Punjab

Rupnagar

RBT/CC/18/328

Manpreet Singh - Complainant(s)

Versus

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

CS Chopra adv

25 Nov 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, CAMP COURT AT LUDHIANA

 

                                    RBT/Consumer Complaint No. 328 of 14.5.2018

                                    Date of Decision: 25.11.2022

 

Manpreet Singh Walia, 8750, Street No.6, New Subhash Nagar, Basti Jodhewal, Ludhiana 

                                                                                  ……Complainant

                                                        Versus

 

1. Apollo Munich Health Insurance Company Limited, 10^th Floor, Building No.10, DLF Cyber City, Phase-II, Gurgaon, Haryana through its authorized signatory/representative
2. Apollo Munich Health Insurance Company Limited, Branch Office, Feroze Gandhi Market, Bhai Wala Chowk, Ludhiana through its authorized person/manager    

                                                                                ….Opposite Parties

Complaint under Consumer Protection Act

QUORUM:-

                SH. RANJIT SINGH, PRESIDENT

                SMT. RANVIR KAUR, MEMBER

 

ARGUED BY:-

      Sh. CS Chopra, Adv. For complainant

      Sh. Ajay Chawla, Adv. For Ops

 

ORDER:-

SH. RANJIT SINGH, PRESIDENT

          The present order of ours will dispose of the above complaint received by way of transfer from District Consumer Commission, Ludhiana, filed under Consumer Protection Act, by the complainant against the opposite parties on the ground that the OP No.1 issued to the complainant easy health floater standard insurance policy for coverage of Rs.3,00,000/- for the period from 14.9.2017 to 13.09.2018 in continuation to its initial policies which started with the Ops from 13.9.2013 regularly without any break, and thus the policy of the complainant is running in the 5^th year from its inception. Further the policy was initially issued under the portability scheme. Insured No.2 in the policy Mrs. Parminder Kaur Walia wife of the complainant was admitted in Fortis Hospital on 15.3.2018 and was discharged on 16.3.2018. After the admission the cashless approval was applied by the complainant and the same was repudiated by the Ops and this gave immense mental torture harassment pain and agony to the complainant, as at the time of giving the policy the complainant was assured that he will not have to pay any amount if ever he gets admitted in the hospital for the treatment. Thereafter when the complainant contacted the Ops the Ops asked him to submit all the original documents to the office and the claim will be paid to him. Thereafter, the complainant submitted all the original documents along with bills to the Ops for a total claim amount of Rs.25,597/- but the complainant was shocked to receive the letter dated 16.3.20178 in which the Ops not only repudiated the claim but terminated the policy. Further in this matter, the complainant personally visited the Ops office and met the officials of the company and has also corresponded the matter through email and other sources, thereby clarifying the entire matter and even presented the report of the doctor to the Ops but the Ops stuck to their arrogant stand and did not paid the claim amount to the complainant and thus the deficiency in service on the part of Ops towards the complainant and further it amounted to unfair trade practices as the Ops had not abided with the terms and condition of the policy. Thus, alleging unfair trade practice and deficiency in service on the part of the OPs, the complainant sought the following reliefs against the OPs:-

1. To pay the claim amount of Rs.80,597/- along with additional and alternative relief be granted to the complainant.
2. In reply, the OP Nos.1 &2 have filed written version taking preliminary objections; that the complaint is not maintainable; that the complainant has no cause of action to file the present complaint; that the complainant has filed the present complaint just to harass the answering Ops; that complaint under reply is an abuse of the process of law and as such the same is liable to be dismissed; that the OP submits that the complainant has created a false story in his complaint to mislead this Hon’ble Commission by concocting and distorting the facts and circumstances of the present case; that Ops submits that claims are paid by any insurance company out of the common pool of funds belonging to all policy holders of the complainant and insurance company has to check the admissibility of a claim before honoring it. On merits, it is denied that the insured No.2 in the policy Mrs.Parminder Kaur Walia was admitted in fortis hospital on 15.3.2018 and was discharged on 16.3.2018. It is denied that after the admission of the cashless approval was applied by the complainant or the same was repudiated by the Ops or this gave immense mental torture harassment pain or agony to the complainant, as at that time of giving the policy the complainant was assured that he will not have to pay any amount if ever he gets admitted in the hospital for treatment as alleged. There is no need to discuss the detail given by the Ops in his written reply as all the allegations levelled by the complainant are denied and prayed for dismissal the present complaint. 
3. The learned counsel for the complainant has tendered affidavit along with documents in support of their version and closed the evidence. On the other hand, the learned counsel for the Ops has tendered documents and closed the evidence.
4. We have heard the learned counsel for the complainant and OPs and have gone through the record file, carefully and minutely.
5. In view of the evidence placed on record by both the parties, the present complaint stands allowed with the directions to the OPs to pay the claim amount already paid by the complainant to the tune of Rs. 80,597/- along with interest @ 7% per annum. The OPs are further directed to pay Rs.50,000/- as compensation along with Rs.11,000/- as litigation expenses.  The Ops are also directed to comply with the said order within a period of 30 days from the date of receipt of certified copy of this order. Free certified copies of this order be supplied to the parties, as per rules. The file be indexed & consigned to the Record Room. 

Announced:

24.11.2022

                                                                            (RANJIT SINGH)

                                                                            PRESIDENT

 

 

 

                                                                            (RANVIR KAUR)

                                                                            MEMBER