Chandigarh

DF-II

CC/623/2014

Mr. Sanjiv Gupta - Complainant(s)

Versus

Apollo Mumnich Health Insurance Co.Ltd. - Opp.Party(s)

Sh. Sanjiv Gupta Adv.

06 Oct 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	623 OF 2014
Date  of  Institution	:	02.12.2014
Date   of   Decision	:	06.10.2015

 

 

 

 

 

Sanjiv Gupta s/o Sh.Rabinder Nath, R/o # 264, Sector 12, Panchkula, Haryana 134113

 

             …..Complainant

Versus

 

1]  Apollo Munich Health Insurance Co. Ltd., SCO No.50-51, 4^th Floor, Sector 34-A, Chandigarh.

 

2]  Apollo Munich Health Insurance Co. Ltd., 10^th Floor, Tower-B, Building No.10, DLF Cyber City, DLF City Phase-II, Gurgaon, Haryana 122002

    2^nd Address:-

Apollo Munich Health Insurance Co. Ltd., Corporate Office, 1^st Floor, SCF 19, Sector 14, Gurgaon, Haryana 122 001.

 

….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         SH.JASWINDER SINGH SIDHU       MEMBER

         MRS.PRITI MALHOTRA             MEMBER

 

 

For complainant(s)      :     Complainant in person.       

 

For Opposite Party(s)   :     Sh.Nitin Thatai, Advocate

 

 

PER JASWINDER SINGH SIDHU, MEMBER

 

 

1]        As per the case, the complainant had been taking medical insurance cover for self and family continuously since March, 2007 from The New India Assurance Company Ltd. (Ann.I). It is averred that on being lured by the representative of OPs for porting the existing Health Insurance Policy from New India Assurance Co. Ltd. to Apollo Munich Health Insurance Co. Ltd., the complainant was issued “Optima Restore Policy” in March, 2013 vide policy Ann.II after pre-policy Health Check-up & tests, valid from 30.3.2013.  It is also averred that the complainant was informed that the coverage’s and benefits of the previous policy would remain intact since this is simply porting of the policy and he was shown that the policy clauses Sec.4B, Sec.4C and Sec.4D related to pre-existing diseases had been waived off in writing on the policy document.

         It is pleaded that in September, 2014, the complainant was advised to undergo Cystoscopy and TURP surgical procedure for the treatment of LUTS (Lower Urinary Tract Symptoms) by Dr.Hemant Hardikar (Ann.IV), as such the complainant sought cashless treatment facility since Fortis Mohali is the empaneled network hospital of Apollo Munich Health Insurance Company, but the same was denied vide Ann.V.  The complainant was hospitalized on 27.9.2014 and discharged on 29.9.2014 from Fortis Hospital, Mohali after successful treatment and made the payments form his own pocket.  Thereafter, the complainant filed a claim with the Opposite Parties for reimbursement of the expenses incurred on the said treatment and also supplied all requisite documents, but the same was cancelled by them on the ground of non disclosure of material facts about a pre existing condition vide letter dated 31.10.2014 (Ann.VIII).  It is also pleaded that the requirement for the surgical procedure arose more than 18 months later i.e. in Sept., 2014 after having ported the policy from New India Assurance Co. to Apollo Munich.  Hence, this complaint has been filed alleging the said cancellation of the claim as illegal and deficiency in service on the part of the Opposite Parties.

 

2]       The OPs have filed joint reply and admitted the issuance of medical insurance policy to the complainant.  It is submitted that along with the proposal form, the complainant also submitted a Portability Form.  The proposal was accepted on the standard rates based on the information provided by the complainant and consequently, the policy in question was issued commencing from 30.3.2013 to 29.3.2014. The treatment undertaken by the complainant during the currency of the policy and payment thereof by the complainant is also admitted.  The denial of cashless facility is also admitted.  It is stated that as the complainant has concealed the material facts about his prior medical history of Lower Urinary Tract Symptoms and Grade 1 Prostatomegaly since February, 2013 as available in the Prescription Dated 26/02/2013 of Sai Clinic, at the time of entering into the contract of insurance with the Opposite Party Company vide proposal form dated 11.3.2013, therefore, insurance contract is void ab-initio and is not binding upon the Opposite Party Company.  It is pleaded that the claim of the complainant was rightly rejected by the Opposite Parties and the policy was cancelled ab-inito from the date of renewal in view of non-disclosure by the complainant of his pre-existing disease in the proposal form.  Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.

 

3]       The Complainant also filed rejoinder thereby reiterating the averments as made in complaint and controverting that of the Opposite Party made in the reply.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the complainant in person, ld. Counsel for Opposite Party and have also perused the record.

 

6]       The complainant has preferred this complaint on the ground that he was insured under Mediclaim policy with New India Assurance Company since 2007 and on being advised of better features of the mediclaim policy of the OPs, preferred to port his existing policy into a new one of the OPs under the name of “Optima Restore” on 11.3.2013 which commenced from 30.3.2013.  The complainant had paid a premium of Rs.24,530/-, for the policy issued by the Opposite Parties on 30.3.2013. Thereafter, the said policy was renewed from March, 2014 by paying premium of Rs.16,230/-.

 

7]       The complainant who fell ill in the month of Sept., 2014 sought the pre-authorization for cashless treatment, but the same was denied citing reasons of pre-existing disease with a rider that the complainant may seek reimbursement by filing complete claim against the said treatment.  The OPs on receiving the claim from the complainant for the amount of Rs.1,16,675/- paid to the hospital for the treatment, but the same was denied citing reasons as non-disclosure of material facts.  The Opposite Parties even went a step further by cancelling and declaring the same as void ab-initio. The complainant claiming deficiency in service on the part of the OPs sought the relief as quoted in the prayer clause. 

8]       The Opposite Parties while filing their reply/version to the complaint of the complainant have held their ground claiming no deficiency in service on their part and have placed documents in support of their version declaring their right to cancel the policy on the ground of non-disclosure of material facts and also declaring the policy in question void ab-initio.

 

9]       We have minutely perused the documents placed on record by the parties and are of the view that the complainant has certainly subscribed for the portability of his health insurance policy initially maintained with the New India Assurance Company to that of “Optima Restore” of the Opposite Parties in the year 2013.  The same policy was thereafter renewed in the month of March, 2014 by the Opposite Parties and it was during the currency of this policy issued in the month of March, 2014 that the complainant suffered an ailment in Sept., 2014 and was hospitalized.  A cashless pre-authorization was requested on the basis of the diagnosis made by the Hospital, which was denied by the Opposite Parties giving him the option to file a complete claim after the treatment seeking reimbursement of the expenses so incurred. The claim of the complainant was repudiated on the basis of the report that the complainant did not disclose the happening of a similar problem while porting his health insurance policy in the year 2013 as she was diagnosed with the prostrate problem on 26.2.2013 and he failed to mention the same when a specific query with regard to his previous ailment was sought while filling up the proposal form for the purpose of portability. 

10]      We understand that the Opposite Parties action in denying the claim of the complainant on the ground of non-disclosure of material fact at the time of porting of the policy in the month of March, 2013 is proved on the basis of the proposal form placed on record by the Opposite Parties which is dated 11.3.2013.  However, this policy had long expired on 29.3.2014, when a fresh policy was issued by the OPs on 30.3.2014 during the currency of which the claim of the complainant had arisen for the ailment in the month of Sept., 2014.  The Opposite Parties have not placed on record any document on the basis of which their claim of non-disclosure of material facts for the issuance of policy on 30.3.2014 could be proved.  At the same time, the action of the Opposite Parties of cancellation of the insurance policy issued in the month of 30.3.2014 being void ab-initio for non-disclosure of the material facts is also bad in the eyes of law, as there is no document to prove that the complainant while renewing the policy in the month of 30.3.2014 have quoted any wrong information.

 

11]      Though the Opposite Parties have not specifically pointed out the number of policy which according to them is void ab-initio for the reason that the policy issued in March, 2013 had already lived its life and no claim had arisen during its existence and furthermore, the policy issued on 30.3.2014 to 29.3.2015 was issued with exclusions of Clauses Sec.4B, Sec.4C and Sec.4D related to pre-existing diseases had been waived off in writing on the policy document (Ann.OP-4 Page 38 of the reply).  

 

12]      The Opposite Parties have not placed on record any copy of the proposal form, copy of disclosure/declaration form signed by the complainant at the time of renewal of the policy issued on 30.3.2014, during the currency of which the claim of the complainant had arisen.  Therefore, in the absence of any such document, the reply/version of the Opposite Parties, cannot be believed and furthermore, the reliance of the Opposite Parties on the documents, which is related to a previous policy that has out lived its tenure/period, carry no force.  It is a settled principle of law that the evidence that deserves to be appreciated should be directly linked to the pleadings.  In the present case, the evidence placed on record by the Opposite Parties belongs to the previous policy and there is no document to prove that the complainant had deliberately concealed the information at the time of issuance of the policy on 30.3.2014.  Therefore, the Opposite Parties having renewed the policy, without demanding any disclosure or declaration before the issuance of the policy on 30.3.2014 cannot lay the blame on the complainant for the fault that he had not committed at the time of subscription of the policy on 30.3.2014. Thus, the action of the Opposite Parties of cancelling the policy issued on 30.3.2014 on the ground of non-disclosure, which were not demanded, amounts deficiency in service on their part for which the complainant deserves to be adequately compensated.

 

13]      In the light of above observations, we are of the concerted view that the Opposite Parties are found deficient in rendering proper service to the complainant. Hence, the present complaint of the Complainant is allowed qua OPs. The Opposite parties are jointly & severally directed as under:-

 

[a] To reimburse an amount of Rs.1,16,675/- incurred by the complainant on his treatment;

 

[b] To pay an amount of Rs.25,000/- to the complainant as consolidated amount of compensation for causing mental agony and harassment on account of deficiency in service;

 

[c] To pay litigation expenses to the tune of Rs.10,000/-

 

         The above said order shall be complied within 45 days of its receipt by the Opposite Parties; thereafter, they shall be liable to pay an interest @18% per annum on the amount of Rs.1,16,675/- and also on the compensation amount of Rs.25,000/- from the date of filing of the complaint till it is paid, apart from paying litigation expenses.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

6^th October, 2015                                                                   sd/-

 (RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (JASWINDER SINGH SIDHU)

MEMBER

 

 

Sd/-

(PRITI MALHOTRA)

MEMBER

Om                                                                                                                        

 

 

DISTRICT FORUM – II

CONSUMER COMPLAINT NO.623 OF 2014

PRESENT:   None   Dated the 6th day of October, 2015

O R D E R                        Vide our detailed order of even date, recorded separately, the complaint has been allowed against the Opposite Parties.                    After compliance, file be consigned to record room.

 

(Priti Malhotra)	(Rajan Dewan)	(Jaswinder Singh Sidhu)
Member	President	Member