BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, JALANDHAR
Complaint No.147 of 2017
Date of Instt. 11.05.2017
Date of Decision: 01.06.2021
Gurpreet Kaur aged about daughter of Late S. Pritpal Singh, resident of H.No. 2-A, New Ghai Nagar, Model House, Near Gurudwara, Jalandhar Punjab.
..........Complainant
Versus
1. Apollo Munich Health Insurance Co. Ltd., having its office at 10th Floor, Tower-B, Building No.10, DLF Cyber City, DLF City Phase-II, Gurgaon, Haryana 122002, through its Manager/President/Authorized Person.
2. Branch Manager, Apollo Munich Health Insurance Co. Ltd., Jalandhar Branch Office at FF, Satnam Complex, BMC Chowk, G.T Road, Jalandhar.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Kuljit Singh (President)
Smt. Jyotsna (Member)
Present: Sh. G. L. Gagneja, Adv. Counsel for the Complainant.
Sh.Vikas Gupta, Adv. Counsel for the OPs.
Order
Kuljit Singh (President)
1. The instant complaint has been filed by the complainant, against OPs on the averments that he had hired the services of OPs by getting her health insurance vide policy no.180200/ 11001/1000254425 on 17.11.2011. The said policy was regularly renewed by the complainant from time to time and same was renewed further on 18.11.2015 and said policy was valid for the period from 16.11.2015 to 15.11.2016. As per policy, the member ID number of the complainant is 10002648661 and insured amount of Rs.2,00,000/- with premium of Rs.4144.45 was paid by the complainant. The complainant further renewed the health insurance policy from OPs on 14.11.2016 by making premium of Rs.4160/- ad said policy was further renewed for the period of one year and said policy has been failing under the category of cash less policy. At the time of issuing the policy, medical check of the complainant was got done by OPs and after completing all the formalities OPs issued above said health insurance policy. In this policy, it has been mentioned that in case complainant will suffer any health problem then entire expenses of the complainant which includes hospital charges, doctor fee and cost of medicines shall be paid by OPs to doctor directly. On 24.05.2016 the complainant suffered from some health problem and she was got admitted in Tagore Hospital & Health Care Centre (P) Ltd Jalandhar and she was remained hospitalized till 28.05.2016 and thereafter discharged from the hospital. At the time of taking the treatment from the above said hospital, the complainant fulfilled all the requisite documents. The total claim of the complainant has come to the tune of Rs.1,64,265.00 the details of the same has been mentioned in para no.5 of the complaint. But till date OPs have not paid the medical health insurance claim of the complainant for which he is legally entitled. In this regard, he approached OPs many times but OPs always put the matter on one pretext or the other. The complainant had fulfilled all the necessary formalities and documentations for the health insurance claim. Thereafter, the complainant served a legal notice dated 29.11.2016 upon OPs but they did not paid any heed. Due to above said act and conduct of OPs, the complainant had suffered mental harassment, therefore, he had filed the present complaint and prayed that the OPs be directed to pay Rs.1,64,265.04 along with interest @ 18% p.a. w.e.f. from the date of claim, besides to pay Rs.2,00,000/- for mental harassment.
2. Upon notice, OPs no.1 and 2 appeared and filed written reply and contested the complaint of the complainant by raising preliminary objections that complaint is frivolous and devoid of merits. The complainant has suppressed the material facts. There is no deficiency in service or negligence on the part of OPs. On merits, it was averred that before acceptance of the proposal by OPs the contents of proposal/application/terms and conditions of the policy and exclusions were explained to the complainant thereafter said policy along with terms and conditions were issued to the complainant. The complainant was given detailed description about the features of the said plan including the premium amount to be paid. On 25.05.2016, cashless claim was received by the OPs from Tagore Hospital and probable diagnosis of ACS, H STEMI/Angina with DOA 24 May 2016 and estimated duration of stay of 1 days and estimated cost of Rs.12000/-. OPs averred that till date they have not received any reimbursement claim for this hospitalization. Rest of the averments of the complainant was denied by OPs and they prayed for dismissal of the complaint.
3. The complainant has tendered into evidence his own affidavit Ex.CW-1/A along with some documents Ex.C-1 to Ex.C-44 and closed the evidence.
4. On the other hand, OPs tendered in evidence documents Ex.OP-1 to Ex.OP-8 and closed the evidence.
5. We have heard learned counsel for the parties and have also gone through the record of the case as well as written arguments filed by both the parties.
6. The complainant has tendered in evidence his affidavit Ex.CW-1/A in support of his case. Ex.C-1 is letter dated 17.11.2011 addressed to complainant by OPs. Ex.C-2 is letter dated 18.11.2015 with schedule of the policy. In which gross premium of Rs.4144.94 has been mentioned. Ex.C-3 is copy of premium acknowledgement. Ex.C-5 is copy of certificate issued by Dr. Nipun Mahajan MD that complainant Gurpreet Kaur was admitted in Tagore Hospital & Heart Care Centre on 24.05.2016 and diagnosed as CAD, NSTE, MI Moderate LV Dysfunction. She has undergone Coronary Angiography followed by PTCA with stent implantation to RCA on 25.05.2016 and discharged on 28.05.2016. Ex.C-6 is letter addressed to OPs regarding total estimate of Rs.1,67,000/- Ex.C-7 is copy of additional information request form dated 25.05.2016. Ex.C-9 is copy of additional information request form dated 26.05.2016. Ex.C-10 is copy of letter. Ex.C-11 is copy of additional information request form. Ex.C-12 is copy of letter. Ex.C-13 is copy of authorization letter. Ex.C-14 is copy of additional information request form. Ex.C-16 and Ex.C-17 are copies of additional information request form. Ex.C-19 is copy of prescription slip of the doctor. Ex.C-21 to Ex.C-37 are copies of payment receipts. Ex.C-39 is copy of letter addressed to OPs regarding delay in clearance of medical claim. Ex.C-40 is copy of postal receipt thereof. Ex.C-41 is copy of legal notice. Ex.C-42 and Ex.C-43 are postal receipts thereof.
7. To counter this evidence, OPs tendered in evidence copy of order issued by Insurance Regulatory and Development Authority as Ex.OP-1 on the record. Ex.OP-2 is copy of insurance policy with terms and conditions. Ex.OP-4 is copy of request for cashless hospitalization for medical insurance policy. Ex.OP-5 is copy of additional information request form. Ex.OP-6 is copy of authorization letter. Ex.OP-7 is copy of additional information request form. Ex.OP-8 is copy of letter addressed to OPs.
8. It is an established fact that the complainant taken health insurance policy from OPs for the period from 16.11.2015 to 15.11.2016 with premium of Rs.4144.95. On 24.05.2016 the complainant suffered from some health problem and she was got admitted in Tagore Hospital and Heart Care Centre (P) Ltd at Banda Bahadur Nagar, Mahavir Nagar Jalandhar for her treatment and she was remained hospitalized till 28.05.2016 and discharged from the hospital. From perusal of Ex.C-2 insurance policy, this fact is clear that the premium amount is Rs.41.44.94 and sum assured amount of Rs.2,00,000/-. OPs have received the premium amount, this fact is clear from premium acknowledgment Ex.C-3 on the record. The complainant admitted in the hospital on 24.05.2016 and discharged on 28.05.2016. This fact is clear from copy of certificate Ex.C-5 on the record. From perusal of this certificate, it is clear that she has diagnosed as CAD, NSTE, MI, Moderate LV Dysfunction. She has undergone coronary Angiography followed by PTCA with stent implantation to RCA on 25.05.2016. The complainant admitted in the hospital as indoor patient. The discharged summary prepared by Tagore Hospital & Heart Care Centre is also placed on the record. In this document the date of admission in the hospital is mentioned as 24.05.2016 and discharged on 28.05.2016. At the time of taking treatment from above said hospital, the complainant fulfilled all the requisite documents with said hospital. The complainant suffered from some health problem and admitted in the hospital on 24.05.2016 and the policy in question is valid from 16.11.2015 to 15.11.2016. The complainant taken treatment from OPs during currency period of the policy. As such, as per terms and conditions of the policy, the OPs are liable to pay the claim of the complainant without any hesitation. The OPs also received the premium amount from the complainant and medically checked up at the time of filing up the proposal form. We do not agree with the submissions of the OPs in this case that claim of the complainant is not genuine. The insurance companies collect the premiums from the insured and find ways to decline the claims without any valid reasons. This fact is settled by Hon’ble Punjab and Haryana High Court at Chandigarh in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others reported in 2008(3) RCR (Civil) Page 111 held as under:-
“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline the claims. All conditions which generally are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay cost of Rs.5000/- for luxury litigation being rich.”
9. From perusal of entire record of the case and after hearing submissions of counsel for the parties, we are considered opinion that the complainant is entitled for Rs.1,64,265.04 as spent by her on her treatment as per bills placed on the record with 6% interest from the date of filing the claim till its realization and accordingly, the complaint of the complainant is partly accepted. The complainant is also entitled for Rs.7000/- as compensation for mental harassment and Rs.3000/- as cost of litigation.
10. The compliance of the order be made within one month from receipt of copy of this order.
11. The complaint could not be decided within the stipulated time frame, due to heavy pendency of the court cases and spread of Covid-19.
12. Copies of the order be sent to the parties, as permissible, under the rules. File be indexed and consigned to the record room after due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
1st Day of June 2021
(Kuljit Singh)
President
(Jyotsna)
Member
