Punjab

Ludhiana

CC/19/269

Manjit Kaur - Complainant(s)

Versus

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

M.S.Sethi Adv.

12 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 269 dated 31.05.2019.                                                        Date of decision: 12.01.2023.

 

Manjit Kaur 57 years W/o. Jagwinder Singh, r/o. Village Nathowal, Raikot, Distt. Ludhiana-142032.                                                                                                                                                                        ..…Complainant

                                                Versus

1. HDFC Ergo General Insurance Co. Ltd., Central Processing Center, 2^nd & 3^rd Floor, ILABS Centre, Plot No/.404/405, Udyog Vihar, Phase-111, Gurgaon-122016 Haryana through authorized signatory.
2. HDFC Ergo General Insurance Co. Ltd., SCO 46-47, Feroze Gandhi Market, Ludhiana through authorized signatory.                                                                                                             …..Opposite parties 

Complaint Under Section 12 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. M.S. Sethi, Advocate.

For OPs                          :         Sh. Ajay Chawla, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                In brief, facts of the case are that the complainant hired services of opposite parties regularly since 19.03.2013 to 14.04.2019. She paid premium of Rs.15,737/- for the renewal of the policy for the period from 15.04.2017 to 14.04.2019 through agent Sarabjit Kaur and she delivered only identification card (Ex. C1) showing policy period and ID 10005388023 and policy No.110600/11108/1000380915-02 with printed terms and conditions. No other terms and conditions were received by the complainant from the opposite parties. During the policy period, the complainant remained admitted in Arora Neuro Centre, Civil Lines, Ludhiana from 16.02.2019 to 21.02.2019 with complaint of unclear speech since 16.02.2019. However, the opposite parties declined cashless facilities and advised him to submit final claim after discharge. Thereafter, the complainant submitted claim of Rs.63,290/- dated 05.03.2019 along with 61 pages of documents (Ex. C2, Ex. C7 and Ex. C26). The opposite parties vide their letter dated 18.03.2019 disclosed claim ID 965426/1 and again asked the complainant to submit the additional documents i.e. all original payment receipt for the final bill and al previous treatment records of cerebrovasclar accident in past. The complainant informed opposite party No.2 that she has already submitted the original documents having 61 pages and she is not in custody of any more documents but opposite parties vide letter dated 25.04.2019 again asked the complainant to submit a previous treatment records of cerebrovasclar accident in past and original receipt of Rs.17,000/-. The opposite parties vide said letter disclosed that if they do not receive any response from her within 15 days they will have to proceed with their decision based on the available documents.  The complainant further submitted that despite again and again disclosing that al materials and non-material documents including receipt of Rs.17,000/- in original already stands submitted to them on 05.03.2019, the opposite parties refused to hear anything. Husband of the complainant vide letter dated 25.04.2019 requested the opposite parties to return 61 pages plus 8 film plus 4 page hospital bill submitted on 05.03.2019 consisting discharge card Arora Neuro Ludhiana, original bills of medicines, MRI, X-ray film and said application was duly received by dealing official of opposite party No.2 along with signatures and date. Thereafter, on receiving call from opposite party No.2, husband of the complainant visited their office on 17.05.2019 and after getting signature on register, opposite party NO.2 returned the original documents to the husband of the complainant while retaining photocopy of the same. On visit to opposite parties on 28.05.2019 to know the fate of lodged claim, opposite parties handed over final reminder letter dated 21.05.2019 again demanding the documents vide letter dated 25.04.2019. The complainant told the opposite parties that she had already submitted the documents with them which opposite party No.1 has duly received but instead of acceding to her genuine request she was told by official of opposite parties that her claim already stand repudiated by them vide rejection letter dated 21.05.2019. The complainant further submitted that the repudiation of the claim is illegal and not based on real facts by opposite parties to deny their liabilities under the policy. Moreover, the complainant has already submitted all the required documents with original receipt of Rs.17,000/- with the opposite parties but they without checking/examining the nature of submitted documents, demanded such documents again and again. The opposite parties returned the original documents including receipt after retaining the copies with them and they have no where disclosed the reason for claiming original receipt just to delay the process of claim deliberately and intentionally. The opposite parties have no right to claim any nature of documents including original receipt of Rs.17,000/- and if they were having any doubt or genuineness of the receipt/documents they were required to visit the concerned hospital or medical store but they failed to do so. Even no terms/conditions prohibiting liability of such claim was agreed by the complainant at any stage nor the same was ever conveyed to the complainant and the claim is payable under the medi-claim insurance and opposite parties have rendered deficient/negligent services and have also adopted unfair trade practice for not serving intimation regarding repudiation of the claim and for claiming certain documents illegally and arbitrarily. In the end, the complainant has made prayer that the letter dated 21.05.2019 or thereafter for claiming certain documents or rejection of the claim be held illegal, arbitrary and be set aside and opposite parties be directed to settle and pay the claim of Rs.63,290/- along with interest @12% and for compensation of Rs.50,000/- and litigation costs of Rs.11,000/-.

2.                Upon notice, opposite parties appeared and filed joint written statement by taking preliminary objections that the compliant is gross abuse of process of law and has been filed to harass and pressurize the opposite parties. The opposite parties further alleged that the complaint is premature, misconceived and incorrect and is also not maintainable in the present form. The complaint is bad for non-joinder and mis-joinder of necessary parties  and is barred by Section 3 of the Consumer Protection Act 1986. The complainant is not entitled to any relief in equity as the complainant has concealed the factum of writing letters dated 20.04.2019, 04.05.2019 and 13.05.2019 to her to provide relevant document to enable it to consider the claim as per policy terms and conditions. However, the complainant had deliberately not provided documents which has compelled the opposite parties to close/reject the claim of the complainant. It appears from the various documents provided by the complainant in support of her claim that she was admitted with complaint of Acute ischaemic Stroke. After reviewing the submitted documents, it was noted on prescription dated 13.02.2019 that the complainant had history of Cerebrovascular Accident (CVA) but duration was not mentioned. The opposite parties requested for the documents from the complainant to know duration of CVA which is reproduced as under:-

          a. Kindly provide all previous treatment record of Cerebrovascular              Accident in past.

          b. Payment receipt of amount of Rs.17,000/- in original for the final bills.

Due to non receipt of the documents, the opposite parties were compelled to close/reject the claim. The opposite parties further alleged that the insurance policy is a contract between the insurer and the insured which is governed by the principles of Indian Contract Law and the same is equally binding over the parties to the contract.

                   Under the head of brief submissions, the opposite parties alleged that the complainant signed and submitted the proposal form No.1101911317 on 19.03.2013 in which it is clearly mentioned that “This proposal will be the basis of any insurance policy that we may issue. You must disclose all facts relevant to all persons proposed to be insured that may affect our decision to issue a policy or its price, terms, conditions and exclusions. Non-compliance my result in the avoidance of the policy. If there is insufficient space for you to provide information whether as requested or otherwise, please attach a separate sheet. If you are in any doubt, please seek the advise of your insurance advisor. We are under no obligation to accept any proposal for insurance. If we accept a proposal for insurance, it shall be subject to the policy terms and conditions and we shall have …….” The complainant was duly informed about the terms and conditions of the policy and after being satisfied with the same, the complainant signed and submitted the proposal form. The opposite parties further alleged that on the basis of the proposal form, a policy Nio.110600/11108/1000380915 was issued w.e.f. 29.03.2013 to 28.03.2015 and the same was being got renewed till 14.04.2019. All the relevant documents were duly sent to the complainant at various times to verify the benefits, terms and conditions of the policy. It was mentioned under Section VII (g) – “Supporting Documentation & Examination” that the insured person is required to provide al documentations including medical records and information as required by the insurance company of the TPA to establish the circumstances of the claim, it s quantum or its liability for the claim. It is also submitted that as per Section VII (i)i)- “Claims Payment”  that insurer shall be under no obligation to make any payment under policy unless the documentation and information  have been provided to establish the circumstances of the claim, its quantum or liability for it. The complainant had submitted the claim for reimbursement with diagnosis of Acute Ischaemic Stroke with date of admission 16.02.2019 and date of discharge 21.02.2019 and final claimed amount of Rs.63,290/-. On post scrutiny of documents, it was noted on prescription dated 13.02.2019 that the complainant had history of Cerebrovascular Accident (CVA) but on that prescription duration was not mentioned. The opposite parties raised a query to the complainant vide letter dated 20.04.2019 and subsequent reminders on 04.05.2019 and 13.05.2019 requesting for documents like “all previous treatment records of Cerebrovascular Accident in Past and Payment receipt of amount of Rs.17,000/- in original for the final bills.” but the opposite parties had not received any reply from the complainant despite repeated reminders on 20.04.2019, 04.05.2019 and 13.05.2019 so the claim was rejected on 23.05.2019 due to non-receipt of the pending documents. The opposite parties further alleged that they have been at all times acting as per terms and conditions of the policy only and is ready to consider the claim of the policy, subject to complainant providing the requisite documents as asked for, since the desired documents for want of which the claim had been rejected are essential to determine the genuineness and admissibility of the claim. The opposite parties further alleged that since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy and as such the opposite parties have rightfully rejected the claim of the complainant as per the terms and conditions of the policy.  

                   On merits, the opposite parties reiterated the facts stated in preliminary objections and brief submissions of the case and denied the deficiency of service on their parties.  In the end, a prayer for dismissal of the complaint has been made.

3.                In support of her claim, the complainant tendered her affidavit Ex. CA in which she reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 copy of the terms and conditions, Ex. C2 is the copy of claim form, Ex. C3 is the copy of query letter dated 18.03.2019, Ex. C4 is the copy of query letter dated 25.04.2019, Ex. C5 is the copy of letter dated 25.04.2019 written by the complainant, Ex. C6 is the copy of final reminder letter dated 21.05.2019, Ex. C7 to Ex. C12, Ex. C16 to Ex. C26 are the copies of medical record, bills/receipts and investigation reports of the complainant, Ex. C13 is the medical report dated 13.02.2019, Ex. C14 is the report of MRI of head dated 16.02.2019, Ex. C15 is the report of MRI scan of brain dated 20.02.2019, Ex. C16 is the and closed the evidence.

4.                On the other hand, counsel for the opposite parties tendered affidavit Ex. OPA of Ms. Deepti Rustagi, Attorney of the opposite parties along with document Annexure-R1 is copy of power of attorney dated 21.12.2017 in favour of Mrs. Deepti Rustagi, Annexure-R2 is the copy of proposal form, Annexure-R3 is the copy of welcome kit dated 30.03.2013, Annexure-R4 is the copy of claim form, Annexure-R5 is the copy of query letter dated 20.04.2019, Annexure-R6 is the copy of rejection letter dated 23.05.2019 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 reply along with affidavit and documents produced on record by both the parties.      

6.                It was contended on behalf of the counsel for the complainant that at the time of submission of the claim, all the necessary documents were provided to the opposite parties and there is inordinate delay on the part of the opposite parties for settling the claim and in order to cover that, the opposite parties just declined the claim due to non-submission of documents consisting of previous treatment record of Cerebrovascular Accident in the past and the payment receipt of Rs.17,000/- in original. The counsel for the complainant further contended that there exists no previous treatment record of Cerebrovascular Accident and as such, the same cannot be provided. Further the payment of receipt of amount of Rs.17,000/- was supplied to the opposite parties.

7.                On the other hand, the opposite parties have denied having received the said documents and further contended that the claim was closed after the complainant failed to provide the required documents after the receipt of reminders.

8.                It may be noticed that the complainant had been availing the policy since March 2013 which has been renewed from time to time. Had there been a history of past Cerebrovascular Accident of the complainant, she must have been hospitalized and must have availed the insurance cover as provided by the opposite parties. So the demand to supply the documents, existence of which cannot be perceived or established, is untenable. The payment receipt had already been provided and has also been adduced in the evidence and this fact also stands acknowledged. In the given facts and circumstances, the requirement of the documents has already been substantially complied by the complainant, so the repudiation of the claim is not justified and as such, it would be just and appropriate if the opposite parties are directed to consider and pay the claim of the complainant along with composite costs of Rs.10,000/-.

9.                As a result of above discussion, the complaint is partly allowed with an order that the opposite parties shall consider and pay the claim of medical expenses of the complainant within 30 days from the date of receipt of copy of order. The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. 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)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

 

Announced in Open Commission.

Dated:12.01.2023.

Gobind Ram.

 

 

 

Manjit Kaur Vs Apollo Munich Health Ins.                               CC/19/269

Present:       Sh. M.S. Sethi, Advocate for complainant.

                   Sh. Ajay Chawla, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with an order that the opposite parties shall consider and pay the claim of medical expenses of the complainant within 30 days from the date of receipt of copy of order. The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

                 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

 

Announced in Open Commission.

Dated:12.01.2023.

Gobind Ram.