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PUNJAB STATE CONSUMER DISPUTES REDRESSAL COMMISSION
Gurcharan Singh Saran, Presiding Judicial Member and Shri Rajinder Kumar Goyal, Member
RENU PARGAL - Appellant
Versus
MAX BUPA HEALTH INSURANCE COMPANY LTD. - Respondent
First Appeal No. 460 of 2017
Decided on : 01-11-2017
Sh. Aman Bansal, Advocate, for the Appellant; Sh. K.S. Cheema, Advocate, for the Respondents
The main legal point established in the judgment is that the rejection of an insurance claim must be based on valid grounds and in accordance with the information sought for by the insurer in the proposal form.
Headnote:
Consumer Protection Act - Health Insurance Policy - Consumer Protection Act, 1986 - [Consumer Protection Act, 1986, Section 2(1)(g), Section 12, Section 14(1)(d)] - The court discussed the provisions of the Consumer Protection Act, 1986, particularly Section 2(1)(g) defining 'consumer', Section 12 regarding the manner of filing a complaint, and Section 14(1)(d) specifying the reliefs which may be granted by the consumer forum. The court emphasized the duty of the insurer to reimburse the insured's medical expenses as per the terms of the health insurance policy and the obligation of the insured to disclose all material facts at the time of taking the policy. The court's decision was influenced by the interpretation of these provisions, holding that there was no material concealment in accordance with the information sought for by the insurer in the proposal form, and therefore, the rejection of the claim was not legally sustainable.
Fact of the Case:
The complainant filed a complaint under the Consumer Protection Act, 1986 against the insurer for rejecting her claim under a health insurance policy. The insurer alleged that the complainant had concealed her pre-existing bronchial asthma at the time of taking the policy.
Finding of the Court:
The court found that there was no material concealment in accordance with the information sought for by the insurer in the proposal form, and therefore, the rejection of the claim was not legally sustainable.
Issues: The issues revolved around the alleged concealment of pre-existing bronchial asthma by the complainant at the time of taking the health insurance policy and the insurer's obligation to reimburse the insured's medical expenses.
Ratio Decidendi: The court held that there was no material concealment in accordance with the information sought for by the insurer in the proposal form, and therefore, the rejection of the claim was not legally sustainable.
Final Decision: The court allowed the appeal, set aside the impugned order, and directed the insurer to pay the reimbursement amount, interest, compensation for harassment, and litigation expenses to the complainant.
ORDER
Gurcharan Singh Saran, Presiding Judicial Member. - The appellant/complainant (hereinafter referred as complainant) has filed the present appeal against the order dated 17.04.2017 passed in consumer complaint No. 714 dated 10.12.2015 by the District Consumer Disputes Redressal Forum, Ludhiana (hereinafter referred as the District Forum) vide which the complaint filed by the complainant was dismissed.
2. Complaint was filed by the complainant under the Consumer Protection Act, 1986 (in short 'the Act') against the respondents/opposite parties (hereinafter referred as Ops) on the averments that she purchased health insurance policy bearing policy No. 30360315201400 under plan "Familyfirst Gold 1 Lac + 20 Lacs" known as 'Heart Beat Health Insurance Policy' from Ops valid for the period 20.10.2014 to 19.10.2015. Under that policy, the complainant and her daughter Ashima Pargal were insured for a maximum amount of Rs. 22 Lacs. The complainant had undergone hysterectomy in Ludhiana Mediways Hospital, Ferozepur Road, Ludhiana and remained admitted there from 22.6.2015 to 26.6.2015 and was operated by the Doctor Ms. Veena Jain and incurred a sum of Rs. 8,910/- as prehospitalization expenses and Rs. 82,746/- on account of hospitalization and Rs. 550/- as post hospitalization expenses, in all Rs. 92,206/-. As per the terms of the health insurance policy, the Ops were bound to reimburse the said expenses. The complainant submitted her claim in the prescribed performa to the Op along with all the required documents i.e. hospital bills, medicine bills, pre-hospitalization, hospitalization and post hospitalization on 16.7.2015. However, the claim No. 141456 was disallowed by the Op vide their letter dated 24.8.2015 on the ground that complainant was having bronchial asthma and seasonal allergy for 2-3 years prior to policy inception and that the complainant did not disclose the same at the time of taking the policy. The complainant vide letter dated 31.8.2015 informed the local office of the Op that she was not suffering from bronchial asthma and it is not a disease under the medical terms and also supported the certificate issued by Dr. Veena Jain. The complainant neither had any previous history of bronchial asthma nor she had been taking any medication for it. Ops vide email dated 6.9.2015 asked the complainant to provide all past medical records for settlement of the claim. The complainant vide letter dated 10.9.2015 informed the Ops that she did not have any past record as she was never hospitalized before this illness. Complainant sent another email dated 18.9.2015 calling upon the Ops to intimate regarding their decision to the claim of the complainant. Vide their email dated 21.9.2015, Ops informed the complainant that they have declined to reconsider its earlier decision to the rejection of the claim of the complainant by the Ops on the alleged ground that the complainant allegedly suffering from bronchial asthma is against the law and facts. The rejection of the claim of the complainant on flimsy grounds is clear cut case of deficiency in service. Accordingly, the complaint was filed by the complainant against the Ops for seeking direction against the Ops to pay the reimbursement amount of Rs. 92,206/- along with interest @ 18% p.a., compensation of Rs. 50,000/- and litigation expenses of Rs. 22,000/-.
3. Upon notice, the Ops appeared and filed their written reply taking preliminary objections that the complainant concealed the material facts from the Forum. With regard to her pre-existing disease, the matter in dispute is complicated required lengthy evidence including cross-examination, which is not possible in summary procedure before the Consumer Forum, therefore, the matter be relegated to the Civil Court. The policy was issued on the basis of proposal form. Policy was sent along with its terms and conditions and the welcom
