Chandigarh

DF-II

CC/103/2018

Achal Jain - Complainant(s)

Versus

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

Vikram Singh Manhas Adv.

18 Oct 2018

ORDER

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

Consumer Complaint  No	:	103 of 2018
Date  of  Institution	:	16.02.2018
Date   of   Decision	:	18.10.2018

 

 

 

 

Achal Jain w/o Late Sh.Raj Kapoor Jain, resident of H.No.3361, Sector 32-D, Chandigarh.         

             …..Complainant

Versus

1]  Apollo Munich Health Insurance Co. Ltd., having its Registered Office at Apollo Hospitals Complex, 8-2-293/82/J III/DH/900 Jubilee Hills, Hyderabad, Teleganan 500033 through its Managing Director.

2]  Apollo Munich Health Insurance Co. Ltd., having its Corporate Office at 1^st Floor, SCF-19, Sector 14, Gurgaon 122001 through its Managing Director

3]  Apollo Munich Health Insurance Co. Ltd., having its Branch Office at SCO 50-51, 4^th Floor, Sector 34-A, Chandigarh through its Branch Manager.  

                          ….. Opposite Parties

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

         SMT.PRITI MALHOTRA        MEMBER

                                SH.RAVINDER SINGH         MEMBER 

 

Argued by: Sh.Vikram Singh Manhas, Adv. for complainant.

Sh.Sachin Ohri, Adv. for OPs.

 

PER PRITI MALHOTRA, MEMBER

 

         The case of the complainant in brief is that he availed Health Insurance Policy-Optima Floater from Opposite Parties for himself and his family members on 7.3.2015 and got it renewed upto 6.3.2019 after paying the due premium amount (Ann.C-1).  It is averred that due to abdominal pain & weakness, the complainant got admitted in hospital where she was diagnosed and treated for Acute Pancreatitis, Diabetes Mellitus Type-2 and NPC from 21.4.2017 to 27.4.2017, thereafter, he lodged the medical reimbursement claim of Rs.90,570/- (Ann.C-2) with OPs.  It is submitted that the complainant was surprised to receive the termination of Medical Insurance Policy letter dated 8.7.2017 as well as rejection of his medical claim on the ground of non-disclosure/suppression of material facts about the disease at the time of taking policy  (Ann.C-3 to C-5).  It is further submitted that the complainant has not been suffering from Diabetes Mellitus since the last 3 years as alleged by the OPs as he came to know about his Diabetic disease for the first time on 23.12.2016 while his visit to New Delhi   (Ann.C-6). Moreover, the treating doctor wrongly mentioned the duration of the disease i.e. Diabetes Mellitus as since last 3 years instead of 3 months and this wrongly revealed fact was acknowledged by the doctor vide letter dated 25.7.2017 clarifying that due to communication gap/by mistake he wrongly mentioned 3 years instead of 3 months at the time of complainant’s admission in the Hospital (Ann.C-7). Thereafter, the complainant again represented the Opposite Parties, but they again rejected the claim vide letter dated 13.7.2017 and also forfeited the insurance premium paid for next two years on ground of non-disclosure of Diabetes Mellitus since 3 years in the proposal form by cancelling the insurance policy.  Alleging the said act & conduct of the Opposite Parties as gross deficiency in service and unfair trade practice, hence this complaint has been filed. 

 

2]       The Opposite Parties have filed joint reply and while admitting the factual matrix of the case, stated that the claim of the complainant was analyzed by technical investigation team and after detailed analysis, the claim was repudiated on the ground that the complainant has concealed his medical history that he is a known case of Diabetes Mellitus since 3 years and the said material fact was not disclosed in the proposal form while taking the policy, therefore, the claim was rightly repudiated vide letter dated 13.7.2017.  It is submitted that since there was a breach of terms & conditions of the policy Section 6 (J), a notice dated 8.7.2017 for termination of the policy was sent to the complainant and later on, on 9.8.2017, the policy was rightly cancelled ab-initio from the date of renewal in view of non-disclosure about suffering from Diabetes Mellitus since 3 years in the proposal form. It is also submitted that the certificate submitted by the complainant from the treating doctor is an afterthought as the patient has colluded with Dr.N.P.Singh to get his history manipulated for sake of getting her claim passed from Opposite Parties.  Pleading no deficiency in service and denying rest of the allegations, the OPs have prayed for dismissal of the complaint.

 

3]       The complainant also filed replication thereby reiterating the assertions as made in the complaint and controverting that of the Opposite Parties made in their reply.

 

4]      Parties led evidence in support of their contentions.

 

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

 

6]       Undisputed facts pertains to the availing of the policy in question by the complainant on 7.3.2015 and thereafter its continuous renewal till 6.3.2019. 

 

7]       During the coverage period of insurance policy from 7.3.2017 to 6.3.2019, the complainant was admitted in Healing Hospital, Sector 34, Chandigarh from 21.4.2017 to 27.4.2017 wherein she got treatment for Diabetes Mellitus Type 2 (ICD-E11), Acute Pancreatitis (ICD-K82), Pain abdomen, Ulcerative Colitis and incurred the expenses to the tune of  Rs.90,570/- for the same. Due claim for reimbursement of the said amount was lodged with the Opposite Parties under the policy in question, which the Opposite Parties wrongly repudiated.

 

8]       Now vide present complaint, the complainant has challenged the repudiation of the claim as well as termination of his medical insurance policy, as illegal and baseless. 

 

9]       The perusal of the record evidents that the rejection of the claim has wrongly been made by the Opposite Parties. It is the ground taken by the Opposite Parties that since the complainant has suppressed the material fact about her suffering from Diabetes Mellitus since 3 years at the time of taking insurance policy for the first time in the year 2015, therefore, her claim has rightly been repudiated and the insurance policy has also been terminated from the date of renewal. 

 

10]      There is no iota of evidence on record produced by the OPs in the form of in-house investigation conducted at their end to establish that the complainant is a known case of Diabetes Mellitus since 3 years or was suffering from such disease at the time of proposing the policy in question for the first time in the year 2015.  Meaning thereby that no independent investigation report has been placed on record by the OPs justifying the stand taken in the repudiation letter as well as in the policy termination letter.  It is observed that the Opposite Parties blindly relied upon the reporting’s recorded in Discharge Summary of the complainant/policyholder and cunningly they overlooked the certificate issued by the Treating Doctor Dr.N.P.Singh whereby he categorically certified that due to miscommunication at the time of admission, the history of Diabetes Mellitus was written as 3 years whereas, as per the version of the patient, the history of Diabetes Mellitus was for 3 months. This cunning overlooking of relevant document done by the OPs clearly reveals their unfairness.

 

11]      At the time of arguments, the counsel for the OPs argued that due to connivance with the treating doctor, the said certificate was arranged by the complainant.  We totally negate this plea of the OPs as the treating doctor is not under any obligation to certify wrongly and there is no such investigation got conducted by the OPs to corroborate the allegations of connivance or manipulation done by the complainant, as alleged. 

 

12]      It is observed that the insurance companies are more inclined towards issuing the policies without conducting the thorough investigation and keep on renewing the same for further period continuously and not bother themselves to investigate even through the coverage period to check the veracity of the information supplied by the proposer/ policyholder.  After issuing the policy without any verification, they go into deep slumber and only get awaken when a claim is raised in the policy coverage period and very lightly, without troubling themselves they tend to repudiate the claims on the basis of authenticated  disclosures made in the Discharge Summaries/medical record claim forms etc.  It is also observed that the insurance company, as like in the present complaint, not only repudiated the genuine claim of the complainant, but also acting arbitrarily had cancelled the policy taking the benefit out of their own wrongs. Such arbitrariness on the part of the Opposite Parties, is nonetheless an unfair trade practice, as the genuine claim of the complainant has not only been repudiated but also the policy in question has illegally been cancelled by the Opposite Parties.   

 

13]      From the above discussion, it is held that the Opposite Parties have wrongly & illegally rejected the claim of the complainant as well as cancelled the policy in question, which clearly amounts to gross deficiency in service and unfair trade practice on their part.  Therefore, the present complaint is allowed against the Opposite Parties with following directions:-

1. To reimburse  the claim amount of Rs.90,570/- to the complainant;
2. To restore the policy of insurance in the name of subscriber/insured with upto date benefits and issue revival letter thereof;
3. To pay an amount of Rs.25,000/- as compensation for rendering deficient services coupled with unfair trade practice, which caused immense harassment & mental agony to the complainant;
4. To pay an amount of Rs.10,000/- towards litigation expenses.

 

         This order be complied with by the OPs within a period of 30 days from the date of receipt of its certified copy, failing which the Opposite Parties shall also be liable to pay additional cost of Rs.20,000/- apart from the above relief.

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

Announced

18^th October, 2018                                                                  Sd/-

                                                                   (RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER