Chandigarh

DF-II

CC/299/2018

Hemant Thakur - Complainant(s)

Versus

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

J S Thakur Adv.

19 Nov 2018

ORDER

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

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Consumer Complaint  No	:	299 of 2018
Date  of  Institution	:	29.05.2018
Date   of   Decision	:	19.11.2018

 

 

 

 

Hemant Thakur s/o Late Sh.Balbir Singh, aged about 46 years, resident of H.No.5921, Modern Housing Complex, Manimajra, UT, Chandigarh   

 

             ……..Complainant

Versus

 

1]  Apollo Munich Health Insurance Co. Ltd., 2^nd & 3^rd Floor, iLabs Centre, Plot No.404-405, Udyog Vihar, Phase-III, Gurgaon 122016

 

2]  Apollo Munich Health Insurance Co., Corporate Office-1^st Floor, SCF No.19, Sector 14, Gurgaon 122001

 

3]  Apollo Munich Health Insurance Co., Regd. Office Apollo Hospitals Complex, Jubilee Hills, Hyderabad 500033

 

4]  Apollo Munich Health Insurance Co., Branch office Manimajra, 1^st Floor SCO 857, Shivalik Enclave, Manimajra, UT, Chandigarh.

 

………. Opposite Parties

 

5]  Paras Bliss Hospital, Sector 5, Mansa Devi Complex, Panchkula

 

………. Proforma Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

SMT.PRITI MALHOTRA        MEMBER

           

 

Argued By: Sh.J.S. Thakur, Adv. for complainant.

Sh.Sachin Ohri, Adv. for OPs No.1 to 4.

Sh.Manoj Sood, Adv. for OP No.5.

 

PER PRITI MALHOTRA, MEMBER

 

         The case of the complainant, in brief is that, he has subscribed and been issued a cashless ‘Easy Health Floater Standard’ Health Insurance Policy by OPs for the period from 28.2.2017 to 27.2.2018 after receipt of premium of Rs.12,171/- (Ann.C-1).  It is averred that the complainant fell ill and remained Hospitalized from 13.2.2018 to 16.2.2.2018 at Paras Hospital, Panchkula and was diagnosed & treated for Typhoid. It is also averred that during investigations, another problem known in medical terminology as B/L Nasal Polypos was diagnosed for which no treatment was given. It is submitted that the bill of Rs.44,820/- was paid by the complainant to the hospital at the time of discharge as the OPs wrongly denied the cashless facility (Ann.C-2).  Thereafter, the complainant submitted a claim along with all requisite documents with Opposite Parties on 19.2.2018 for reimbursement of Rs.44,820/-, but the same too was declined by OPs vide letter dated 22.2.2018 stating that the disease known as “Bilateral Nasal Polyps” is not covered under the policy (Ann.C-8) and falls under the exclusion clause.  It is stated that the complainant has not been treated for the said “Bilateral Nasal Polyps” but has been treated for fever (Typhoid).  Alleging the said repudiation as illegal and deficiency in service, hence this complaint has been filed.

 

 

2]       The OPs No.1 to 4 have filed joint reply and while admitting the factual matrix of the case, stated that during investigation, the treating doctor submitted a certificate that the complainant was suffering from Pansinusitis, Nasal Polyps and deviated nasal septum.  It is stated that as per Discharge Summary, the complainant was diagnosed of Pansinusitis with Nasal Polyp.  It is submitted that the claim of the complainant was analyzed by the in-house doctor of the answering OPs and it was found that the claim is not payable because as per available medical documents of the complainant for which treatment is sought, comes under the 2 years exclusion list of the policy terms & conditions i.e. the treatment of the complainant is excluded from the policy if admitted in 2 years of policy inception date.  It is also submitted that the illness of the complainant has specific 2 years of waiting period as per policy and policy start date is 28.2.2017 and the treatment was taken from 13.2.2018 to 16.2.2018.  It is, therefore, the claim has rightly been repudiated (Ann.R-7). Pleading no deficiency in service and denying all other allegations, the OPs NO.1 to 4 have prayed for dismissal of the complaint.  

         The Opposite Party No.5 has also filed short reply stating that the complainant approached the Hospital on 13.2.2018 with compliant of high fever which was diagnosed as Typhoid by the expert doctors attending the complainant.  It is stated that during further investigations, the Hospital detected another problem known as ‘Bilateral Nasal Polyps” but the complainant did not go ahead with the treatment as the insurance company refused to provide cashless facility.  It is also stated that the complainant was discharged on 16.2.2018 after treatment of Typhoid and for ‘Bilateral Nasal Polyps’, he was advised to follow-up with ENT OPD. Denying other allegations for want of knowledge, the Opposite Party No.5 has prayed for dismissal of the complaint qua it.

 

3]       The complainant has also filed rejoinder thereby reiterating the assertions as made in the complaint and controverting that of the OPs No.1 to 4 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]       Admittedly, the complainant availed medical health insurance policy i.e. ‘Easy Health Floater Standard’ (Ann.C-1) for the period from 28.2.2017 to 27.2.2018 by paying premium of Rs.12171/-.  Further, it is admitted that during the coverage period, the complainant fell ill, got hospitalized and was treated for Typhoid and discharged on 16.2.2018.

 

7]       Evidently, the cashless request as well the claim lodged for reimbursement of the expenditure incurred on the treatment, got rejected by the OP Insurance Company (OPs No.1 to 4) stating the reason that the treatment availed by the complainant, during his stay in the Hospital, is excluded from the policy for 2 years from the date of policy inception. Claimed that the policy commencement date is 28.2.2017 and the treatment is taken from 13.2.2018 to 16.2.2018, so is not covered under the waiting period of 2 years.

 

8]       The OP Insurance Company submitted that the claim lodged by the complainant was thoroughly analyzed by the inhouse doctor of the OPs.  It is further claimed that the complainant was diagnosed and treated for Pansinusitis with B/L Nasal Polyps, which has specific 2 years waiting period, as per policy conditions.

 

9]       We are astonished by the defence putforth by the OPs NO.1 to 4 as the Discharge Summary Ann.R-6, placed on record by the OPs, clearly mentions that the complainant was hospitalized and treated for management of high grade fever and it is only during the treatment, he was diagnosed with B/L Nasal Polyps Pansinusitis, but was not treated for the same.  For the convenience, the history of illness & the course of treatment adopted in the Hospital, is reproduced as under:-

         “HISTORY OF PRESENT ILLNESS:

Patient presented with episodes of fever since 1.5 months Admitted here for further management No h/o pain abdomen, burning micturition P/H:   h/o B12 and Vitamin D deficiency in Aug, 2017           No h/o diabetes, hypertension, epilepsy,           tuberculosis           h/o #calcaneus in 1995           Allergic to Diclofenac F/H:NAD

   

    COURSE IN HOSPITAL:

With above mentioned complaints he has been admitted at Paras Bliss hospital.  During hospital stay he developed B/L ear pain for which ENT consultation has been obtained. ENT evaluation revealed B/L nasal polyps with pansinusitis.  He has been suggested surgery by the ENT surgeon. With antibiotics his fever improved so he is being discharged in stable condition. TREATMENT:       IVF NS WITH INJ MVI 100ML/HR                              INJ PCM I/V STAT, INJ RANTAC I/V                              INJ MONOCEF I/V BD, INJ                                             PERFALGAN I/V TDS                              INJ PANTOCID I/V OD, TAB,                                          NEUROBION FORTE OD

 

10]     In addition to the above, we would like to reproduce the contents of the Certificate issued by the treating doctor, which is as under:-

“This is to certify that Mr.Hemant Kumar 45 years old gentleman Registration no.9103 has been admitted at Paras Bliss Hospital Panchkula on 13-02-2018 with the complaint of Fever (on off) since one and a half month.  At presentation there were no other associated symptoms.  So he has admitted with a provisional diagnosis of Enteric fever & investigations were sent to confirm the same & rule out other causes.  Injection Ceftriaxone has been started for the same. During hospital stay he developed ear pain. ENT work up done revealed bilateral Nasal Polyps with Pansinusits.  Blood culture, Malaria Antigen, Dengue Serology was negative.  In view of negative Blood culture report & ENT finding of Pansinusitis final diagnosis of bilateral Nasal Polyps with Pansinusitis has been made.  His fever was settled with antibiotics.  So he had been discharged with an advice for further follow up in ENT Opd.”

   

11]      Admittedly, the complainant lodged the claim with Opposite Parties by filing his claim along with all the available documents including the above referred certificate issued by the treating doctor, which clearly establish that the complainant, during his stay in the Hospital, was treated for Enteric fever/Typhoid and was only diagnosed with the problem of Pansinusitis for which he was advised for further follow-up in the ENT OPD.  Thus, no question for taking treatment for Pansinusitis arose and therefore, the rejection of claim on that ground is not sustainable.   

        

12]      The OPs No.1 to 4 though claimed that the claim was duly investigated by their inhouse doctor, but failed to brought forward the affidavit of the doctor concerned, who wrongly investigated the documents including Discharge Summary submitted by the complainant along with claim.  Surprisingly, the OPs No.1 to 4 also overlooked the certificate so issued by the treating doctor Dr.Ashish Arora (Ann.R-4), which evidents that the complainant was treated for Typhoid fever only, though was also diagnosed with Bilateral Nasal Polyps with Pansinusitis.  This intentional overlooking of the documents reflects not only the highhandedness of the present Insurance Company, but also sounds that the Insurance Companies are only there to enrich their coffers by getting hefty premiums from the gullible consumers with dishonest intentions to reject even the genuine claims.  This dishonest motive to get the premiums only with deceitful intention to reject the genuine claims clearly amounts to misappropriation of public money.  In order to highlight the callous attitude of the Opposite Parties No.1 to 4 in the present complaint also, we would like to reproduce the relevant part of Para No.3 of the reply filed by OP No.5/Paras Bliss Hospital, where the complainant got treatment for Typhoid fever, which does not fall under any of the exclusion clause of the policy in question.  The relevant para is reproduced as under:-

 ‘That the complainant approached the answering-Hospital on 13.2.2018 with complaint of high fever which was diagnosed as Typhoid by the expert doctors attending the complainant.  During further investigation, the answering-Hospital detected another problem known as ‘Bilateral Nasal Polyps’ but the complainant did not go ahead with the treatment as the insurance company refused to provide cashless facility.  The complainant was ultimately discharged on 16.2.2.108 after treatment of Typhoid.  For ‘Bilateral Nasal Polyps’ the complainant was advised to follow up with ENT OPD.’  

 

13]    From the above reply of Opposite Party No.5, it is quite clear that no treatment for Bilateral Nasal Polyps was taken by the complainant, which further corroborates that OPs No.1 to 4 illegally rejected the genuine claim of the complainant, adopting unfair trade practice besides rendering deficient services towards the complainant, which warrants imposing of penalty upon the OPs, in order to deter insurance companies like OPs for resorting to unfair trade practice with further caution to process and appreciate the genuine claims of the claimants adopting right perspective.

 

14]      In view of the above findings, the complaint is allowed with directions to the Opposite Parties No.1 to 4/Apollo Munich Health Insurance Company to reimburse an amount of Rs.44,820/- to the complainant and also to pay compensation of Rs.15,000/- for causing him mental & physical harassment, along with litigation cost of Rs.7000/-.

        The Opposite Parties No.1 to 4/Apollo Munich Health Insurance Company is also imposed with penalty cost of Rs.2.00 lacs on account of their misdeed, as discussed above, which shall be deposited with Department of Radiotherapy & Oncology, PGIMER (Post Graduate Institute of Medical Education & Research), Chandigarh, through its Head of Department, for its usage for the treatment of needy/poor patients. 

 

15]      This order shall be complied with by the Opposite Parties No.1 to 4 in toto within a period of 30 days from the date of receipt of copy of this order, failing which it shall also be liable to pay additional compensatory cost of Rs.10,000/- to the complainant.

         In case the OPs No.1 to 4 failed to deposit the penalty amount with Department of Radiotherapy & Oncology, PGIMER (Post Graduate Institute of Medical Education & Research), Chandigarh, the Head of that Department shall be at liberty to take due recourse of law, which it deem proper, in order to recover the awarded penal amount.

 

16]      However, the complaint qua Opposite Party No.5/Paras Bliss Hospital, stands dismissed.

         Certified copy of this order be sent to the parties as well as to The Head of Department, Department of Radiotherapy & Oncology, PGIMER (Post Graduate Institute of Medical Education & Research), Chandigarh, free of cost. File be consigned to record room.

Announced

19^th November, 2018             

                                                                                       Sd/-