Chandigarh

DF-I

CC/593/2017

Davinder Pal Singh - Complainant(s)

Versus

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

Manjula Sharma

07 Nov 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

 

                               

Consumer Complaint No.	:	CC/593/2017
Date of Institution	:	23/08/2017
Date of Decision	:	07/11/2017

 

Davinder Pal Singh son of late S. Joginder Singh, resident of House No.131, First Floor, Sector 21-A, Chandigarh.

…..Complainant

V E R S U S

1.     Apollo Munich Health Insurance Company Ltd., through its Managing Director/Authorised Person, Central Processing Center, 2^nd and 3^rd Floor, iLabs Centre, Plot No.404-405, Udyog Vihar, Phase-III, Gurugram-122016 (Haryana).

2.     Apollo Munich Health Insurance Company Ltd., through its Authorised Person, S.C.O. No.50-51, 4^th Floor, Sector 34-A, Chandigarh 160022.

……Opposite Parties

CORAM :	RAJAN DEWAN	PRESIDENT
	MRS.SURJEET KAUR	MEMBER

 

                                                                       

ARGUED BY	:	Sh. Amarbir S. Dhaliwal, Counsel for complainant.
	:	OPs ex-parte.

 

Per Rajan Dewan, President

1.                The facts of the consumer complaint, in brief, are that the complainant took an insurance policy dated 27.3.2015 from the OPs and lastly re-validated the same for the period from 27.3.2017 to 26.3.2018.  On 15.4.2017, the complainant got operated for coronary artery disease at the PGI, Chandigarh and was discharged on 16.4.2017. The complainant spent an amount of Rs.1,06,740/- for the operation and accordingly applied to the OPs for disbursement/reimbursement of the claim.  However, the OPs rejected the claim vide their letter dated 27.6.2017. While rejecting the claim, the OPs requested the complainant to submit certain documents to enable them to reopen the claim.  As per the complainant, though the said documents were not in any way concerned for the reimbursement of the claim, yet, to avoid any controversy, he sent the same to the OPs.  However, despite writing registered letter dated 10.7.2017, the OPs failed to settle the claim.  Alleging that the aforesaid act and conduct of the OPs amount to deficiency in service and unfair trade practice on their part, the complainant has filed the instant complaint.

2.                OPs did not appear despite due service, therefore, they were proceeded ex-parte vide order dated 12.10.2017.

3.                The complainant led evidence in support of his contentions. 

4.                We have gone through the record and heard the arguments addressed by the learned Counsel for the complainant.

5.                Annexure C-2 is the impugned letter dated 27.6.2017 vide which the OPs repudiated the claim of the complainant on account of the following reasons :-

“1.    As per the query letters sent to you, we have observed that requirement raised by us has not been complied. Hence due to Non compliance of the requested documents we regret to inform you that your claim is repudiated under Sec.6 of the policy. Please submit below documents at earliest to unable us to reopen the claim & decide on admissibility.

2.     All investigation, treatment and follow up records pertaining to osteoarthritis of knee since first diagnosis.

3.     All investigation, treatment and follow up records pertaining to coronary artery disease since first diagnosis.

4.     First Films of X-ray and report for knee joint pain.

5.     All laboratories report during hospitalization.”

6.                The case of the complainant is that though the documents sought for by the OPs were not in any way concerned for reimbursement of the claim, yet, to avoid any controversy, he again sent the same, copies of which are at Annexure C-4. The complainant thereafter sent a registered letter dated 10.7.2017 to the OPs for settlement of his claim, but, till date, the OPs have not settled the claim.  The complainant has also filed his affidavit in support of his contentions. On the other hand, since the OPs chose not to appear and contest the complaint, therefore, the version of the complainant has gone unrebutted.  As such, the act of the OPs in not settling the claim of the complainant amounts to deficiency in service on their part.

7.                In view of the above discussion, the present consumer complaint deserves to succeed and the same is accordingly allowed. The OPs are directed as under:-

i)         To immediately pay the claim of Rs.1,06,740/- to the complainant;

ii)        To pay Rs.15,000/- to the complainant as compensation for mental agony and harassment caused to him.

iii)      To pay to the complainant Rs.10,000/- as costs of litigation.

8.                This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr. No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr. No.(iii) above.

9.                The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
07/11/2017	[Surjeet Kaur]	[Rajan Dewan]
hg	Member	President