ORDERS:
Charanjit Singh, President;
1 The complainant has filed the present complaint under Section 34, 35 and 36 of the Consumer Protection Act (herein after called as 'the Act') against the opposite parties by alleging that the complainant had taken a health insurance policy from the agent namely Kawaljit Kaur of opposite parties at Tarn Taran i.e. as per the policy schedule-optima Restore Floater-2016 its policy type family-floater and the policy bearing policy No. 110900/11121/AA01214453 in his name including his family which includes the complainant, his wife and daughters and son on 30.9.2019 from the opposite parties by paying the amount of Rs. 27,498.72 Paise as premium on 30.9.2019 for a period of 30.9.2019 to 29.9.2020. As per the above said insurance policy, the complainant alongwith the above said family members of the complainant was insured with health insurance policy of the opposite parties with a cover of Rs. 10 Lakh sum insured. The complainant was assured by the opposite parties with a cover of Rs. 10 Lakh sum insured . The complainant was assured by the opposite parties at the time of health insurance policy, in case the complainant as well as any family members of the complainant who were covered / insured by the above said policy/ whose name mentioned in the policy cover note fell ill and the amount of treatment incurred by him thereon, the company shall bear all the medical treatment expenses. At the time of taking the above said policy from the opposite parties, all the family members of the complainant which includes Snehleen Kaur, his daughter was having good health and does not suffer from any ailment. After purchasing the policy, the daughter of the complainant namely Snehleen Kaur was suffering from fever, vomiting and pain in abdomen and the condition of the complainant’s daughter Snehleen Kaur due to this reason became worse and she had been got admitted to Fortis Escorts Hospital, Amritsar on 28.11.2019 by the complainant and where the diagnosis as well as lab tests, ultrasound of the daughter of the complainant was done and found suffering from AFI with Thrombocytopenia probable Dengue Hypothyroidism as per the Diagnosis and lab tests reports and she had been given regular treatment in the said hospital by the Dr. Rajeev Mehra in the hospital up to 1.12.2019 for the above said disease and after completion of the medical treatment for the said disease and after completion of the medical treatment for the said disease in the said hospital, the daughter of the complainant namely Snehleen Kaur was discharged on 1.12.2019 during period of the above said policy as per the discharge summary. While admission in the said hospital, the complainant spent an amount on his daughter’s medical treatment of the said disease and paid Rs. 41,516/- to the hospital management for treatment of his daughter Snehleen Kaur as per the bills issued by the above said hospital. After discharging from the said hospital, the complainant submitted insurance claim of Rs. 41,516/- on filing the claim form ID No. 1231891 to the opposite parties for reimbursement of the expenses incurred by the complainant in the hospital by completing the formalities but the opposite parties have not honored the insurance claim of the complainant and rejected the claim of the complainant against the treatment of Snehleen Kaur without assigning any reason in the claim information sheet which is wrong as the daughter of complainant was suddenly ill after two months from taking the above said policy. The disease which was suffering to Snehleen Kaur was due to sudden and it is God’s will and pleasure and foreordination by God. The act of rejecting/ repudiation of claim of the complainant is highly wrong, illegal and is not sustainable in the eyes of law and they are thus deficient in service and the act and conduct of the opposite parties rejecting the genuine medical claim of the complainant as mentioned above in detail and in the claim form is the result of unfair trade practice of the opposite parties whereas, the opposite party is duty bound to pay all claim as per the terms and conditions of the policy as the disease to Snehleen Kaur was due to sudden and not before taking the policy. The complainant approached to the opposite parties many times after that for claim on the basis of insurance cover which the complainant had taken from opposite parties but the opposite parties lingered on the matter on one pretext or the other and intentionally and deliberately rejected the claim of the complainant. The complainant has paid an amount of premium of Rs. 27,498.72 at the time of taking the above said policy from the opposite parties, as such, the complainant alongwith the daughter namely Snehleen Kaur and other members whose name mentioned in the cover note of the policy is the consumer of the above said insurance company- opposite parties and he is very much entitled to receive the above said medical claim of his daughter and other benefits as per the terms and conditions of the health insurance policy being the consumer of the opposite parties. The complainant prayed the following relieves:-
- The opposite parties may kindly be directed to reimburse the whole medical claim amount of Rs. 41,516/- alongwith 9% interest thereon as assessed this commission from the date of submission of insurance claim till final payment be awarded to him.
- The opposite parties may kindly be directed to pay compensation of Rs. 1,00,000/-on account of mental and physical harassment caused to the complainant at the hands of opposite parties and on account of short come, deficient and negligent service and also directed to pay Rs. 50,000/- as litigation expenses in the interest of justice, equity and fair play.
Alongwith the complaint, the complainant has placed on record self attested copy of his affidavit Ex. C-, Self attested copy of policy cover note Ex. C-2, Self attested copy of claim form dated 13.12.2019 to the tune of Rs. 41,516/- Ex. C-3, Self attested copy of Adhar Card of complainant Ex. C-4, Self attested copy of discharge summary dated 1.12.2019 Ex. C-5, Self attested copy of Bill dated 1.12.2009 Ex. C-6, Self attested copy of claim information dated 17.12.2019 Ex. C-7.
2 Notice of this complaint was sent to the opposite parties and the opposite parties appeared through counsel and filed written version by interalia pleadings that Housing Development Finance Corporation Ltd. ("HDFC Ltd.") had acquired a majority stake (i.e. 51.16%) of the respondent i.e. Apollo Munich Health Insurance Company Ltd. post receipt of the necessary regulatory approvals. Based on the said acquisition, Apollo Munich Health Insurance Company Limited had been renamed as HDFC ERGO HEALTH INSURANCE LIMITED with effect from January 9th 2020. The National Company Law Tribunal (NCLT), Mumbai bench, vide its order dated September 29, 2020, has approved the scheme of amalgamation of HDFC ERGO Health Insurance Limited with HDFC ERGO General Insurance Company Limited Further, pursuant to the Joint and composite application made by HDFC ERGO General Insurance Company Limited and HDFC ERGO Health Insurance Limited dated June 25, 2019, the IRDAI vide its letters dated January 1st, 2020 and November 11th , 2020 had granted an in-principle and final approval respectively for the said merger with effect from November 13th, 2020. However, now there is no company with name "Apollo Munich Health Insurance Co. Ltd" and "HDFC ERGO Health Insurance Limited" in existence. The present Complaint is pre-mature, misconceived, misrepresented, travesty of truth, devoid of any merits, crafty, colored, uncalled for and unsustainable in terms 7/8 of the insurance policy and qua the theft as well as the provisions of the Consumer Protection Act, 2019. The complaint is liable to be relegated to the civil court of competent jurisdiction since the adjudication of the matter requires recording of elaborate evidence, oral, documentary and medical and the same is not possible by way of summary trial. The Complaint had submitted the Application/Proposal Form (Hereafter referred as "PF") bearing No. KDSNXZU60P. The date of the Proposal/ Application form was 26.09.2019. On the basis of the information and the contents of the proposal form submitted by the Complainant and believing the above said declaration, information and details provided by the Complainant including the medical history in the PF to be true, correct and complete in all respect, giving due credence to the under writing norms of Opposite Party Company, a Policy No. 110900/11121/AA01214453 was issued for sum assured opted as per PF, to the Complainant for the period between 30.09.2019 to 29.09.2020 and the policy was further renewed for period 30.09.2020 to 29.09.2021 A copy of Policy schedule and policy wordings are hereto annexed and marked as Annexure-B. The Policy Kit containing all relevant documents were duly sent and delivered to the Applicant/proposer at various time, thereby giving an opportunity to Complainant to verify and examine the benefits, terms and conditions of the Policy taken by the Applicant. It was mentioned under Section VI (g) "Supporting Documentation & Examination" that the Insured Person is required to provide all documentations including medical records and information as required by the Insurance Company to establish the circumstances of the claim, its quantum or its liability for the claim. As per Section VI (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 relevant Sections are reproduced herewith for ready reference:
g. Supporting Documentation & Examination
The Insured Person or someone claiming on Your behalf shall provide Us with any documentation, medical records and Information We may request to establish the circumstances of the claim, its quantum or Our liability for the claim within 15 days of the earlier of Our request or the Insured Person's discharge from Hospitalisation or completion of treatment. The Company may accept claims where documents have been provided after a delayed interval only in special circumstances and for the reasons beyond the control of the insured. Such documentation will include but is not limited to the following:
- Our claim form, duly completed and signed for on behalf of the Insured Person.
- Original Bills (including but not limited to pharmacy purchase bill, consultation bill, diagnostic bill) and any attachments thereto like receipts or prescriptions in support of any amount claimed which will then become Our property.
- All reports and records, including but not limited to all medical reports, case histories/Indoor case papers, Investigation reports, treatment papers, discharge summaries.
- A precise diagnosis of the treatment for which a claim is made.
- A detailed list of the individual medical services and treatments provided and a unit price for each (detailed break up).
- Prescriptions that name the Insured Person and in the case of drugs: the drugs prescribed, their price and a receipt for payment. Prescriptions must be submitted with the corresponding Doctor’s invoice.
- All pre and post investigation, treatment and follow up consultation) records pertaining to the present ailment for which claim is being made.
- All investigation, treatment and follow up records pertaining to the past ailment(s) since their first diagnoses or detection.
- Treating doctor’s certificate regarding missing information in case histories e.g. circumstances of injury and Alcohol or drug influence at the time of accident .
- Copy of settlement letter from other insurance company or TPA
- Stickers and invoice of implants used during surgery
- Copy of MLC (Medico legal case) records and FIR (First information report), in case of claims arising out of an accident.
- Regulatory requirements as amended from time to time, currently mandatory NEFT (to enable direct credit of claim amount in bank account) and KYC recent ID/Address proof and photograph) requirements.
- Legal heir certificate
i. Claims Payment
i) We shall be under no obligation to make any payment under this policy unless we have received all premium payments in full in time and all payments have been raised and we have been provided with the documentation and information we have requested to establish the circumstances of the claim, its quantum or our liability for it, and unless the insured person has complied with the obligations under this policy.
It is further submitted that the policy kit containing all relevant documents were duly received by the policy holder thereby giving an opportunity to the complainant / policy holder to verify and examine the benefits, terms and conditions of policy taken by him. The complainant/ proposer never approached the company stating that any information given in the documents in the policy kit was incorrect or any term and condition therein is not understandable or acceptable to him within the free look period i.e. 15 days from the receipt of the policy document. As no objection was received from the complainant, therefore, the complainant is strictly bound by the terms and conditions of the policy. The complainant has not come to this commission with clean hands and filed the present complaint on false and incorrect facts. The opposite party company received the cashless request on 28.11.2019 from Forties Hospital Limited for patient Mr. Snehleen Kaur for complaint of fever. After reviewing the submitted documents it was observed that patient had post medical history of PCOD Polycystic Ovarian Disease) and policy is only two month old hence, opposite party company asked previous medical documents from complainant/ Hospital had not submitted the required documents which was necessary to decide the cashless request hence, cashless request was rejected by the opposite party stating that “We have been requesting for additional documents to decide on the admissibility of the case, which are not yet submitted. Hence, in the absence of the mentioned documents we are not in a position to take confirmed decision. Details of the documents pending are : Exact duration of PCOD, first consultation paper, all previous treatment records pertaining to the same. On 14.12.2019, the complainant submitted the same claim for reimbursement of expenses incurred by patient with respect to hospitalsiation of patient at Fortis Hospital Limited with Date of Admission 28.11.2019 and date of discharge 1.12.2019 for the treatment of AFI with thrombocytopenia Probable Dengue Hypothyroidism with final claimed amount Rs. 41,516/-. Copy of claim form and discharge summary are hereto annexed and marked as Annexure C. Post reviewing the documents as query vide letter dated 21.12.2019 was raised and the below mentioned documents were requested for the complainant:-
- All investigation, treatment and follow up records pertaining to PCOD (Polycystic ovary syndrome) since first diagnosis.
- Copy of cancelled cheque or bank passport or bank statement with proposer’s name Mr. Jagdeep Singh, IFSC code and account number.
The complainant did not submit the requisite documents to process the claim, therefore, a reminder letter dated 3.1.2020 and 14.1.2020 were issued to the complainant to provide the complete requisite papers for adjudicate the claim but the complainant failed to do so. When the opposite parties did not receive any response from the side of complainant, the claim of the complainant was rejected due to non submission of documents which was necessary to decide the claim. The copy of letters dated 21.12.2019, 3.1.2020 and 14.1.2020 thereto annexed and marked as Annexure-D. The copy of self attested affidavit of Manoj Kumar Manager legal HDFC Ergo Noida U.P is Annexure E. 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. In the light of above, the opposite party company has rightly rejected the claim of the complainant as per the terms and conditions of the policy. The opposite parties have denied the other contents of the complaint and prayed for dismissal of the same.
3 We have heard the Ld. counsel for the complainant and opposite parties and have carefully gone through the record.
4 In the present case it is not disputed that the complainant has purchased health insurance policy from the opposite parties.
5 The case of the complainant is that the daughter of the complainant namely Snehleen Kaur who was also covered under the policy in question was suffering from fever, vomiting and pain in abdomen and the condition of the complainant’s daughter Snehleen Kaur, due to this reason became worse and she had been got admitted to Fortis Escorts Hospital, Amritsar on 28.11.2019 by the complainant and where the diagnosis as well as lab tests, ultrasound of the daughter of the complainant was done and found suffering from AFI with Thrombocytopenia probable Dengue Hypothyroidism as per the Diagnosis and lab tests reports and she had been given regular treatment in the said hospital by the Dr. Rajeev Mehra in the hospital up to 1.12.2019 for the above said disease and after completion of the medical treatment for the said disease in the said hospital, the daughter of the complainant namely Snehleen Kaur was discharged on 1.12.2019 during period of the above said policy as per the discharge summary. While admission in the said hospital, the complainant spent an amount on his daughter’s medical treatment of the said disease and paid Rs. 41,516/- to the hospital management for treatment of his daughter Snehleen Kaur as per the bills issued by the above said hospital. After discharging from the said hospital, the complainant submitted insurance claim of Rs. 41,516/- on filing the claim form ID No. 1231891 to the opposite parties for reimbursement of the expenses incurred by the complainant in the hospital by completing the formalities but the opposite parties have not honored the insurance claim of the complainant. On the other hands, the stand of the oppose parties is that Post reviewing the documents as query vide letter dated 21.12.2019 was raised and the below mentioned documents were requested for the complainant:-
- All investigation, treatment and follow up records pertaining to PCOD (Polycystic ovary syndrome) since first diagnosis.
- Copy of cancelled cheque or bank passport or bank statement with proposer’s name Mr. Jagdeep Singh, IFSC code and account number.
The complainant did not submit the requisite documents to process the claim, therefore, a reminder letter dated 3.1.2020 and 14.1.2020 were issued to the complainant to provide the complete requisite papers to adjudicate the claim but the complainant failed to do so. When the opposite parties did not receive any response from the side of complainant, the claim of the complainant was rejected due to non-submission of documents which was necessary to decide the claim.
7 According to opposite parties and letters dated 21.12.2019, 3.1.2020 and 14.1.2020 it shows that the claim kept pending for a long time due to non submission of documents and in both the letters the status of claim shows pending. In case Balu Waman Kadam vs. ICICI Lombard General Insurance Co. IV (2013) CPJ 16A (CN) (Mah.), the matter was similar, wherein the Insurance Company was asking the complainant to submit the documents again and again and the complainant was alleging that he had already submitted the requisite documents to the Insurance Company. In such circumstances, the Hon’ble State Consumer Disputes Redressal Commission Maharashtra disposed of the matter, by directing the Insurance Company to reconsider the claim of the complainant within one month on receipt of the required documents from the complainant.
8 While relying upon the above said authority, the Hon’ble State Commission, Punjab, Chandigarh passed the similar orders in case M/s Trends, through its Proprietor vs The Oriental Insurance Company Limited & Anr. Consumer Complaint No.245 of 2015 decided on 04.08.2017; and M/s Gurbir Rice Mills v. United India Insurance Company Ltd. & Ors. Consumer Complaint No.404 of 2016, decided on 09.10.2017, directing the Insurance Company to reconsider the claim of the complainant after submission of requisite documents by the complainant to it.
9 In view of our above discussion as well as keeping in view the ratio of above said judgments, we are of the opinion that the ends of justice would be met, if the Insurance Company be directed to decide the claim of the complainant, after the complainant submit all the requisite documents.
10 In view of the above discussion, the present complaint is disposed of with the direction to the complainant to submit the documents as per letter dated 14.1.2020 for deciding the claim within a period of 15 days from the date of receipt of copy of order and on approaching the complaint for supplying the requisite documents, the opposite parties will issue proper receipt acknowledging the same. The opposite parties shall decide the claim of the complainant within a further period of two months therefrom and in case of failure on the part of the opposite parties the claim case of the complainant deemed to have been accepted. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this commission. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.
Announced in Open Commission
21.8.2024