BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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Anirudh Sharma R/o # C-11, CSSRI, Karnal, Haryana.

…..Complainant

                 V E R S U S

Apollo Munich Health Insurance Company Ltd., SCO 50-51, 4^th Floor, Sector 34-A, Chandigarh, through its Managing Director/Branch Manager.

                      ……Opposite Party

CORAM:   SH.P.D.GOEL                 PRESIDENT

         SH.RAJINDER SINGH GILL       MEMBER

        DR.(MRS).MADANJIT KAUR SAHOTA  MEMBER

Argued by: Sh.Ranjan Lohan, Counsel for Complainant.

           Sh.R.S.Dhull, Counsel for OP.

PER P.D.GOEL, PRESIDENT

         The Complainant got himself insured under Health Insurance Policy (Ann.C-1) of OP Company, on making payment of Rs.12,236/- as premium.

         In the month of Sept., 2010, the complainant, on account of pain on his back, legs, upper thighs, consulted Dr.M.S.Virk (M.S.Ortho.), Karnal, who prescribed some pain killer and bed rest(Ann.C-2), but even then, the pain did not subsist, as such he visited Fortis Hospital, New Delhi, where Dr.Puneet Girdhar opined that he was suffering from Lumber-disk Pain due to Nerve Compression Syndrome and suggested early surgery (Ann.C-3).  Thereafter, complainant consulted Dr.Yogender Singh Pundir (MS Orth.) of Sterling Hospital of Add Life India Limited, Vadodhara, Gujrat, and also got MRI Test (Ann.R-4). Thereafter, the complainant was admitted on 30.10.2010 at the Sterling Hospital and Nucleoplasty was performed on his body by Dr.Yogender Singh Pundhir. He was discharged on 31.10.2010. The total expenditure of Rs.52,052/- were incurred on the treatment. 

         Despite nucleoplasty, the condition of complainant did not improve, so he was again admitted in the said Hospital on 10.11.2010 and was operated for spinal disc L4-L5-S1herniation surgery, by Dr.Pundhir.  The spinal disc L4-L5-S1 herniation was removed by discectomy. On 18.11.2010, the complainant was discharged and due to non-supportive behaviour of OP, again he had to pay for the bills/expenditure of the treatment. 

        However, still the condition of complainant did not improve, rather deteriorated, so, he was again admitted in the said hospital on 22.12.2010.  Various tests of the complainant were conducted. On 23.12.2010, the Team of doctors recommended for complainant’s physiotherapy treatment, as all reports had failed to diagnose the real cause. As such on 3.1.2011, the blood test of the complainant was done by dry chemistry vitros 250.  He was discharged on 13.1.2011. The complainant again paid the bill of Rs.40,376/- from his pocket, as OP failed to reimburse the expenditure.  The complainant also spent an amount of Rs.2,997/- for pharmacy and Rs.1170/- for blood test, x-ray, physiotherapy etc. 

         A claim of Rs.1,34,030/- was sent to the OP for reimbursement on account of the expenses incurred by the complainant on his treatment, but the OPs illegally & arbitrary, repudiated the claim of the complainant on flimsy ground vide letter dated 14.4.2011. Hence, this complaint alleging the above repudiation as illegal and deficiency in service on the part of OP.

2]       OP filed reply and admitted the issuance of health policy to the complainant as well a rejection of cashless hospitalization request of the hospital. It is stated that the complainant took the treatment of L4, L5, S1, Disc prolapsed, Prolapsed Inter Vertebral disk, but such type of surgeries are specifically excluded for the first two years of the policy, as per its terms & conditions (Ann.R-2 & R-3), hence this claim was rejected.  It is also stated that the complainant was duty bound to inform the OPs within 7 days of discharge, but he opted not to inform/claim anything until expiry of 5 months from the date of discharge.  Further, for any subsequent treatment/admission, the complainant was required to inform the OP at least 7 days prior to the date of admission, which he did not do.  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 learned counsel for the parties and have also perused the record.

5]       The ld.Counsel for the complainant has argued that the complainant was insured under Easy Health Individual Premium Plan (Ann.C-1) of the OP.  He contended that in the month of Sept., 2010, the complainant, on account of pain on his back, legs, upper thighs, consulted Dr.M.S.Virk and Dr.Puneet Girdhar.  He also consulted Dr.Yogender Singh Pundir of Sterling Hospital of Add Life India Limited, Gujrat.  The complainant was admitted on 30.10.2010 at the Sterling Hospital, where Nucleoplasty was performed on his person.  He incurred expenditure of Rs.52,052/- on his treatment.

6]       It was further argued that despite nucleoplasty, the condition of complainant did not improve, so he was again admitted on 10.11.2010 and was operated for spinal disc L4-L5-S1 herniation surgery. The spinal disc L4-L5-S1 herniation was removed by discectomy. The complainant had to pay the bills due to non-supportive behaviour of the OP.

7]      It was also argued that the condition of complainant did not improve, so he was again admitted in the Hospital on 22.12.2010. On 23.12.2010, the Team of Doctors recommended physiotherapy treatment.  The blood test of the complainant was done by dry chemistry vitros 250.  The complainant again paid the bill of Rs.40,376/- from his pocket, as OP failed to reimburse the same.  The complainant also spent an amount of Rs.2,997/- for pharmacy and Rs.1170/- for blood test etc.  It was lastly argued that the claim of Rs.1,34,030/- was sent to the OP for reimbursement on account of the expenses incurred on the treatment, but it was illegally & arbitrary, repudiated by the OP Company on flimsy ground.

8]       The ld.Counsel for the OP admitted the factum of issuance of Easy Health Individual Premium Plan (Ann.C-1) to the complainant.  He also conceded to the rejection of cashless hospitalization request of the Hospital.  It was argued that the complainant took the treatment of L4, L5, S1, Disc prolapsed, Prolapsed Inter Vertebral disk, which was excluded in the first 2 year of the policy, as per its terms & conditions, so the claim was rightly repudiated. It was further argued that the complainant was duty bound to inform the OPs within 7 days of discharge, but he opted not to inform until expiry of 5 months from the date of discharge.  The complainant was also required to inform the OP at least 7 days, for any subsequent treatment, prior to the date of admission, which he did not do.

9]       Now the point for consideration is whether the treatment undergone by the complainant is excluded for the first two years of the policy, per its terms & conditions.  The answer to this is in the affirmative.

10]      The repudiation letters placed on record are Ann.C-8 to C-10, wherein the claim has been repudiated on the following grounds:-

“As there is delay in submission of claim documents, and the submitted claim is for the illness which has a specific two years of waiting period as per the policy and the policy start date is 26 Feb 2010.  Hence we regret to inform you that the claim is repudiated under Section 6)c of the policy.”

11]      The proposal form, dated 26.2.2010 has been placed on record as Ann.R-1.

12]      In the proposal form Ann.R-1, the Question No.6(viii) at Page No.6, has been answered in negative by the complainant.  The same is reproduced as under:-

         “6. MEDICAL & LIFE STYLE INFORMATION

             i…

             ii.

             iii.

             iv……

             v….

viii.    Arthritis, Spondylosis or any other        disorder of the muscle/bone/joint. NO“

12]      The complainant was admitted in the Fortis Hospital, New Delhi for the first time on 23.10.2010, per Annexure C-3.

13]      Now it is clear that the complainant/policyholder was admitted for the first time on 23.10.2010 and the proposal form was filled-up on 26.2.2010.  It is also proved that the complainant/policyholder has given the answer in Negative to the Question NO.6(viii) of the Proposal Form under the heading Medical & Life Style Information, referred to above.

14]      At page No.11 of the reply, the OP has annexed PREATHORISATION FORM/ADMISSION REQUEST NOTE   under FAMILY HEALTH PLAN LIMITED, wherein under the heading/column of Provisional/ Differential diagnosis, it has been specifically written as L4-5 L5-SI, Disc Prolapse and in the column of Proposed Line of treatment, it has been mentioned as Surgery – Nucleoplasty L4-5, LS-S1.

15]      Further, at Page No.48 of the reply, the OP has placed on record the Narrative Summary/Discharge Card, dated 18.11.2010 of Sterling Hospital, wherein under the Column of Diagnosis, it has been recorded as “L4 L5 S1 DISC PROLAPSE – UNDERWENT L5 S1 – LT WITH RT-L4 L5 DISCECTOMY BY DR.Y.PUNDIR.”  On Page NO.49 of the reply under the Column of Operation Details, it has been specified as “L4 L5 S1 DISC PROLAPSE-UNDERWENT L5 S1-LT WITH RT-L4 L5 DISCECTOMY BY DR.Y.PUNDIR”.    

16]      The OP has also placed on record the Certificate from Dr.Y.S.Pundir, Orthopedic Surgeon, Sterling Hospital, Vadodara, dated 04.03.2011 (Placed at Page NO.73 of the reply), wherein it has been stated that :-

“.....Mr.Anirudh Sharma age 31 years has been under my care for L4-L5 S1 Disc Prolapse since 30/10/10 and has been continuously under treatment for the same since then.” 

17]      This certificate has gone unrebutted & uncontroverted from the side of the complainant.  Thus it is held that the complainant is suffering from L4 L5 S1 Disc Prolapse problem since 30.10.2010, whereas the Proposal Form (Ann.R-1) was filled-up by the complainant on 26.2.2010. Therefore, it is evident that the complainant/policyholder took the treatment for  L4 L5 S1 Disc Prolapse problem within 2 years of the commencement of the policy. 

18]      Section 6 (c)(ii) of the Exclusions Clause of the Policy Document (Ann.R-3 at Page NO.36 of the reply), reads as under:-

“ii) Treatment : benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to adenoidectomy, mastoidectomy, tonsillectomy and tympanoplasty); dilatation and curettage (D & C); hysterectomy for menorrhagia or fibromyoma or prolapse or uterus unless necessitated by malignancy; joint replacement; myomectomy for fibroids; surgery of gallbladder and bile duct unless necessitated by malignancy, surgery of genitor urinary system unless necessitated by malignancy; surgery of benign prostatic hypertrophy; surgery of hernia; surgery of hydrocele; surgery for prolapsed inter vertebral disk; surgery of varicose veins and varicose ulcers; surgery on tonsits and sinuses.”

19]      It is a matter of record that the complainant took the treatment for L4 L5 S1 Disc Prolapse problem, within a period of 2 years from the date of commencement of the policy.  Therefore, we are of the opinion that the claim is not payable in view of the Exclusions Clause No.6(c)(ii) of the Policy, referred to above, wherein such type of surgeries had been excluded for the first 2 years of the policy.

20]      As a result of the above discussion, it is held that the OP has rightly repudiated the claim filed by the complainant.  Therefore, the complaint is dismissed.  However, there is no order as to costs.

         Certified copies of this order be sent to the parties free of cost.  The file be consigned.