Chandigarh

DF-II

CC/437/2014

Satish Jindal - Complainant(s)

Versus

Apollo Munich Health Insurance Co. Limited - Opp.Party(s)

Gaurav Bhardwaj, Adv.

05 Jun 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	437 of 2014
Date  of  Institution	:	26.08.2014
Date   of   Decision	:	05.06.2015

 

 

 

 

 

Satish Jindal son of Sh.Ram Kumar Jindal, r/o H.No.1047, Sector 38-B, Chandigarh.  

 

             …..Complainant

 

Versus

 

1]  Apollo Munich Health Insurance Company Ltd., Branch Office:- SCO 50-51, 4^th Floor, Sector 34-A, Chandigarh through its Manager.

 

2]  Apollo Munich Health Insurance Company Ltd., Head Office:- 10^th Floor, Tower-B, Building No.10, DLF Cyber City, DLF City, Phase-II, Gurgaon Haryana 122002 through its Managing Director.

 

….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         SH.JASWINDER SINGH SIDHU       MEMBER

         MRS.PRITI MALHOTRA             MEMBER

 

Argued By:  Sh.Gaurav Bhardwaj, Counsel for the complainant

Sh.R.S.Dhull, Counsel for the OPs

 

PER JASWINDER SINGH SIDHU , MEMBER

 

 

          The case of the complainant is that he was having a Mediclaim health policy for the last four five years and the said policy was issued by New India Assurance Company Ltd., in continuation of that, the complainant took a Mediclaim policy – Easy Health Floater Standard for himself and his family from the Opposite Party valid from 15.1.2013 to 14.1.2014 having sum insured of Rs.3.00 lacs (Ann.C-1).  It is averred that unfortunately on 31.10.2013 due to car accident, the right arm of the complainant got fractured. He was taken to Shivalik Hospital, Mohali, where the complainant was admitted on 1.11.2013 and surgery was performed.  Ultimately, the complainant was discharged from the said Hospital on 3.11.2013. It is also averred that plating was done and the implants were inserted (Ann.C-2 & C-3 colly.).  Thereafter, time and again the complainant visited the Hospital for follow up of his treatment and had spent an amount of Rs.1,35,321/- on surgery, physiotherapy and medicines etc. (Ann.C-4 colly.).  Then, the complainant lodged a claim with the Opposite Parties and also provided all documents as required from time to time, but still the Opposite Parties repudiated the claim on the ground that he has not disclosed the details of his previous illness and concealed the facts from the Opposite Parties (Ann.C-6).  It is pleaded that the treatment was taken by the complainant for a fracture of right arm in a road accident and the same had no relation with his past illness.  The Opposite Parties even renewed the policy of the complainant for two more years from 15.1.2014 to 14.1.2016 before repudiating the claim (Ann.C-7 colly.).  Hence, alleging the said repudiation as illegal and deficiency in service on the part of the Opposite Parties, the present complaint has been filed.

 

2]       The OPs No.1 & 2 have filed joint reply and admitted the issuance of Mediclaim policy in question to the complainant.  The occurrence of accident, as alleged by the complainant, has been denied.  The filing of the claim by the complainant and its repudiation on ground of non-disclosure of material facts has been admitted.  It is submitted that from the medical documents received, self-declaration of the complainant and discharge summary, it is evident that the complainant was fully aware that he was suffering from ‘seizure disorder’ and also had taken treatment for the same prior to inception of the said policy. Therefore, by not disclosing the same at the proposal stage, even answered in ‘negative’ against the relevant question in the proposal form, amounts to non-disclosure/deliberate suppression of material facts. Accordingly, the policy was also cancelled on 26.6.2014. Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.

 

3]       Parties led evidence in support of their contentions.

 

4]       We have heard the ld.Counsel for the parties and have also perused the record.

 

5]      The complainant, who is the bona fide consumer of the OPs by virtue of the insurance policy subscribed by him for the period between 15.1.2013 to 14.1.2014 was covered for all ailments and other medical conditions insured to a total sum of Rs.3.00 lacs.  The complainant, who suffered a car accident on 31.10.2013 was treated at Shivalik Hospital Mohali and after undergoing a surgical procedure, spent an amount of Rs.1,35,321/-. The complainant seeking reimbursement of his medical expenses, filed a claim with the Opposite Parties along with all the necessary documents, but is aggrieved by the non-settlement of his genuine claim repudiated vide Ann.C-6, dated 28^th May, 2014.  The complainant has claimed that during the processing of the claim in question, the Opposite Parties renewed his Mediclaim policy for another two years period on 15^th Jan., 2013 upto 14^th Jan, 2016 after receiving Rs.12,986.44, even though they preferred to repudiate his genuine claim on the basis of the policy subscribed by him, which according to the OPs was null & void, ab initio on account of suppression of material facts. The Opposite Parties has alleged in their repudiation letter that the complainant failed to disclose about the existence of condition of epilepsy for which he was under medication at the time of subscription of the policy on 15^th Jan., 2013.     

 

6]       The Opposite Parties during the process of settlement of claim had demanded some documents from the complainant and the complainant vide his letters find annexed as Page No.85, 88, 89 disclosed about his treatment and submitted the records of Silver Oak Hospital from where it is confirmed that the complainant was certainly having condition of epilepsy at the time of subscription of the policy on 15^th Jan., 2013 under which he preferred to file a claim, therefore, we feel that the Opposite Parties came to the knowledge of this suppression of information by the complainant when the records of Silver Oak Hospital, Mohali, were tendered along with his communication with them.  The Opposite Parties have also placed on record the copy of the proposal form, which was got filled up by the complainant in  Clause No.6-A (v) and 6-B (xv) clearly mentioned that he did not suffer from epilepsy and nor was under any regular medication (self or prescribed) and having signed this document himself as a proposer, has certainly withheld necessary information, which was sought by the OPs at the time of solicitation of the Health Insurance under which the claim had arisen.  Therefore, we feel that the Opposite Parties is not deficient in giving proper service to the complainant on this score.

 

7]       However, the second allegation of the complainant with regard to the renewal of the Health Policy in question by the Opposite Parties for subsequent two years beginning 15^th Jan., 2014 to 14^th Jan., 2016 on receipt of Rs.12,986.44, even though having denied the claim of the complainant on the previous policy on the basis of which, such renewal was made, certainly deserves merit.  The Opposite Parties while replying to the averments of the complainant in this regard has failed to give any satisfactory answer as to what was the status of the renewed policies even though the Opposite Parties having declared the initial policy as null and void and having forfeited the entire premium of his previous policy along with having denied his claim. 

 

8]       We feel that though the Opposite Parties were certainly within their domain while dealing with the claim of the complainant and also repudiating the same on account of non-disclosure of material information, but at the same time, the complainant certainly deserved a definite answer about the status of his renewed policy, whether he was entitled for the refund of Rs.12,986.44 or in case of such non refund, whether these policies were valid and effective for the complainant to enjoy its benefits.  As the OPs have failed to answer this factum conclusively, we feel that the complainant is entitled for the refund of the premium amounting to Rs.12,986.44 and the silence on the part of the Opposite Parties in this regard certainly amounts to deficiency in service on their part. The act of withholding the premium amount of Rs.12,986.44 without valid entitlement also amounts to unfair trade practice on the part of the Opposite Parties. Therefore, the present complaint of the complainant deserves to succeed on this score alone.  However, we are restrained to not award the refund of his medi-claim bills in the absence of any merit to that effect.  

 

9]       In the light of above observations, we are of the concerted view that the Opposite Parties are found deficient in rendering proper service to the complainant and also having indulged into unfair trade practice.  Hence, the present complaint of the Complainant is partially allowed qua OPs jointly & severally. The Opposite Parties are directed jointly & severally as under:-

 

[a] The Opposite Parties are directed to refund Rs.12,986.44 to the complainant  and pay an interest @9% p.a. from 15.1.2014 till it is paid;

[b] The Opposite Parties are also directed to pay Rs.10,000/- as compensation on account of deficiency in service and unfair trade practice;

[c] The OPs are also directed to pay Rs.7000/- towards litigation expenses to the complainant.  

 

         The above said order shall be complied within 45 days of its receipt by the Opposite Parties; thereafter, they shall be liable for an interest @18% per annum on the amount of Rs.12,986.44 from 15.1.2014 till it is paid and also on the compensation amount of Rs.10,000/- from the date of filing of the complaint till it is paid, apart from paying litigation expenses of Rs.7,000/-.

 

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

05.06.2015          

                                                                             Sd/-

 (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER

 

 

Sd/-

PRITI MALHOTRA

MEMBER

                                                                                                                      

 

 

DISTRICT FORUM – II

CONSUMER COMPLAINT NO.437 OF 2014

PRESENT:   None   Dated the 5th day of June, 2015

O R D E R                        Vide our detailed order of even date, recorded separately, the complaint has been partially allowed against Opposite Parties.                    After compliance, file be consigned to record room.

 

(Priti Malhotra)	(Rajan Dewan)	(Jaswinder Singh Sidhu)
Member	President	Member