Tamil Nadu

North Chennai

CC/33/2015

Mrs.S.Umayal, W/o.R.M.Sethuraman, - Complainant(s)

Versus

Apollo Munich Health Insurance Co Ltd., Rep by its Chief Executive Officer Mr.Antony Jacob, - Opp.Party(s)

Mr.Asifali

21 Dec 2017

ORDER

 

                                                            Complaint presented on: 08.01.2015

                                                                Order pronounced on: 21.12.2017 

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

    2^nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3

 

        PRESENT: THIRU.K.JAYABALAN, B.Sc., B.L.,        PRESIDENT

              THIRU. M.UYIRROLI KANNAN B.B.A., B.L.,      MEMBER - I

 

THURSDAY  THE 21^st  DAY OF DECEMBER 2017

 

C.C.NO.33/2015

 

 

Mrs.S.Umayal,

W/o.R.M.Sethuraman,

No.47, Secretariat Colony, 2^nd Street,

Kellys, Chennai – 600 010.

 

 

                                                                                    ….. Complainant

 

..Vs..

 

1. Apollo Munich Health Insurance Co. Ltd.,

Rep. by its Chief Executive Officer: Mr.Antony Jacob,

Old No.3, New No.4, Valluvarkottam, High Road,

Nungambakkam, Chennai – 600 034.

 

2. Apollo Munich Health Insurance Co. Ltd.,

Rep.by it’s Customer Relationship Manager, Mr.Adarsh Dwivedi,

iLABS Centre, 2^nd & 3^rd Floor,

Plot No.404-405,

Udyog Vihar, Phase – III,

Gurgaon – 122 016. HARYANA.

.....Opposite Parties

Date of complaint                                 : 24.02.2015

Counsel for Complainant                      : Mr.Asif Ali

Counsel for Opposite Parties                    : Mrs.Elveera Ravindran, K.Vinod

 

 

O R D E R

 

BY PRESIDENT THIRU. K.JAYABALAN B.Sc., B.L.,

This complaint is filed by the complainant to direct the opposite parties to pay a sum of Rs.1,03,787/- towards medical expenses with 18% interest from 18.10.2014 and also to pay a sum of Rs.50,000/- towards compensation for deficiency in service and mental agony with cost of the complaint u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The complainant took ‘Easy Health Group Insurance Policy’ with the opposite parties and the policy is for Rs.5,00,000/- to cover the period from 15.05.2014 to 14.05.2015. The complainant paid a premium amount of Rs.4,499/- and accordingly certificate of insurance dated 10.07.2014 was issued in her favour. The complainant had policy with Bajaji Alliance General Insurance Company and renewed for seven consecutive years. In continuation of the same due to recommendation of the Manager, Canara Bank, Park Town, Chennai – 3, the complainant switched over from Bajaji Alliance to the opposite parties and took the present policy as group insurance.

          2. The complainant fell ill and she was diagnosed as ‘Muliple Fibroid Uterious, abnormal Uterine bleeding’ and she was admitted on 23.09.2014, underwent operation at Apollo First Med  Hospital, Chennai – 10 and she was discharged on 25.09.2014. For the said treatment the complainant incurred a sum of Rs.1,03,787/-  towards medical expenses. The complainant submitted claim form to the 1^st opposite party claiming the above said expenses on 26.09.2014. However, the opposite parties have rejected the claim vide their letter dated 18.10.2014 on the ground that the illness which has a specific One year of waiting period as per the policy and that the policy starting date is on 15.05.2014. Hence she was informed that as her claim is repudiated under clause 5 (c) of the terms and conditions of the policy. The opposite parties or their agent has not informed the complainant that there is one year waiting period.

3. The opposite parties under the guise of one year waiting period repudiated the claim is an unfair trade practice. In view of the rejection of the claim by the opposite parties, the complainant suffered with   mental agony and inconvenience. Hence the complainant filed this complaint to direct the opposite parties to pay a sum of Rs.1,03,787/- towards medical expenses with 18% interest from 18.10.2014 and also to pay a sum of Rs.50,000/- towards compensation for deficiency in service and mental agony with cost of the complaint. 

4. WRITTEN VERSION OF THE  OPPOSITE PARTIES IN BRIEF:

          An Easy Health Group Insurance Policy No.120100/12001/2013/A00328/170 was issued to the complainant for a sum assured of Rs.5,00,000/- to the complainant on 15.05.2014 for the period between 15.05.2014 to 14.05.2015. The policy Kit containing all relevant documents were duly sent and delivered to the complainant, thereby giving an opportunity to the complainant to verify and examine the benefits, terms and conditions of the policy taken by the complainant. The complainant never approached the opposite party stating that any information given in the documents in the Policy Kit was incorrect or any terms and condition therein was not acceptable to her, as the opposite party has strictly issued the policy based on information disclosed by the complainant.

          5. That Pre-authorization form for cashless Facility was received by the opposite parties from Apollo First Med Hospital, Chennai for the treatment of Heavy Menstrual Bleeding with Anemia and the duration of illness for six months. She was diagnosed as Multiple Fibroid uterus, Abnormal Uterine Bleeding. She was to undergo Lap assisted Vaginal Hysterectomy with expected date of admission on 23.09.2014. The estimated cost of the treatment was Rs.80,000/-. The copy of Pre-Authorization Form was provided along with medical reports. Since the treatment of the complainant is “hysterectomy for menorrhagia or fibromyoma” was covered under the policy with waiting period of 1 year of policy and as such request for cashless facility was refused. The claim form along with documents was received on 26.09.2014, with the Discharge Summary with date of admission as 23.09.2014  and the  date of discharge as 25.09.2014, medical lab reports and bills.

          6. The opposite parties reviewed all the documents submitted by the complainant and it was noted that the complainant was admitted with the fibroid uterus and heavy bleeding PV for vaginal hysterectomy and the same done on 23.09.2014.  The surgery done was Vaginal Hysterectomy + Bilaera Salphingo – Oopherectomy. It is very relevant to mention here that Hysterectomy is the surgical removal of the uterus and it may also involve removal of the cervix, ovaries, fallopian tubes and other surrounding structures. As per section 5 (c) of the terms and conditions, the treatment of hysterectomy for menorrhagia of fibromyoma has a specific waiting period of 1 year under the policy and the policy of the complainant is in the first year only. That in the light of the terms and conditions of the policy and on the basis of the submitted documents, the claim of the complainant was repudiated vide letter dated 18.10.2014. The other averments made in the complaint are denied. The opposite parties have not committed deficiency in service and pray to dismiss the complaint with costs.

7. POINTS FOR CONSIDERATION:

          1. Whether there is deficiency in service on the part of the opposite parties?

          2. Whether the complainant is entitled to any relief? If so to what extent?

8. POINT NO :1 

          The admitted facts are that the  opposite parties  have issued  a  ‘Easy Health Group Insurance Policy’ to the complainant  covering the period from 15.05.2014 to 14.05.2015 and the policy  issued for Rs.5,00,000/- and the  certificate of insurance health issued to the complainant for the above period is marked as Ex.A1 & Ex.B2 and  the complainant paid a premium amount of Rs.4,499/- for the said policy and the complainant fell ill and she was  diagnosed as ‘Multiple Fibroid Uterus, abnormal uterine bleeding’ and she was admitted on 23.09.2014  and underwent operation at Apollo  First Med Hospital, Chennai – 10 and she was discharged on 25.09.2014 and the said hospital issued Ex.A2 discharge summary and  bills  for an amount of Rs.1,03,787/-  towards medical expenses and the complainant submitted  Ex.A3 claim form to the 1^st opposite party  for claiming the above said expenses on 26.09.2014 and however, the opposite parties have repudiated the claim under Ex.B7  letter dated 18.10.2014 on the ground that the illness which has a specific one year of waiting period as per the policy and that the policy starting date is 15.05.2014 and  she was further informed under Ex.A4 letter dated 27.11.2014 that  her claim is repudiated under 5 (c) of the terms and conditions of the policy.

          9. The complainant would contend that she was not aware of the terms and conditions of the policy and the same was not informed to her and further the complainant had policy and renewed for seven consecutive years with the Bajaji Alliance General Insurance Company previously and only on the recommendation of the Manager of the Canara Bank branch, Park Town, Chennai – 3, she had switched over to the opposite parties and obtained the policy in dispute on payment of premium amount of Rs.4499/- to the opposite parties and since she is having this policy in continuous to the policy issued by the Bajaji Alliance General insurance Company, the clause 5 (c) of the terms and  conditions of the opposite parties will not apply in this case and therefore, prays to pass an order in her favour .

          10. The opposite parties would contend that the Ex.A1 policy is the first year policy with this opposite parties and therefore clause 5 (c) of the terms and condition of the policy will apply to the complainant and therefore the repudiation made by the opposite parties is just and in order and therefore prays to dismiss the complaint.

          11. Admittedly the complainant was suffering with ‘Muliple Fibroid Uterus and abnormal uterine bleeding’ and she underwent surgery for the same and the said disease was also covered under clause 5 (c) of Ex.B3 terms and conditions of the policy. It is the specific case of the complainant that she already had policy with the Bajaji Alliance for seven consecutive years and switched over to this opposite parties only on the recommendation of the Manager, Canara Bank, Chennai-3.The fact  that the complainant availed Ex.A1 policy only on the recommendation of the Manager, Canara Bank  and further she had the policy previously for seven consecutive years with Bajaji Alliance which was not denied by the opposite parties either in their written version or in their proof affidavit. Therefore, the case of the complainant that before availing the policy with the opposite parties, she had policy for seven consecutive years has been proved by the complainant. Hence it is held that the complainant availed this policy only in continuation of her earlier policy with Bajaji Alliance. When the complainant switched over to the opposite parties and obtained Group Insurance Policy was very well known to the opposite parties. Therefore, it is further held that the complainant is having the   policy continuously for more than one year and hence clause 5 (c) of terms and conditions of the policy is not applicable to the facts of this case and in such circumstances, the repudiation made by the opposite parties is not sustainable and they have committed deficiency in service in repudiating the claim of the complainant.

12. POINT NO:2

           It is held above that the opposite parties have committed deficiency in service in repudiating the claim made by the complainant. Therefore, the opposite parties can be directed to pay the claim amount of Rs.1,03,787/- to the complainant with reasonable interest  rate of 9%  from 18.10.2014. Further, due to denial of claim the complainant suffered with mental agony is accepted and for the same, it would be appropriate to direct the opposite parties to pay a sum of Rs.25,000/- as compensation besides a sum of Rs.5,000/- towards litigation expenses.

          In the result the Complaint is partly allowed. The Opposite Parties 1 & 2 jointly or severally are ordered to pay a sum of Rs.1,03,787/- (Rupees one lakh three thousand seven hundred and eighty seven only) towards the claim amount with 9% interest from 18.10.2014  to till the date of this order to the complainant and also to pay  a sum of Rs. 25,000/- (Rupees twenty  five thousand only) towards compensation for mental agony, besides a sum of Rs. 5,000/- (Rupees five thousand only)  towards litigation expenses.

The above amount shall be paid to the complainant within 6 weeks from the date of receipt of the copy of this order failing which the above said amount shall carry 9% interest till the date of payment.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 21^st day of December 2017.

 

MEMBER – I                                                                PRESIDENT

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 10.07.2014                   Certificate of Insurance Health

Ex.A2 dated 26.09.2014                   Discharge Summary of the complainant

Ex.A3 dated 26.09.2014                   Claim Form submitted by complainant

Ex.A4 dated 27.11.2014                   Repudiation of claim by opposite party

Ex.A5 dated 01.11.2014                   Legal Notice to complaint

 

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTIES :

 

Ex.B1 dated NIL                     Power of Attorney of Executants

 

Ex.B2 dated NIL                     Certificate of Insurance Health

 

Ex.B3 dated NIL                     Terms and conditions of the policy

 

Ex.B4 dated NIL                     Request for cashless Hospitalization

 

Ex.B5 dated NIL                     Claim Form

 

Ex.B6 dated 18.09.2014                   Letter denying the cashless service

 

Ex.B7 dated 18.10.2014                   Letter denying the cashless service

 

Ex.B8 dated NIL                     Medical documents (series)                        

 

 

 

MEMBER – I                                                               PRESIDENT