State Consumer Disputes Redressal Commission
Max Bupa Health Insurance Co. Ltd. vs Kamla Devi on 13 August, 2015
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
First Appeal No. 586 of 2014
Date of institution: 22.5.2014
Date of Decision: 13.8.2015
1. Max Bupa Health Insurance Ltd., D-1, 2nd Floor, Salcon Ras Vilas,
District Centre, Saket, New Delhi - 110 017 through its Managing
Director.
2. Max Bupa Health Insurance Ltd., Kunal Tower, Mall Road, Ludhiana
through its Manager.
3. Max Bupa Health Insurance Ltd., Office Max New Your, G.T. Road,
Near Bus Stand, Jalandhar through its Branch Manager.
Appellant/Op Nos. 1, 2 & 4
Versus
1. Kamla Devi wife of Mr. Ranjit Kumar
2. Ranjit Kumar son of Banta Ram,
Both C/o Fancy Tent House, G.T. Road, Jalandhar City.
Respondents/Complainants
First Appeal against the order dated 17.4.2014
passed by the District Consumer Disputes
Redressal Forum, Jalandhar.
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member
Shri Jasbir Singh Gill, Member
Mrs. Surinder Pal Kaur, Member
Present:-
For the appellants : Sh. G.S. Sandhu, Advocate
For the respondents : Sh. H.K. Sammi, Advocate
First Appeal No. 586 of 2014 2
Gurcharan Singh Saran, Presiding Judicial Member
ORDER
The appellants/OPs (hereinafter referred as "OPs") have filed the present appeal against the order dated 17.4.2014 passed by the District Consumer Disputes Redressal Forum, Jalandhar(hereinafter referred as the District Forum) in consumer complaint No.266 dated 24.6.2013 vide which the complaint filed by the respondents/complainants(hereinafter referred as the complainants) was allowed with a direction to Ops to pay Rs. 1,67,000/- to the complainant alongwith interest @ 9% from the date of filing the complaint till payment and also pay Rs. 3,000/- as litigation expenses.
2. A consumer complaint was filed by the complainant under the Consumer Protection Act, 1986 (in short 'the Act') against OPs on the averments that complainant No. 1 Ranjit Kumar purchased a policy bearing No. 30091088201200 under the plan "Health Companion Silver 02 Lacs for 2 Adults". Under the said policy, complainant No. 2 Ranjit Kumar and his wife Kamla Devi were covered upto free medical treatment for Rs. 2 lacs for the period 2.4.2012 to 1.4.2013, which was purchased from the Agent of Op Nos. 1 & 2 at Jalandhar, on payment of premium of Rs. 14,082/-. Both the complainants were quite hale and healthy before taking the policy and were medically checked up by the Doctors of Op Nos. 1 & 2 before issuing the policy. However, Kamla Devi suffered heart attack and was admitted to BBC Heart Care, Paruthi Hospital, Jalandhar on 17.10.2012. Its intimation was given to OP. Kamla Devi First Appeal No. 586 of 2014 3 remained admitted in the hospital upto 29.10.2012 and a sum of Rs. 1,67,000/- was spent on her treatment. The complainant submitted the claim of the abovesaid amount to OPs duly supported by treating documents. However, it was shocking for the complainant when he received a letter dated 13.3.2013 from Op No. 1 vide which Op No. 1 rejected the claim of the complainants illegally on the ground of suppression of material information such as Diabetes and Hypertension. Even the Discharge Certificate dated 29.10.2012 issued by Dr. A.K. Chaudhry, Chief Cardiac Surgeon, says that complainant No. 1 was suffering from hypertension and diabetes mellitus, recently detected, therefore, the claim of the complainant was wrongly rejected by Op No. 1. The conduct of OPs amounted to deficiency in services. Hence, the complaint with a direction to OPs to pass the medical claim of Rs. 1,67,000/- alongwith interest @ 12% p.a. and also pay compensation and litigation expenses.
3. The complaint was contested by OPs. Op Nos. 1, 2 & 4 in their written reply took the preliminary objections that Mr. Anand Roop Choudhary was authorised representative of OPs and competent to file this written statement; the complaint was not maintainable as the same was without any cause of action; the insurance was a contract of good faith, which was violated by the complainants. The complainants approached OPs for health insurance and OPs explained the entire policy covers alongwith its terms and conditions to the complainant, after understanding the same the complainant filled the proposal form; OPs believed the information given in proposal form to be true and issued the Policy First Appeal No. 586 of 2014 4 No. 30091088201200 for the period 2.4.2012 to 1.4.2013, however, lateron the complainant was diagnosed with Atherosclerotic Coronary Artery Disease and was admitted in Pruthi Hospital, Jalandhar for the period 18.10.2012 to 29.10.2012 before the treatment of Dr. K.K. Choudhary and after discharge, she submitted the claim for reimbursement of medical expenses. Against claim No. 25038 OPs asked treating Dr. A.K. Choudhary to fill up a questionnaire in relation to the treatment of the complainant in Pruthi Hospital. The treating Doctor mentioned that the complainant was suffering from Diabetes Mellitus for 1-2 years and hyper tension for the last 5 years prior to inception of the policy on 2.4.2012. The pre-existing disease of the complainant was the main cause for Atherosclerotic Coronary Heart disease and she did not disclose this disease at the time of filling the proposal form. In view of the advice given by the Doctor, claim was repudiated and that there was no deficiency in services on the part of Ops, therefore, the complaint was not maintainable. On merits also, issuance of the policy was admitted. However, it was again reiterated that the complainant suffered from pre-existing disease at the time of taking the policy, which was violative to the terms and conditions of the policy, therefore, the claim filed by the complainant was correctly repudiated by OPs. There was no deficiency in services on the part of OPs. The complaint was without merit and it be dismissed.
4. The parties were allowed by the learned District Forum to lead their evidence.
5. In support of his allegations, the complainant had tendered into evidence affidavit of Kamla Devi Ex. CA, legal notice First Appeal No. 586 of 2014 5 Ex. C-2, policyholder servicing turnaround times Ex. C-3, letter of Op Ex. C-4, letter Ex. C-5, premium receipt Ex. C-6, insurance cert. Ex. C-7, policy details Ex. C-8, operative summary Ex. C-9, report of Dr. A.K. Choudhary Ex. C-10, payment details Ex. C-11. On the other hand, OPs had tendered into evidence affidavit of Anand R Choudhary Ex. Op-1/A, resolution copy Ex. Op-1, proposal form Ex. Op-2, temporary receipt Ex. Op-3, copy of DL Ex. Op-4, Questionnaire for Treating Doctor Ex. Op-5.
6. After going through the allegations in the complaint, written reply filed by OPs, evidence and documents brought on the record, the complaint was allowed by the District Forum as referred above.
7. Aggrieved with the order passed by the learned District Forum, the appellants/OPs have filed the present appeal.
8. We have heard the learned counsel for the parties.
9. In the appeal, it has been argued by the counsel for the appellants that the claim of the complainant was correctly repudiated by OPs on the ground of non-disclosure of pre-existing disease at the time of taking the policy. However, the learned District Forum has not properly appreciated the evidence on the record and terms and conditions of the policy and has wrongly allowed the complaint, therefore, the order so passed by the learned District Forum is liable to be set-aside. The complaint was not maintainable, therefore, it was liable to be dismissed.
10. No doubt that at the time of filling the proposal form, the complainants did not refer with regard to any pre-existing disease as First Appeal No. 586 of 2014 6 is clear from proposal form Ex. Op-2. The main reliance of OPs is upon document Ex. Op-5 i.e. questionnaire, which was filled up by the treating Doctor and in column No. 3, it was mentioned Diabetic Mellitus for 10 years and the hyper tension for the last 5-6 years. However, the counsel for the respondent/complainant has argued that the document Ex. Op-5 given by the treating doctor is contrary to its own operative summary in which final diagnosis mentioned as under:-
"Atherosclerotic Coronary Artery Disease LCMA 95% Triple Vessel Disease Normal LV Function Diabetes Mellitus (Recently detected)"
11. It does not disclose any hyper tension and diabetes mellitus recently detected, it does not disclose the approximate period. There is no documentary evidence produced on the record by OPs that before taking the policy, any treatment was taken by the life assured for this treatment. Therefore, firstly, there is no evidence on the file produced on the record by OPs that before taking the policy, the complainant Kamla Devi was suffering from any pre-existing disease. Even if it is taken that she had some symptoms of these pre- existing disease then no treatment was taken of coronary artery disease. It has not been established by the counsel for OPs that diabetes mellitus and hyper tension were the main reasons for CAD, therefore, in case OPs have not been able to establish nexus between CAD and Diabetes Mellitus/hyper tension. No findings can First Appeal No. 586 of 2014 7 be given that the CAD was due to Diabetes Mellitus/Hyper Tension. It was held by the Hon'ble National Commission in III (2012) CPJ 208 (NC) "Life Insurance Corporation of India & Anr. Versus Naseem Bano", that bed head ticket cannot be the conclusive proof. There was no piece of evidence which may prove that prior to filling up of proposal form, record of any hospital, slips of doctors, any prescriptions showing the name of medicines which deceased must be taking, saw the light of the day. Heart attack has no nexus with ailments like Diabetic Mellitus and Hypertension. Repudiation was not justified." In another judgment "Life Insurance Corporation Ltd. Vs. Shitla Devi" I (2011) CPJ 128. In that case, deceased died due to heart failure which had no nexus with the previous disease, which has been alleged to be suppressed. It was observed that there is no material fact/fraud on the part of the policy holder.
12. Further the District Forum has relied upon the judgment "Life Insurance Corporation of India vs. Sushma Sharma" I(2008) CPJ 213 wherein it was observed that no doubt hypertension is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. First Appeal No. 586 of 2014 8
13. Therefore, taking the case of the complainant from any angle, OPs have not been able to establish that the complainant Kamla Devi was suffering from any pre-existing disease at the time of taking the policy. The opinion of the Doctor is contradictory to its operative summary. No evidence has been produced on the record that before taking the policy, insured was taking any treatment with any hospital. Therefore, the counsel for OPs was unable to establish on the record that the insured was suffering from any pre-existing disease before taking the policy. The order so passed by the learned District Forum is justified. We affirm the same.
14. We do not see any merit in the appeal and the same is dismissed with no order as to costs.
15. The appellants had deposited an amount of Rs. 25,000/- & Rs. 75,000/- with this Commission in the appeal. These amounts with interest accrued thereon, if any, be remitted by the registry to the respondents in equal share by way of a crossed cheque/demand draft after the expiry of 45 days, from the despatch of the order to the parties; subject to stay, if any, by the higher Fora/Court.
16. Remaining amount, if any due, shall be paid by the appellants to the respondents within 30 days from the receipt of the copy of the order.
17. The arguments in this appeal were heard on 10.8.2015 and the order was reserved. Now the order be communicated to the parties as per rules.
First Appeal No. 586 of 2014 9
18. The appeal could not be decided within the statutory period due to heavy pendency of Court cases.
(Gurcharan Singh Saran) Presiding Judicial Member (Jasbir Singh Gill) Member August 13, 2015. (Surinder Pal Kaur) as Member