Punjab

Ludhiana

CC/19/263

dinesh Soni - Complainant(s)

Versus

Apollo Munich Health Ins. - Opp.Party(s)

Vijay Kumar Adv.

21 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No: 263 dated 29.05.2019.                              Date of decision: 21.08.2024. 

 

Dinesh Soni Son of the Late Shri Beas Lal Soni resident of House no.8860/1, Street no.7, New Subash Nagar, Rahon Road, Ludhiana.

                                                                                      ..…Complainant

                                                Versus

1. HDFC Ergo Health Insurance formally known as Apollo Munich Health Insurance Co. Ltd., 2^nd & 3^rd Floor, iLABS Centre, Plot No.404-405, Udyog Vihar, Phase-III, Gurgaon, Haryana through its Manager/Managing Person/Regional Manager.
2. HDFC Ergo Health Insurance formally known as Apollo Munich Health Insurance Co. Ltd., SCO 146, 2^nd Floor, Feroze Gandhi Market, Ludhiana through its Manager.                                                                                                                     …..Opposite parties 

Complaint Under Section 12 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Vijay Kumar, Advocate.

For OPs                          :         Sh. Alok Mohindra, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that earlier in 2008, the complainant availed insurance policy from Bajaj Allianz for himself and his family members on regular basis but he never raised any claim from Bajaj Allianz Company. The complainant stated that in 2015, the officials of the OPs approached and allured him to get the policy of the OPs being best in settling the claim. Believing their assurance, the complainant got insured himself and his family members with OPs vide policy No.110600/11121/AA00197076 w.e.f. 13.03.2015 go 12.03.2016. The complainant was properly fit and not suffering from any ailment at the time of obtaining the policy and even the OPs also examined the complainant. The policy was cashless.

                   The complainant further stated that in September 2015, he suffered pain in his teeth for which he got himself checked from Bhagat Tarsem Lal Ji Maharaj Charitable Hospital and remained admitted in the hospital. As per advise of the doctors as well as officials of the OPs, the complainant got conducted test and examined the Rec. Multiple Greyish White Soft Tissue Pieces measuring and reported that “SUPERFICIAL BIOPSY HOWEVER APPEARANCES ARE HIGHLY SUGGESTIVE OF VERRUCOUS CARCINOMA: BIOPSY ORAL MUCOSA. SUGGEST DEEPER BIOPSY AND HPE.” The complainant incurred Rs.10,200/- on his hospitalization. As the complainant was not satisfied with the treatment of said hospital, so he visited Rajiv Gandhi Cancer Institute and Research Centre, Delhi where his test was conducted and was admitted in the hospital. Intimation was given to the OPs regarding hospitalization of the complainant upon which surveyor of the OPs visited the hospital and lodged the claim of the complainant with assurance to pass the claim after his operation and getting the bills. The complainant further stated that the doctors operated him for VERRUCOUS CARCINOMA-RIGHT GINGIVO-BUCCAL MUCOSA and remained admitted in hospital from 10.10.2015 to 21.10.2015. The complainant informed the OPs regarding his operation and the OPs sent their surveyor for collecting documents and estimate bill from the hospital who collected the documents and estimate of the bill but the OPs did not pass any claim. The complainant was discharged in stable condition and he spent Rs.4,81,188/- on his treatment. However, he did not receive any official communication from the OPs. He many times approached the OPs for enquiring about his claim but the officials of the OPs kept delaying the matter. The complainant further stated that on 06.04.2017, the officials of the OPs told the complainant that his claim has been rejected but no reason was disclosed. On 06.04.2017, the complainant submitted letter to the OPs to provide closure report and original documents in the month of July 2017. The complainant received original documents from the OPs but never received the closure report. According to the complainant, the claim is payable to him as per terms and conditions of the policies as he was not suffering from any disease at the time of purchase of policy in question and even the OPs issued the policy after being satisfied regarding health condition of the complainant and his family. The rejection of claim amounts to deficiency in service and unfair trade practice on the part of the OPs due to which the complainant has suffered mental tension and agony for which he is entitled for compensation beside hospitalization charges. In the end, the complainant has prayed for issuing direction to the OPs to pay the medical expenses of Rs.4,81,188/- along with compensation of Rs.2,00,000/- and litigation expenses of Rs.6500/-.

2.                Upon notice, the OPs appeared and filed joint written statement and assailed the complaint by taking preliminary objections on the ground of maintainability; lack of jurisdiction and cause of action; the complaint being an abuse of process of law; suppression of material facts; non-joinder and mis-joinder of necessary parties; the complaint being misconceived; barred by limitation etc. The OPs stated that the claim of the complainant was finally closed/rejected on 19.03.2016 as per policy terms and conditions and the complainant filed the present complaint in 2019 and as such, the complaint is barred by limitation. The complainant is not entitled to any benefit under the policy.

                   Under the column Brief Submissions, the OPs stated that the complaint is premature, misconceived, devoid of any merits etc. The complainant approached them for availing insurance policy and submitted proposal form No.6101205781 dated 20.02.2015 for issuing Optima Restore Insurance Policy, on the basis of which, the policy No.110600/11119/AA00202113  w.e.f. 13.03.2015 to 12.03.2016 was issued. The policy kit and documents were provided to the complainant. According to the OPs, on 08.10.2015, cashless request was received from the complainant w.r.t. admission at Rajiv Gandhi Cancer Institute and Research Centre with probable date of admission 10.10.2015 for surgery in a C/O Right Buccal Mucosa CA having estimate medical expenses of Rs.4,25,000/-. On post scrutiny of documents, the OPs raised request vide later to provide : “underlying cause of the carcinoma, any h/o tobacco chewing or other carcinogenic agent duly attested by the treating doctor – exact duration with all previous treatment record, first consultation paper.’ But the complainant/hospital did not provide the information and as such, the cashless request was rejected and intimated to the complainant/hospital on the ground that “Cashless facility cannot be granted as the required information/documents has not been provided by the provider/Insured to decide admissibility. However, the insured can file the claim for reimbursement post completion of the treatment with all medical & financial records. The admissibility of the claim would be decided post review of the documents and policy documents.” Thereafter, the complainant submitted claim for reimbursement of medical expenses of Rs.4,91,388/- for hospitalization from 10.10.2015 to 21.10.2015 for diagnosis of Carcinoma right-buccal mucosa. The OPs further stated that after reviewing the documents, it was observed from discharge summary that complainant had lesion in buccal mucosa for 2½ year and same is prior to policy inception and as such, a query letter was sent to the complainant, which is reproduced as under:-

1. All past treatment records, consultation papers, investigation reports related to the growth in the cheek and gums since very first diagnosis and first notice.
2. Any past history of smoking, Pan or Guthka chewing (in any form) and since when and in what quantity.
3. Copy of indoor case papers including admission notes, vitals and inputs/output charts along with daily progress notes.
4. Copy of residence proof (Electricity or Telephone bill not older than 6 months) in the name of proposer. Please check claim form for rest of the acceptable residence proofs.
5. Passport size photograph (not older than 6 months) of the proposer.

The Ops further stated that the complainant submitted few documents and failed to submit remaining queries even after repeated reminder. Further discharge summary and prescription dated 05.10.2015 shows that the complainant had past medical history of ulcerated lesion of buccal mucosa since 2015 which is before policy inception. The OPs claimed to have sent reminders to the complainant to provide the documents of past medical history for deciding the claim but no response was received from the complainant and as such, his claim was closed on 29.03.2019 on the ground: “All previous investigation reports, treatment and follow up records dated prior to inception pertaining to ulcerated lesion of buccal mucosa since 2.5 years.” However, the OPs stated that it is ready to consider the claim of the complainant as per terms and conditions of the policy subject to providing the requisite documents by the complainant.

                    On merits, the OPs reiterated the crux of averments made in the preliminary objections and Brief Submissions. The OPs have denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                The OPs filed an application for substitute the name from Apollo Munich Heath Insurance Company Ltd. to HDFC Ergo Health Insurance Limited by pleading that name of Apollo Munich Health Insurance has been changed to HDFC Ergo Health Insurance Limited. However, the said application was also allowed vide order dated 23.02.2024.

4.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 is the copy of kit of policy No.110600/11121/AA00197076, Ex. C2 is the copy of letter of the complainant regarding change/correction in policy details, Ex. C3 and Ex. C4 are the copies of Generic Contingency Policy Schedule and closed the evidence.

                   The complainant filed application for leading additional evidence, which was allowed vide order dated 11.10.2023 subject to payment of costs of Rs.1000/-.

                   In additional evidence, the complainant tendered documents Ex. C5 is the copy of policy w.e.f. 13.03.2008 to 12.03.2009 of Bajaj Allianz, Ex. C6 is the copy of policy w.e.f. 13.03.2009 to 12.03.2010 of Bajaj Allianz, Ex. C7 is the copy of policy w.e.f. 13.03.2010 to 12.03.2011 of Bajaj Allianz, Ex. C8 is the copy of policy w.e.f. 13.03.2011 to 12.03.2012 of Bajaj Allianz, Ex. C9 is the copy of policy w.e.f. 13.03.2012 to 12.03.2013 of Bajaj Allianz, Ex. C10 is the copy of policy w.e.f. 13.03.2013 to 12.03.2014 of Bajaj Allianz, Ex. C11 is the copy of policy w.e.f. 13.03.2014 to 12.03.2015 of Religare Health Insurance and closed the additional evidence.

                   Further the complainant filed application for adducing additional evidence for bringing on record the treatment record given to him at Bhagat Tarsem Lal Maharaj Charitable Hospital and reply submitted by the complainant in response to closure letter. The said application was allowed vide order dated 04.04.2024 subject to costs of Rs.500/-.

                   The complainant closed his additional evidence by tendering affidavit Ex. CX along with documents Ex. C12 to Ex. C16(Ex. C1 to Ex. C11 already on record). He further suffered statement that his earlier affidavit Ex. CA may not be considered. Ex. C12 is the copy of self declaration of the complainant, Ex. C13 is the copy of bill of Bhagat Tarsem Lal Ji Maharaj Charitable Hospital, Ex. C14 is the copy of reference letter of Bhagat Tarsem Lal Ji Maharaj Charitable Hospital, Ex. C15 is the copy of Discharge Card issued by Bhagat Tarsem Lal Ji Maharaj Charitable Hospital, Ex. C16 is the copy of MRI Scan of Face & Neck dated 22.09.2015.

4.                On the other hand, the counsel for the OPs tendered affidavit  Ex. RW1/A of Sh. Abhishek Sharma, Authorized Representative of the OPs along with documents Ex. R1 is the copy of  proposal form dated 19.02.2015, Ex. R2 is the copy of policy documents for policy w.e.f. 13.03.2015 to 12.03.2016, Ex. R3 is the copy of Claim Form Part-A as well as medical record, Ex. R4 is the copy of OPD card, discharge summary and medical record of Rajiv Gandhi Cancer Institute and Research Centre, Ex. R5 is the copy of closure letter dated 19.03.2016 and closed the evidence.                                                         

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written statement along with affidavit and documents produced on record by both the parties.

6.                Undisputably, the complainant remained hospitalized at Rajiv Gandhi Cancer Institute and Research Centre, Delhi from 10.10.2015 to 21.10.2015 where he was operated upon for C/O Right Buccal Mucosa CA. The complainant was discharged from the said hospital vide discharge summary Ex. C4 vide which the complainant was diagnosed to be a case of CARCINOMA RIGHT BUCCAL MUCOSA (E T2 NO) and was discharged in stable condition. On 08.10.2015, a cashless request was made to the OPs, to which the Ops raised a query to provide : “underlying cause of carcinoma, any h/o tobacco chewing or other carcinogenic agent duly attested by the treating doctor – exact duration with all previous treatment record, first consultation paper.” Later on, due to non-receipt of any information from the complainant or hospital, the said cashless request was rejected by the OPs. Thereafter, the complainant submitted the Claim Form Ex. R3 for reimbursement for an amount of Rs.4,91,388/-  with the OPs. The OPs also closed the claim of the complainant vide Closure Letter dated 19.03.2016 Ex. R5, the operative part of which is reproduced as under:-

“This is to inform you that, inspite of repeated reminders sent to you on 04 Feb 2016, 19 Feb 2016 and 27 Feb 2016, we have still not received the pending documents which are necessary to process your claims. Hence we regret to inform that your claim has been closed.

 

SL No.	Bill No.	Particulars of Details / Documents Required	Amount	Status	Requirement Type
2.		All previous investigation reports, treatment and follow up records dated prior to inception pertaining to ulcerated lesion of buccal mucosa since 2.5 years.	473006	Pending	Mandatory

 

However, the OPs in their written statement  in para No.16 of the Brief Submissions as well as para No.4 of Reply On Merits stated that the complainant has not provided the requisite documents as necessary for proceed the realization of the claim amount till time to them. Hence the claim was closed and they are ready to consider the claim as per policy terms and conditions.

7.                It may be noted that in written statement, the OPs have referred to mentioning of lesion of buccal mucosa since 2.5 years which the OPs considered it to be prior to policy inception and al the queries by the OPs were made in this context. The OPs are required to take note of the fact that the complainant had been availing policies since the year 2008 and which are Ex. C5 to Ex. C11. So the inception of the policy in this case will be considered to be w.e.f. 13.03.2008 to 12.03.2009 (Ex. C5). Ex. C12 is the copy of self declaration furnished by the complainant wherein he has tried to meet out the objections raised by the OPs during the process of settlement of the claim, which is reproduced as under:-

“I Dinesh Soni want to declare that all the required documents related to above said claim deposit in your branch. As per your Company they are asking for cal past treatment records, consultation papers & investigation reports related to the growth in cheek and gum since any first diagnosis and first notice] Hence I want to declare that before my operation at Rajiv Gandhi Cancer Hospital doctor asked to me about swelling on my gum. Then I told him its about 2 ½ years back. But I did not feel any problem and didn’t take any treatment pending swelling on by gum. I came to about cancer in gum when I went  to Bhagat Tarsem Lal Charitable Hospital for the treatment of my teeth when  I feel pain in my teeth. During my treatment doctor saw swelling on my gum and advised me for test of cancer. This is the first time when I came to know cancer in my gum.

          And your 2^nd requirement [Any history of smoking, PAN or Guthkha, chewing in any form] and since when and in what quantity. For this I have already given the written statement to your company investigator. 15 y back I had once in my intake Tombacu with my friends.

          I am insured from last 7 to 8 years and didn’t take any claim regarding any illness. Last year I part my policy to Apollo Munich. Before Apollo Munich I was insured with Religare Health Insurance and before Religare I was insured with Bajaj Allianz. I have not taken any claim with previous companies.

          So I am requesting you kindly settle my claim as soon as possible. I am asking for my genuine claim.”

 

Therefore, it is expected that at the time of settling the present claim, the OPs will consider the aforesaid material aspect of previous policies as well as self declaration of the complainant. The insurance companies are required to be more liberal in their approach without being too technical while settling the genuine claims.

8.                In this regard, reference can be made to 2022(2) Apex Court Judgment 281 (SC) in case title Gurmel Singh Vs Branch Manager National Insurance Company Ltd. whereby it has been held by the Hon’ble Supreme Court of India that the insurance company has become too technical while settling the claim and has acted arbitrarily. The appellant has been asked to furnish the documents which were beyond the control of the appellant to    procure and furnish. Once, there was a valid insurance on payment of huge sum by way of premium and the Truck was stolen, the insurance company ought not to have become too technical and ought not to have refused to settle the claim on non­-submission of the duplicate certified copy of certificate of registration, which the appellant could not produce due to the circumstances beyond his control. In many cases, it is found that the insurance companies are refusing the claim on flimsy grounds and/or technical grounds. While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control. In the given set of circumstances, it would be just and appropriate if the complainant is directed to submit the documents required as per Closure Letter dated 19.03.2016 Ex. R5, available with him, if any, with the OPs within 15 days from the date of receipt of copy of order and thereafter, the OPs shall settle and pay claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant. 

9.                As a result of above discussion, the complaint is partly allowed with an order that the complainant is directed to submit the documents required as per Closure Letter dated 19.03.2016 Ex. R5, available with him, if any, with the OPs within 15 days from the date of receipt of copy of order and thereafter, the OPs shall settle and pay claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant, failing which the complainant shall be held entitled to interest @8% per annum on the settled amount from the date of order till its actual payment.  Further if the complainant is not in possession of remaining documents, then the OP shall settle and pay the claim to the complainant on the basis of already submitted documents within 45 days from the receipt of copy of this order. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.       

10.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:21.08.2024.

Gobind Ram.