’s medical expenses to be incurred during complainant’s hospitalization for the expected date from 04.09.2023 to 06.09.2023 in Institute of Liver and Biliary Sciences for the provisional diagnosis of Insomnia Dyspepsia.  As per submitted documents, complainant has a history of Bipolar disorder since 25 years and depression since 7-8 years, which is prior to policy start date. This was not disclosed at policy issuance stage, therefore, the pre-authorization is not payable under non-disclosure, policy clause 5.1.2 and 5.1.14 and hence policy stands terminated as on date 07.09.2023, as per the policy terms and conditions. The cancellation notice was sent to the complainant. It is further pleaded that complainant approached the Insurance Ombudsman with his grievance. However, the Insurance Ombudsman after hearing the parties dismissed the complaint filed by the complainant. It is denied that complainant has not taken any treatment of medicine for past 24-25 years. As per discharge summary the complainant had Bipolar disorder since 25 years and was on medication. He stopped taking medicine in January, 2023 due to which he developed Insomnia and Gastric Problem for which he took treatment. The treatment taken by the complainant is directly related to the past medical history of the complainant. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint

4.             Parties then led their respective evidence.

5.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of health insurance policy for the period from 06.07.2023 to 05.07.2024 Ex.C1, copy of health insurance policy for the period from 06.07.2017 to 05.07.2018 Ex.C2, copy of denial letter dated 06.09.2023 regarding cashless facility Ex.C3, copy of bill (inpatient) Ex.C4, copy of notes of Agent alongwith reports Ex.C5, copy of initial discharge summary dated 06.09.2023 Ex.C6, copy of revised discharge summary Ex.C7, copy of letter dated 30.06.2017 Ex.C8, copy of notice dated 07.09.2023 regarding cancellation of the policy Ex.C9, copy of rejection of claim letter Ex.C10, copy of award of Insurance Ombudsman, Chandigarh Ex.C11, copy of certificate from treating doctor Ex.C12 and closed the evidence on 29.05.2024 by suffering separate statement.

6.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Rahul Raunak, Assistant Manager Ex.OP1/A, copy of letter dated 17.06.2023 Ex.OP1, copy of policy kit Ex.OP2, copy of request form with medical report Ex.OP3, copy of discharge summary dated 06.09.2023 Ex.OP4, copy of letter dated 06.09.2023 Ex.OP5, copy of email Ex.OP6, copy of award passed by Insurance Ombudsman Ex.OP7 and closed the evidence on 06.08.2024 by suffering separate statement.

7.             We have heard the learned counsel for the parties and perused the case file carefully and also gone through the evidence led by the parties.

8.             Learned counsel for the complainant, while reiterating the contents of complaint, has vehemently argued that complainant purchased a health insurance policy from the OPs, since the year 2017  and same is continue without any break. On 04.09.2023, complainant was hospitalized in Institute of Liver and Biliary Science, New Delhi and discharge on 06.09.2023. Complainant spent an amount of Rs.41,316/- on his treatment. After discharge from the hospital, complainant submitted the claim for reimbursement of the abovesaid amount but OPs not only rejected the claim of complainant but has also cancel the policy on the false and frivolous ground 

9.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that the claim of the complainant has been duly processed and observed that complainant has a history of Bipolar disorder since 25 years and depression since 7-8 years. This fact had not been disclosed by the complainant at the time of inception of the policy, Thus, the claim of the complainant has rightly been rejected and policy has also  been cancelled and lastly prayed for dismissal of the complaint.

10.           We have duly considered the rival contentions of the parties.

11.           Admittedly, in the year of 2017, complainant availed a Health Insurance Policy from the OPs. It is also admitted that during the subsistence of the insurance policy the complainant has taken treatment from Institute of Liver and Biliary Science, New Delhi and has spent an amount of Rs.41,316/- on his treatment.

12.           The claim of the complainant has been denied and policy has also been cancelled by the OPs, vide letter Ex.C9 dated 07.09.2023 on the ground of mis-representation, mis-description of non-disclosure of material facts with regard to his health at the time of purchasing the policy.

13.           The case of the OPs is based upon discharge summary Ex.OP4/Ex.C6 dated 06.09.2023 issued by Institute of Liver & Biliary Sciences, New Delhi prepared by treating Doctor namely Mohit Kr. Varshney, MBBS MD DM, Assistant Professor, Psychiatry Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi. But on 20.05.2024 the abovesaid treating doctor has issued a certificate which is reproduced as under:-

                        “Certificate to whom it may concern

Mr.Khajanchi Lal, 59 years old male son of Shri Deva Ram resident of Nissing was admitted in ILNS with complaints of Insomnia, Dyspepsia and Gastric Burning since past 3 days on 04.09.2023. He had issues of Gastric dyspepsia 25 years back and recovered symptomatically following treatment. Thereafter, he was not on any medication for the last 24-25 years. It was inadvertently mentioned in the history of discharge summary issued on 06.09.2023, which was corrected afterwards. In January, 2023, this patient developed Insomnia and Gastric Symptoms. He came to ILBS in OPD in April, 2023, this patient developed Insomnia and Gastric Symptoms. He came to ILBS in OPD in April, 2023 and was started on medications for BPAD. He improved and showed response within a week of treatment. Currently he was admitted on 04.09.2023 and was evaluated for his complaints. Presently, he has these problems of NAFLD for the last 7-8 months. There is no history of TB/COPD/Thyroid disorders. There is no history of consumption of usage of alcohol or tobacco products. He has no history of fever vomiting, oily stools, diarrhea or bleeding. There is no family history of Psychiatric illness or past history of hospital admissions or treatment”

 14.          The said certificate has been issued by the treating doctor. The duration of the Bipolar disorder since 25 years and depression since 7-8 years mentioned in the discharge summary Ex.R4 dated 06.09.2023 has been rectified by the treating doctor vide certificate Ex.C12. In the said certificate, treating doctor has specifically mentioned that patient was not on any medication for the last 24-25 years and it was inadvertently mentioned in the history of discharge summary issued on 06.09.2023, which was correctly afterwards. Thus, it has been proved from the said certificate that complainant was not having pre-existing disease at the time of purchasing the policy.

15.           Moreover, As per insurance policy Ex.C1, the date of birth of complainant is 10.06.1964 and policy in question purchased on 06.07.2017. Thus, at that time the age of complainant was more than 53 years. Hence, it was the duty of the OPs to get the medical examination of the complainant as per the instructions issued by Insurance Regulatory & Development Authority of India (IRDAI). In this regard, we place reliance upon case titled as  National Insurance Company Ltd. Versus Harbirinder Singh appeal no.220 of 2016 decided on 30.09.2016, wherein Hon’ble State Commission U.T. Chandigarh has held that if the complainant and his wife both are older than 45 years of age but there is nothing on record to show that before insurance policy was issued to them, the appellants got them medically examined, which as per instructions issued by Insurance Regularly & Development Authority of India (IRDAI) is must in such like cases. Similarly, view was taken by Hon’ble Chandigarh State Commission in case of M/s Max Bupa Health Insurance Co.Ltd. Vs. Rakesh Walia, appeal no.191 of 2016 decided on 18.08.2016  and held that if contrary to the instructions issued by IRDAI, an insured above the age of 45 years, was not put to through medical examination, claim raised after issuance of insurance of policy cannot be rejected on account of non-disclosure of the fact of pre-existing disease when policy was obtained.

 16.          Furthermore, nowadays it has become a trend of insurance companies that they get portal the policy done by giving false assurances and while giving claim amount, they make excuses for early claim and pre-existing disease etc. In this regard, we place reliance upon case law of the Hon’ble Punjab and Haryana High Court titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.”

 

17.           Keeping in view that the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OPs while denial of the claim and cancellation of the insurance policy of the complainant amounts to deficiency in service and unfair trade practice.

18.           The complainant has spent Rs.41,316/- on his treatment and in this regard he has placed on file medical bill Ex.C4. The said bill amount has neither denied nor rebutted by the OPs.  Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

19.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.41,316/- to the complainant alongwith interest @ 9% per annum from the date of repudiation/cancellation of the policy till its realization. We further direct the OPs to regular the policy in question on receipt of pending premium amount, if any, by the complainant. We further direct the OPs to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated:24.10.2024

         President,

      District Consumer Disputes                           

      Redressal Commission, Karnal.

 

                   ( Neeru Agarwal)            (Sarvjeet Kaur)

                          Member                        Member