Punjab

Ludhiana

CC/14/513

Mohd.Ameen Ansari - Complainant(s)

Versus

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

27 Mar 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

   Complaint No: 513 of 23.07.2014

                                                                                     Date of Decision: 27.03.2015

                                                                                                                   

Mohd. Ameen Ansari resident of H.No.2321, Shaheed Bhagat Singh Nagar, Sherpur Kalan, Ludhiana.

……Complainant

Versus 

1. Apollo Munich Health Insurance Co. Ltd., SCO-146, 2^nd Floor, Near Park Plaza, Feroze Gandhi Market, Ludhiana, through Branch Manager.

2. Apollo Munich Health Insurance Co. Ltd., Plot no.277, 2^nd Floor, Udyog Vihar, Phase-IV, Gurgaon, Haryana, through its Managing Director/Chairman/Authoirzed Signatory.

…..Opposite parties

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:     Sh.R.L.Ahuja, President

                     Sh.Sat Paul Garg, Member

                     Smt.Babita, Member

 

Present:       Sh.Amit Rai, Advocate for complainant.

                   Sh.Ajay Chawla, Advocate for OPs.  

 

                   

                        ORDER

 

(SAT PAUL GARG, MEMBER)

 

 

1.               Present complaint under Section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Mohd. Ameen Ansari resident of H.No.2321, Shaheed Bhagat Singh Nagar, Sherpur Kalan, Ludhiana (herein-after in short to be referred as ‘complainant’) against Apollo Munich Health Insurance Co. Ltd., SCO-146, 2^nd Floor, Near Park Plaza, Feroze Gandhi Market, Ludhiana, through Branch Manager and others (herein-after in short to be referred as ‘OPs’)- directing them to make the payment of the claim amount of Rs.40,967/- to the complainant under insurance policy, to pay Rs.1.00 lac as compensation and to pay Rs.11,000/- as litigation expenses to the complainant alongwith any other additional or alternative relief to which the complainant is found entitled to.

2.                Brief facts of the complaint are that the complainant is holder of Health Insurance Policy no.110600/11001/1000365660 valid upto 20.2.14. Unfortunately the complainant met with an accident and suffered back internal injury and was admitted in Kharay Hospital, Dhuri Line Flyover, Gali no.2, Vishkarma Town, Link Road, Ludhiana and remained admitted w.e.f 2.12.13 to 12.12.13 as indoor patient. He is still getting treatment as outdoor patient and he is still unfit due to the said accident. The complainant spent more than Rs.50,000/- on his treatment. The complainant approached the Ops and submitted all the documents as per their directions and requested the OPs to pay him compensation as per insurance policy. Thereafter, the complainant approached the Ops several times for payment of the compensation, but the OPs always postponed the matter on one or the other false pretext and the Ops always sending the letter to the complainant for the demand of different documents. The complainant has provided some documents with regard to OP’s letter dated 22.1.14, but thereafter again the OP intentionally sent the letter to the complainant and again demanded other documents. The complainant even got served a registered A.D. Legal notice dated 29.5.14 posted on 2.6.14, through his counsel. Said notice was duly received by the complainant, but they neither replied nor comply with the same. Claiming the above act as deficiency in service on the part of the complainant, the complainant has filed this complaint.

3.                On notice of the complaint, OPs appeared through their counsel and filed written statement taking preliminary objections that the complaint under the reply is not maintainable and is liable to be dismissed; prima facie no cause has arisen in favour of the complainant’s to file the present complaint; complainant has created a false story in his complaint to misled this Forum by concocting and distorting the facts and circumstances of the present case. Further submitted that complainant Mohd. Ameen Ansari “Life Assured” (hereinafter referred to as LA) had submitted to the OP a proposal/application dated 8.2.13 for the purchase of Easy Health Individual Standard Plan from OP, the proposal was accepted on the standard rates and policy bearing no.110600/11001/1000365760 dated 21.2.13 commenced on 21.2.13 valid upto 20.2.14. The premium of Rs.1784/- was paid for one year. The OPs received the claim from dated 31.12.13 alongwith the documents supplied by the complainant for the treatment of complainant. The complainant was admitted from 2.12.13 to 12.12.13 in Kharay Hospital, Ludhiana for the treatment of LBA with without deficit (PIVD) L4 L5, L5-S1 Lumber canal Stenosis with right sciatica and admitted for physiotherapy and medical management. The complainant was treated by the said hospital and the claim documents were sent to the OPs. After reviewing the documents the OPs vide its letter dated 4.1.14 raised the query for the following:-

1. Attested copies of Indore case papers of hospitalization including admission and daily progress notes.

2. To provide investigation report supporting diagnosis.

3. Previous treatment records prior to hospitalization including 1^st consultation letter.

4. Treating doctor’s certificate for indication of prolong hospitalization.

 

                   The complainant did not reply to the said letter and the OP sent reminder on 22.1.14 and 1.2.14. On 10.2.14 updated query was sent as under:-

1. To provide the investigation report supporting diagnosis.

2. To provide the detail of transaction used during hospitalization.

3. Previous treatment records prior to hospitalization including 1^st consultation letter.

4. Treating doctor’s certificate for indication of prolongs hospitalization.

5. Xerox copy of medicine stock register from hospital during hospitalization period.

 

                   The complainant again miserably failed to send the said documents or any reply to the reminders of the OP to evaluate the claim as per the terms and conditions of the policy. Finally when no reply was received by the OP from the complainant, the OP was left with no alternative, but to close the case of the complainant on 21.2.14. On 5.3.14 a review request was received from the complainant with a certificate from the hospital. The complainant failed to submit all the pending documents to OP and so in light of the pending mandatory documents the case was closed and a letter dated 10.3.14 was sent to the policy holder complainant. On 28.3.14 a request to reopen the claim was received, which was closed on 2.4.14 again with the following pending queries:-

1. To provide the investigation report supporting diagnosis.

2. Treating doctor’s certificate for indication of prolongs hospitalization.

3. Xerox copy of medicine stock register from hospital during hospitalization period.

 

                   It submitted that since the complainant had not supplied mandatory documents as sought in the above letter, the said claim was again closed on 2.4.14. The Ops have rightly closed the claim of the complainant, as the OPs will not be able to process the claim without providing the pending queries. On merits, denying the contents of all other paras, OPs prayed for the dismissal of the complaint.

4.                Ld. counsel for complainant has adduced the evidence by way of duly sworn affidavit of complainant Sh.Mohd. Ameen Ansari Ex.CA, wherein, the same facts have been reiterated as narrated in the complaint and affidavit of Sh.Sanjeet Kumar aged 33 years s/o Sh.Ram Lochan, resident of H.No.8169, Gali No.4, Mohalla Gurmit Nagar, Near Hargobind School, Ludhiana Ex.CA/1 and also attached the documents Ex.A1 to A4, Ex.AA1 alongwith Mark A-5 to Mark A-12. On the other hand, Ld. counsel for OPs had adduced the evidence by way of duly sworn affidavit of Dr.Sriharsha A. Achar, Chief People Officer of Apollo Munich Health Insurance Co. Ltd. Ex.RA, wherein, the same facts have been reiterated, as narrated in the written statement and also attached documents Ex.R1 to Ex.R12.

5.                Case was fixed for arguments, Ld. counsel for complainant argued that complainant availed Health Insurance Policy bearing no.110600/11001/1000365660 valid for the period 21.2.13 to 20.2.14. Unfortunately the complainant met with an accident and suffered back internal injury and was admitted in Kharay Hospita, Duri Line Flyover, Gali no.2, Vishkarma Town, Link Road, Ludhiana w.e.f. 2.12.13 to 12.12.13 as indoor patient, where he spent more than an amount of Rs.50,000/-.

6.                Refuting the allegations leveled by the complainant, Ld. counsel for OPs argued that complainant has miserably failed to file the claim in due sense and many documents which are necessary and considered mandatory and were demanded from the complainant, vide letter dated 4.1.14, 10.2.14 and other letters, but the complainant failed to supply these documents.

7.                We have gone through the pleadings of the complainant as well as defence taken by the Ops and have also perused the entire record placed on file.

8.                It is evident that the complainant was the holder of Easy Health Individual Standard policy valid for the period 21.2.13 to 20.2.14 and complainant met with an accident and suffered back internal injury, which was during the subsistence of the policy. It is also observed from the document Ex.R11 submitted by the OPs that relevant papers were supplied to the OPs, but OPs went on demanding the said papers again and again, which were considered to be mandatory, the detail of which, are as follows:-

1. To provide the investigation report supporting diagnosis.

2. To provide the detail of transaction used during hospitalization.

3. Previous treatment records prior to hospitalization including 1^st consultation letter.

4. Treating doctor’s certificate for indication of prolongs hospitalization.

5. Xerox copy of medicine stock register from hospital during hospitalization period.

                   It is observed that how these documents are mandatory is not proved by the OPs, whether there is any provision or law, which make them mandatory and how they were considered to be mandatory for the settlement of the claim. It is also not proved for what purpose these documents were required for the settlement of the claim. There seems to be no force in the averment made by the OPs. The perusal of the record clearly shows that these documents are so cumbersome that it was not easy to arrange by the complainant. Moreover why it was the necessary requirement to ask for stock register from the hospital, when the cash memos were very much provided.

9.                Sequel to the above discussion, the present complaint is allowed and Ops are directed to settle and pay the claim of the complainant, which is allowable as per the terms and conditions of the policy. However, the complainant will try to procure the documents, which were demanded by the OPs, which are of utmost requirement, if he can make available from the hospital within 15 days of the receipt of the copy of the order. Copy of the order be supplied to the parties, free of costs. File be consigned to record room.

 

                   (Babita)                          (S.P.Garg)                      (R.L.Ahuja)

                   Member                           Member                         President

Announced in Open Forum.

Dated:27.03.2015 

Hardeep Singh