State Consumer Disputes Redressal Commission
Shivinder Singh vs Max Bupa Health Insurance Com. Ltd. on 12 December, 2022
Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH.
Consumer Complaint No.869 of 2019
Date of institution : 04.12.2019
Reserved on : 22.11.2022
Date of decision : 12.12.2022
Shivinder Singh S/o Sh.Balwant Singh, R/o Ward No.5, Rajinder
Road, Dharmkoat, Moga, Punjab-142042.
....Complainant
Versus
1. Max Bupa Health Insurance Com. Ltd., through its Managing
Director, having its office at Block-B1/1-2, Mohan Co-operative
Industrial Estate, Mathura Road, New Delhi-110044, Email ID-
[email protected]
2. Max Bupa Health Insurance Com. Ltd., through its Branch
Manager, having its office at Unit No.3, Plot No.88, Second Floor,
Kunal Tower, Mall Road, Opposite Axis Bank, Ludhiana, Punjab-
141001.Email [email protected].
3. Max Bupa Health Insurance Com. Ltd., through its Insurance Agent
Ms.Shiwani Garg, Intermediary Code: LUD0109593, having its
office at Unit No.3, Plot No.88, Second Floor, Kunal Tower, Mall
Road, Opposite Axis Bank, Ludhiana, Punjab-141001, Email ID-
[email protected].
....Opposite Parties
Consumer Complaint under Section 17
of the Consumer Protection Act, 1986.
Consumer Complaint No.869 of 2019 2
Quorum:-
Mr. Harinderpal Singh Mahal, Presiding Judicial Member
Mrs. Kiran Sibal, Member Argued By:-
For the complainant : Sh.Pankaj Katia, Advocate
For the opposite parties : Sh.Nitin Thatai, Advocate
HARINDERPAL SINGH MAHAL, PRESIDING JUDICIAL MEMBER The present complainant-Shivinder Singh has filed this complaint under Section 17 of the Consumer Protection Act, 1986, (in short "C.P. Act") seeking following directions to the opposite parties:-
(i) To release the claim of the complainant for an amount of Rs.50 lacs.
(ii) Grant interest @18% p.a. from the date of medical condition/cause of action till realization;
(iii) to pay Rs.10,00,000/- as compensation to the complainant on account of mental tension, agony and harassment suffered by the complainant; and the
(iv) to pay Rs.1,00,000/- as costs of litigation.
2. Brief facts culminating to the institution of the present complaint are that the complainant purchased a Health Insurance -CritiCare policy bearing No.30785476201800 from the opposite parties for the period 06.07.2018 to 05.07.2019 and deposited one annual premium of Rs.31,370/- for sum insured of Rs.50 lacs, which included first heart attack of specified severity. No terms and conditions were ever issued to the complainant. On 19.01.2019, when the complainant was on a business tour to Bhiwani he started feeling uneasiness and pain in Consumer Complaint No.869 of 2019 3 chest at around 9:00 to 10:00 p.m. and reached Deepanjali Hospital, Near Old Bus Stand, Bhiwani, where he got admitted at 11:30 p.m. itself after conducting of few tests. Thereafter, after giving first aid, the complainant was referred to Deepanjali Multispeciality Hospital, Gohana Road, Near Bus Stand, Meham (Rohtak) for Cardiologist opinion, where he was admitted on 20.01.2019 for further treatment. Thereafter, he was discharged from the hospital on 23.01.2019 and was advised of follow up treatment. Then, he lodged his claim with opposite party No.2 in February, 2019 and a surveyor was deputed by opposite party No.2 for investigation. The original documents were supplied to the surveyor by the complainant and the surveyor obtained the signatures of the complainant on some blank printed forms. The complainant approached number of times to opposite party No.2 for his claim but of no use. On 05.09.2019, the complainant visited the office of opposite party No.2, where he was told that his claim is not likely to be released. Having no option, the complainant sent a legal notice dated 29.10.2019 to the opposite parties. In reply, the opposite parties stated that the claim of the complainant has been repudiated on the ground that 'due to not providing the required test report along with all Hospitalization treatment record indoor cases papers without which company is not able to adjudicate the claim.' Further submitted that the complainant also purchased a similar critical illness policy from Aegon Life Insurance Company Ltd. bearing No.180714826433, who after investigation disbursed the claim amount to the complainant on 09.07.2019. The act and conduct of the opposite parties for not settling the claim of the complainant amounts to deficiency in service Consumer Complaint No.869 of 2019 4 and unfair trade practice. Feeling aggrieved, the complainant filed this complaint seeking all the reliefs, as mentioned above.
3. Upon notice, opposite parties appeared and filed their joint written statement taking preliminary objections that the complaint is not maintainable as the complainant has attempted to misguide and mislead this Commission and also on account of policy terms and conditions. It is submitted that in the absence of all the criteria's specified for First Heart Attack, which was not met, the claim of the complainant was rightly repudiated. It is submitted that the diagnosis of Myocardial Infarction should be evidenced by all of the criterias mentioned in the said definition. As per the terms and conditions that on diagnosis itself (not treatment) the Sum insured becomes payable, however, there are certain criteria's that needs to be fulfilled, which are
(a) a history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infarction (for e.g. typical chest pain) (b) new characteristic electrocardiogram changes (c) elevation of infarction specific enzymes, Troponins or other specific biochemical markers, which are necessary to be provided in this case also. No cause of action ever arose in favour of the complainant. The complaint is an abuse of process of law and, as such, the same is liable to be dismissed. The complaint is filed with the motive to harass and humiliate the opposite parties. The complainant has not specifically denied the factum of receipt of policy documents in the complaint. The complainant was fully aware about the terms and conditions of the insurance contract. The complainant was explained about the contents of the proposal / application form. In the form submitted by the Consumer Complaint No.869 of 2019 5 complainant on 25.02.2019, it was submitted that the early symptoms were noted by him when he was travelling to Kolkata in November, 2018 and he experienced chest pain. He further stated that he consulted Dr.Ghosh who conducted his Blood tests and ECG. He also stated that around 8-10 years back, he experienced fast heart beat while exercising in gym and he consulted Dr.Amritpal Singh. The complainant was not having either of the treatment records. It is submitted that complainant willingly refused to hand over the ECG and Troponins tests. In the case of the complainant, out of three requirements, one has been met but the required documents have not been provided by the complainant, therefore, the claim of the complainant was rightly denied. The disputed questions of facts are involved in the present complaint which can only be decided by the Civil Court and this Commission does not have the jurisdiction to try and decide the present complaint. On merits, all the contentions as detailed in the preliminary objections have been reiterated and denied all the averments as averred by the complainant in his complaint. Lastly, the opposite parties prayed for dismissal of the complaint.
4. The complainant filed rejoinder to the written statement of opposite parties denying the contentions of the opposite parties and reiterated all the averments as averred by the complainant in his complaint. Further prayed for acceptance of the complaint.
5. The complainant in support of his averments has filed his affidavit dated 20.11.2019 along with photocopies of the documents i.e. Insurance Policy 06.07.2018 as Ex.C-1, Admission record dated 20.01.2019 as Ex.C-2, Admission record dated 23.01.2019 as Ex.C-3, Consumer Complaint No.869 of 2019 6 Legal Notice dated 16.09.2019 as Ex.C-4, Reply dated 29.10.2019 as Ex.C-5, Communication dated 15.05.2008 as Ex.C-8 and treatment record dated 02.10.2012 as Ex.C-7 (colly).
6. On the other hand, the opposite parties filed the affidavit of Sh.Chandrika Bhattacharaya, Chief Manager, dated 08.01.2020 along with photocopies of documents as Authorization Letter dated 01.02.2019 as Ex.OP-1, Online Proposal Form as Ex.OP-2, Insurance Policy dated 09.07.2018 as Ex.OP-3, Claim Form dated 04.02.2019 as Ex.OP-4, Questionnaire Insured/Claimant dated 25.02.2019 as Ex.OP- 5, Hospital Discharge Summary from dated 19.01.2019 to 20.01.2019 as Ex.OP-6 and Endoscopy report as Ex.OP-7.
7. We have heard the learned counsel for the parties at length and given our thoughtful consideration to the contentions on the same. We have also gone through the written arguments filed by the parties.
8. The basic facts of the complaint filed by the complainant which are not controverted by the opposite parties and need not to be proved are that the Health Insurance-Criticare Policy of one year for the asum insured of Rs.50 lacs, was purchased by the complainant after paying the premium of Rs.31,370/- and the said policy covering the complainant against certain health conditions and it also includes the heart attack. The policy is Ex.C-1. The period of the policy starts from 06.07.2018 to 05.07.2019.
9. The facts put forth by the complainant are that he went to a business trip at Bhiwani, where he felt chest pain and was admitted to Deepanjali Hospital, Bhiwani, who initially examined the complainant and then referred him to the bigger hospital Deepanjali Multispecialty Consumer Complaint No.869 of 2019 7 Hospital, Gohana Road, Meham, Rohtak on 20.01.2019. The admission record is Ex.C-2. The complainant was treated at Deepanjali Multispecialty Hospital, Gohana Road, Meham, Rohtak and was ultimately discharged on 23.01.2019, vide Ex.C-3. The complainant informed the opposite parties regarding his ailment and treatment received by him at the hospital and he also handed over the documents to the representative of the opposite parties. It is alleged by the complainant that all the original documents concerning his treatment in the said hospital was handed over to the opposite parties. Afterwards, the complainant persuaded his claim but ultimately his claim was not released and he filed the present complaint.
10. The complainant in his written arguments as well as orally contended that since the complainant was initially examined before issuing the policy and found no problem with the health of the complainant and that is why the policy was issued to the complainant finding that there was no pre-existing medical history. He further submitted that Ex.C-2 and Ex.C-3 i.e. hospital record shows that the medical card was duly submitted but the claim of the complainant was rejected merely on the ground that there was only one day hospitalization, which is not reasonable to reject the claim of the complainant when the policy itself is for Health-Criticare Policy. Even the stamps of rejection put by the opposite parties on the medical record itself shows that it was sent by him but they rejected the claim of the complainant just to wriggle out of their responsibility. He further urged that the rejection of claim of the complainant by the opposite parties merely on the basis of questionnaire which was got filled from Consumer Complaint No.869 of 2019 8 the nephew of the complainant that the complainant had undergone the treatment of heart 8-10 years back, is totally irrelevant because the complainant never authorized any such person to fill the alleged questionnaire on his behalf and this is not supported by any affidavit or any supporting documents and carries no meaning in the eyes of law. Even the terms and conditions of the policy were never supplied to the complainant. The terms and conditions were never part of the policy and the same cannot be taken into consideration, although it was the duty of the opposite parties to explain the terms and conditions at the initial stage when the policy was issued. So, the rejection of the claim by the opposite parties is totally illegal.
11. Per contra, learned counsel for the opposite parties in their written arguments as well as orally contended that the present claim of the complainant is not maintainable because even the ECG and Troponin test was not conducted of the complainant which does not attract the heart disease of myocardial infarction because the definition of 'First Heart Attack' for Criticare policy is very much mentioned in the policy terms and conditions and as per these terms and conditions, three criterias should be met for the claim to be payable and he pointed out some conditions for the diagnosis a) Acute Myocardial Infarction, which are typical chest pain, b) New characteristic electrocardiogram changes c) Elevation of infarction specific enzymes, Troponins or other specific biochemical markers. These guidelines were given by IRDAI. The patient, as diagnosed, is admitted due to chest pain. The criteria is 'New characteristic electrocardiogram changes, Elevation of infarction specific enzymes, Troponins or other Consumer Complaint No.869 of 2019 9 specific biochemical markers' but in the case of the complainant, no proper ECG and Troponin tests was there and the claim of the complainant was rightly repudiated. He admitted that policy bearing No.30785476201800 with the sum insured of Rs.50 lacs was issued and terms and conditions of the policy were duly intimated to the complainant and he was much aware of the same at the time of submission of the proposal form. He also submitted that as per the questionnaire submitted by the complainant to the query of the opposite parties he declared that the complainant also felt some symptoms of chest pain when he was travelling to Kolkata and he consulted Dr.Ghosh about 8-10 years back. The complainant just to hide his previous history and genuineness of the claim, ECG and Troponin tests were not produced by him intentionally. Factually, he was denied ECG and Troponin tests because there was no genuine illness of the complainant. He even stressed upon the fact that the medical record produced by the complainant are not genuine. First of all, all these are photocopies, secondly the hospital namely Deepanjali Multispecialty Hospital, Meham, Rohtak, to which this record pertained and other documents are false and fabricated one. He further submitted that no endeavour was made by the complainant to summon the signatory Dr.Deepak Kumar to prove the authenticity of the documents. Even the efforts made by the opposite parties to summon this doctor failed with the report that he is not available or his whereabouts are not known. So, all these facts need thorough investigation and even the reports of ECG are to be thoroughly Consumer Complaint No.869 of 2019 10 scrutinized medically and this doctor Deepak Kumar statement is utmost necessary to substantiate the claim of the complainant.
12. After hearing the rival contentions of both the parties, it transpires that the complainant -Sh.Shivinder Singh, obtained a policy with sum insured of Rs.50 lacs. The Insurance Policy, dated 06.07.2018 is Ex.C-1. The plea of the complainant is that he suffered from heart attack when he visited Bhiwani and after examining he was referred to Deepanjali Multispeciality Hospital at Rohtak, where he remained admitted from 20.01.2019 to 23.01.2019, however, his claim has been wrongly rejected by the opposite parties. First of all, it is very important to go through the terms and conditions of the policy as well as disease covered, which is reproduced hereunder:
"2.2 CritiCare Cover (individual or Family Floater Option) If an Insured Person suffers & Critical illness during the policy period and while the Policy is in force, we will pay the Sum insured provide that:
2.2.1 Such Critical illness first occurs or manifests itself during the Policy Period; and 2.2.2 The signs and symptoms of such Critical illness commence after 90 days from the date of commencement of the Policy i.e. the benefit would not be payable if the signs or symptoms occurred during the first 90 days or earlier from the date of commencement of coverage, as specified in the Schedule of Insurance Certificate; and 2.2.3 The Insured Person survives for a minimum period of at least 30 days from the date of diagnosis of such Critical Illness for the claim to be admissible under 2.2. 2.2.4 If this Critical Illness cover is in force on a Family Floater basis, then;Consumer Complaint No.869 of 2019 11
2.2.4.1 We will not be liable to make payment under this cover in respect of any and all insured persons more than once in a Policy Year;
2.2.4.2 If we have admitted a claim under this cover for an insured person in any policy year, this cover shall not be renewed in respect of that insured person for any subsequent policy year, but the cover will be renewable for the other insured persons.
2.2.5 The benefit shall be paid as per the benefit option chosen at inception.
2.2.5.1. Benefit Option 1: Sum insured as lumpsum. 2.2.5.2 Benefit Option 2: Sum insured as lump sum along with 10% of the sum insured payable annually at the beginning of each year from the date of payment of lump sum benefit, for subsequent 5 years. The coverage under the policy shall cease for that insured person. This cover shall not be renewed in respect of that insured person for any subsequent policy year, but the cover will be renewed for the other insured persons.
Once the benefit gets triggered, the annual benefits shall be paid at respective intervals irrespective of the survival status of the insured.
For Ex. If the Sum insured chosen at inception of Rs.50,00,000 then as per chosen option:
- Option 1 Rs.50,00,000 shall be paid as lump sum
- Option 2 Rs.50,00,000 is paid as lump sum on 1st June 2016, in addition, from next year onwards at the beginning of each year for subsequent 5 years i.e. on 1st June of every year from 2017 to 2021, payout equal to Rs.5,00,000 shall be made to the beneficiary."
13. In the disease of Myocardial Infarction the following conditions requires to be fulfilled:
2. Myocardial Infarction:
(First Heart Attack of Specific Severity) Consumer Complaint No.869 of 2019 12 I. The first occurrence of heart attack or myocardial infarction, which means the death of a portion of the heart muscles as a result of inadequate blood supply to the relevant area. The diagnosis for Myocardial Infarction should be evidenced by all the following criteria:
i) A history of typical clinical symptoms consistent with the diagnosis of acute myocardial infarction (For e.g. typical chest pain).
ii) New characteristic electrocardiogram changes.
iii) Elevation of infarction specific enzymes, Troponins or other specific biochemical makers......"
14. It is very important for the complainant to meet out these conditions before preceding his case for compensation. With regard to that complainant, no doubt, has placed certain photocopies of the medical record but no proper ECG or Troponins test has been produced by the complainant, although the learned counsel for the complainant has pointed out that ECG is there on the record which has not been looked into by the opposite parties while rejecting his claim. But the perusal of the record reveals that there is no proper ECG report to show that the disease suffered by the complainant at a particular place and treatment received by him. It was the prime duty of the complainant to produce the original record of his treatment before this Commission but all the record produced by the complainant is photocopies. Although the complainant as well as his counsel asserted that whole original record was handed over by him to the opposite parties for the settlement of the claim but there is not an iota of evidence on the file to prove that to whom this record was handed over. The photocopies, no doubt, can be considered, if it is proved in the secondary evidence as per the Indian Evidence Act, 1872 but no Consumer Complaint No.869 of 2019 13 efforts were made by the complainant to produce the same as per the provisions of Section 65 of the Act.
15. In the absence of these original documents, it is very difficult to ascertain the actual treatment received by the complainant at Deepanjali Multispecialty Hospital, Rohtak, or the medicines taken by him. The much stress has been laid down by the learned counsel for the opposite parties is that all his record is forged and fabricated and the hospital in the name of Deepanjali Multispecialty is not at all in existence at the place as per the address given on the medical record. He further pleaded that their efforts to summon Dr.Deepak Kumar, who signed on his record, failed because he is not traceable nor he has ever come present to the court to prove this record. Although, it was the duty of the complainant to produce Dr.Deepak Kumar to prove the authenticity of the medical record so produced by him before this Commission but no such efforts were made by him and he is claiming the compensation merely on the basis of photocopies which are unproved and has no authenticity.
Moreover, it is also a matter of investigation, as the complainant himself, mentioned in para 11 of the complaint that he also took a similar critical illness policy from Ageon Life Insurance Company Ltd. and the said Insurance Company after investigation had already disbursed the claim amount to the complainant on 09.07.2019. It is to be seen, whether the complainant is entitled for getting the same claim from two Insurance Companies.
16. In view of this, all the facts and circumstances of the case and the plea of fraud and deceit taken by the opposite parties regarding Consumer Complaint No.869 of 2019 14 treatment of the complainant and his medical record produced by him, we are of the view that complicated questions of law and facts are involved in the present complaint which requires voluminous documents and evidence for determination which is not possible in the summary procedure under the Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court.
17. We rely upon the judgment of the Hon'ble Apex Court in the case titled "Oriental Insurance Company Ltd versus Munimahesh Patel reported in 2006(4) CivCC 203" Page 1 wherein it is held that proceedings before Commission are essentially summary in nature and issue which involve dispute factual questions should not be adjudicated by the Commission. We find that complex factual matrix requires in this case that matter should be examined by an appropriate court of law in regular proceedings and not in summary manner by this Commission. Since in the present case, there is dispute regarding production and issuance of false documents, which the complainant is not able to prove it as genuine and on the basis of which the complainant lodged his claim for settlement, needs proper investigation and evidence. Therefore, it is deemed appropriate to lay our hands off the adjudication in this case.
18. The Larger bench of National Commission has held in "Reliance Industries Ltd. Versus United India Insurance Co. Ltd.,"
reported in 1998(1) CPJ 13 that question of ownership of goods, conspiracy and fraud were raised, which required elaborate inquiry for disposal. The matter can be properly decided by civil court and not under Consumer Protection Act. Hon'ble National Commission has Consumer Complaint No.869 of 2019 15 also held in "M/s Singhal Swaroop Ispat Ltd versus United Commercial Bank" reported in 1992(3) CPJ 50 that where the allegations of fraud, forgery have been raised by the parties against one another requiring elaborate oral or documentary evidence, the matter be relegated to civil court for adjudication.
19. In view of the above, we are of this view that the factual matrix in this case is quite complex, which cannot be adjudicated in summary manner by Consumer Fora. Accordingly, the complaint filed by the complainant is dismissed and the complaint is relegated to the Civil Court to avail appropriate remedy in accordance with law. The complainant is at liberty to invoke the provision of Section 14 of Limitation Act 1963 before competent court/Tribunal.
20. The complaint could not be decided within the statutory period due to heavy pendency of court cases.
(HARINDERPAL SINGH MAHAL) PRESIDING JUDICIAL MEMBER (KIRAN SIBAL) MEMBER December 12, 2022 parmod