The District Consumer Disputes Redressal Forum-III here directed Max Bupa Health Insurance Company Limited to return Rs.1,15,353 along with a compensation of Rs.50,000 to a customer for deficiency in service.
The order based on a complaint from Syed Tajuddin Khandri, a resident of Gandhi Nagar, who wrote to the forum that the insurance company had refused the ‘cashless treatment’ facility for his wife in spite of having a valid policy effective from January 17, 2013, which was valid for a year. His spouse, Syed Khazima, was admitted for surgery at Aditya Hospital at Boggulkunta on November 27, 2013.
Mr. Khadri in his petition wrote that in spite of raising a request to solve the matter in March 2015 by writing a letter to the company, the matter was not resolved.
In its response, the Max Bupra Health Insurance Company Limited alleged that Ms. Khazima’s weight was ‘misrepresented’ as 73 kilograms when the policy was taken, whereas her weight was over 100 kg for the last three to four years. The insurance company said that Mr. Khadri failed to comply with clause No.5 of the ‘proposal form’, and also ‘misrepresented’ her age and weight, which is why his request was rejected. However, after scrutinising all the evidence, the forum ruled that his wife’s age was not wrongly mentioned, as he had provided her Aadhar card, which corroborated the information he had provided. The forum also said that it was ‘unable’ to accept the insurance company’s allegation that Ms. Khazima’s weight was over 100 kg, as there was no material evidence to prove it. It ruled that during the period from taking the policy till the date Aditya Hospital had checked her weight, there was a possibility of her gaining weight, it said and also pointed out that this was no bar for taking a policy.
Ruling that the company took an ‘untenable defence to avoid liability’, the forum said that it amounted to deficiency of service, and directed it to reimburse the complainant Rs.1,15,353 he had spent and another Rs.50,000 as compensation to him.